Autologous Fat Transfer: Art, Science, and Clinical Practice

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 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009926019 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper 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 fields. The first 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 first steps in this field 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.

Rome, Italy

With great affection 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 fillers, 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, completing the three-dimensional correction of the face, and elevating depressions and deficits. Fat transfer may also prevent excessive fibrosis 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 attributed to the contribution of liposuction by Fischer that was first 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

3

2

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

5

3

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

11

4

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

19

5

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

29

6

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

37

Part II Preoperative 7

Preoperative Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

43

Part III Techniques for Aesthetic Procedures 8

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

47

9

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

53

10

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

59

ix

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Contents

11

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

65

12

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

69

13

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

79

14

Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert W. Alexander

87

15

Fat Transfer to the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman and Mitchell V. Kaminski

113

16

Fat Autograft Retention with Albumin . . . . . . . . . . . . . . . . . . . . . . . . . Mitchell V. Kaminski and Rose M. Lopez de Vaughan

123

17

Aesthetic Face-lift Using Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . Anthony Erian and Aqib Hafeez

135

18

Fat Transfer to the Glabella and Forehead . . . . . . . . . . . . . . . . . . . . . . Felix-Rüdiger G. Giebler

147

19

Eyebrow Lift with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Giorgio Fischer

153

20

Treatment of Sunken Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dae Hwan Park

155

21

Fat Graft Postvertical Myectomy for Crow’s Feet Wrinkle Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fausto Viterbo

165

Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Allison T. Pontius and Edwin F. Williams III

171

22

23

Autologous Fat Transfer to the Cheeks and Chin. . . . . . . . . . . . . . . . . Steven B. Hopping

179

24

Nasal Augmentation with Autologous Fat Transfer . . . . . . . . . . . . . . . Jongki Lee

185

25

Lipotransfer to the Nasolabial Folds and Marionette Lines . . . . . . . . Robert M. Dryden and Dustin M. Heringer

189

26

Autologous Fat Transplantation to the Lips . . . . . . . . . . . . . . . . . . . . . Steven B. Hopping, Lina I. Naga, and Jeremy B. White

197

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27

Three Dimensional Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sid J. Mirrafati

203

28

Complementary Fat Grafting of the Face . . . . . . . . . . . . . . . . . . . . . . . Samuel M. Lam, Mark J. Glasgold, and Robert A. Glasgold

209

29

Fat Transplants in Male and Female Genitals . . . . . . . . . . . . . . . . . . . Enrique Hernández-Pérez, Hassan Abbas Khawaja, José Enrique Hernández-Pérez, and Mauricio Hernández-Pérez

217

30

History of Breast Augmentation with Autologous Fat . . . . . . . . . . . . . Melvin A. Shiffman

223

31

Breast Augmentation with Autologous Fat . . . . . . . . . . . . . . . . . . . . . . Tetsuo Shu

229

32

Fat Transfer and Implant Breast Augmentation. . . . . . . . . . . . . . . . . . Katsuya Takasu and Shizu Takasu

237

33

Fat Transfer with Platelet-Rich Plasma for Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert W. Alexander

243

Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue . . . . . . . . . . . . . . . . . . . . . Kotaro Yoshimura, Katsujiro Sato, and Daisuke Matsumoto

261

34

35

Fat Transfer to the Hand for Rejuvenation . . . . . . . . . . . . . . . . . . . . . . Pierre F. Fournier

36

Correction of Deep Gluteal and Trochanteric Depressions Using a Combination of Liposculpturing with Lipo-Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert F. Jackson and Todd P. Mangione

37

Buttocks and Legs Fat Transfer: Beautification, Enlargement, and Correction of Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lina Valero de Pedroza

273

281

291

38

Autologous Fat Transfer for Gluteal Augmentation . . . . . . . . . . . . . . . Adrien E. Aiache

297

39

Autologous Fat for Liposuction Defects . . . . . . . . . . . . . . . . . . . . . . . . . Pierre F. Fournier

301

40

Periorbital Fat Transfer with Platelet Growth Factor . . . . . . . . . . . . . Julio A. Ferreira and Gustavo Ferreira

303

41

Cryopreserved Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bernard I. Raskin

305

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Contents

Part IV Techniques for Non-Aesthetic Procedures 42

Fat Transfer for Non-Aesthetic Procedures. . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman, Enrique Hernández-Pérez, Hassan Abbas Khawaja , José Enrique Hernández-Pérez, and Mauricio Hernández-Pérez

315

43

Fat Transplantation for Mild Pectus Excavatum . . . . . . . . . . . . . . . . . Luiz Haroldo Pereira and Aris Sterodimas

323

44

Correction of Hemifacial Atrophy with Fat Transfer. . . . . . . . . . . . . . Qing Feng Li, Yun Xie, and Danning Zheng

331

45

Recontouring Postradiation Thigh Defect with Autologous Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Richard H. Tholen, Ian T. Jackson, Richard Simman, and Vincent D. DiNick

46

Management of Migraine Headaches with Botulinum Toxin and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . Devra Becker and Bahman Guyuron

47 Retropharyngeal Fat Transfer for Congenital Short Palate . . . . . . . . P. H. Dejonckere 48

49

Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Total Joint Prostheses to Prevent Heterotopic Bone . . . . . . . . . . . . . . . . . . . . . . . . Larry M. Wolford and Daniel Serra Cassano Autologous Fat Grafts for Skull Base Repair After Craniotomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jose E. Barrera, Sam P. Most, and Griffith R. Harsh IV

341

347

357

361

383

Part V Fat Processing and Survival 50

Fat Processing Techniques in Autologous Fat Transfer . . . . . . . . . . . . Nancy Kim and John G. Rose Jr.

391

51

Injection Gun Used as a Precision Device for Fat Transfer . . . . . . . . . Joseph Niamtu

397

52

Tissue Processing Considerations for Autologous Fat Grafting . . . . . Adam J. Katz and Peter B. Arnold

403

53

Fat Grafting Review and Fate of the Subperiostal Fat Graft . . . . . . . Defne Önel, Ufuk Emekli, M. Orhan Çizmeci, Funda Aköz, and Bilge Bilgiç

407

Contents

xiii

Part VI Complications 54

Complications of Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Giovanni Guaraldi, Pier Luigi Bonucci, and Domenico De Fazio

56

Lid Deformity Secondary to Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . Brian D. Cohen and Jason A. Spector

417

427

433

Part VII Miscellaneous 57

The Viability of Human Adipocytes After Liposuction Harvest . . . . . John K. Jones

58

Autologous Fat Grafting: A Study of Residual Intracellular Adipocyte Lidocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert W. Alexander

59

Autologous Fat Transfer National Consensus Survey: Trends in Techniques and Results for Harvest, Preparation, and Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

439

445

451

60

Medical Legal Aspects of Autologous Fat Transplantation . . . . . . . . . Melvin A. Shiffman

459

61

Editor’s Commentary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

463

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

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, [email protected] 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 Sorsfield 220, 1640 Martinez, Buenos Aires, Argentina, [email protected] Julio A. Ferreira Santiago Del Estero 102 (1640), Buenos Aires, Argentina, [email protected] Giorgio Fischer Via della Camiluccia, 643, 00135 Rome, Italy, [email protected] 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

Contributors

xvii

Griffith 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, Southfield, 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

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, [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 Parkı 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

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, Pontifical 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 – 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

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

Contributors

Part History, Principles, Fat Cell Physiology and Metabolism

I

1

History of Autologous Fat Transfer1 Melvin A. Shiffman

1.1  Introduction The history of autologous fat augmentation gives an insight into the development of fat transfer for both cosmetic and non-cosmetic problems. Transplantation of pieces of fat and occasionally diced pieces of fat advanced to the removal of small segments of fat by liposuction after the development of the technique by Fischer and Fischer, reported in 1975.

1.2  History Neuber (1) reported the use of small pieces of fat from the upper arm to reconstruct a depressed area of the face resulting from tuberculosis osteitis. He concluded that small pieces of fat, of bean or almond size, appeared to have a good chance of survival. Czerny (2) used a large lipoma to fill a defect in the breast following resection of a benign mass. The transplanted breast, however, appeared darker in color and smaller in volume than the opposite breast. Verderame (4) observed that fat transplants solved the problem of shrinkage at the transplant site. Lexer (3) reported personal experience with fat transplants and found that larger pieces of fat gave better results. Bruning (5) used fat grafts to  fill a post-rhinoplasty deformity by placing fat in a  syringe and injecting the tissue through a needle. 1

Reprinted with permission of Lippincott Williams & Wilkins.

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA, 92780-2302, USA e-mail: [email protected]

Tuffier (6) inserted fat into the extrapleural space to treat pulmonary conditions. Biopsy of the fat 4 months post transplant showed that most of the fat was resorbed and replaced by fibrous tissue. Straatsma and Peer (7) used free fat grafts to repair postauricular fistulas and depressions or fistulas resulting from frontal sinus operations. Cotton (8) used a technique of broad undercutting and insertion of finely cut fat that was molded to fill defects. Peer (9) noted that grafts the size of a walnut appear to lose less bulk after transplanting than do smaller multiple grafts. He also found that free fat grafts lose about 45% of their weight and volume 1 year or more following the transplantation because of the failure of some fat cells to survive the trauma of grafting as well as the new environment. Fat grafts are affected by trauma, exposure, infection, and excessive pressure from dressings (10). Peer (11) stated that microscopically, grafts appear like normal adipose tissue 8 months after trans­ plantation. Liposuction was conceived by Fischer and Fischer in 1974 (12) and put into practice in 1975 (13). Fischer (14) first reported removal of fat by means of 5 mm incisions using a “rotating, alternating instrument electrically and air powered.” This allowed aspiration of fat through a cannula. Through a separate incision, saline solution was injected to dilute the fat. In 1977 (15), they reviewed 245 cases of liposuction with the “planotome” for treatment of cellulite in the lateral trochanteric areas. There was a 4.9% incidence of seromas despite wound suction catheters and compression dressings. Pseudocyst formation, which required removal of the capsule through a wider incision and the use of the planotome, occurred in 2% of cases. The advent of liposuction spurred a move toward using the liposuctioned fat for reinjecting areas of the body for filling defects or augmentation. Bircoll (16)

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_1, © Springer-Verlag Berlin Heidelberg 2010

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first reported the use of autologous fat from liposuction for contouring and filling defects. Illouz (17) claimed that in 1983, he began to inject aspirated fat. Johnson (18) stated that in 1983, he began to use auto­ logous fat injection for contouring defects of the buttocks, anterior tibial area, lateral thighs, coccyx area, breasts, and face. Bircoll (19) presented the method of injecting fat that had been removed by liposuction. Krulig (20) asserted that he began to use fat grafts by means of a needle and syringe. He called the procedure “lipoinjection.” He began to use a disposable fat trap to  facilitate the collection process and to ensure the fat’s sterility. Newman (21) stated that he began reinjecting fat in 1985. The idea of utilizing the aspirated fat, which was otherwise wasted, was an attractive idea and other surgeons began to make use of the aspirate to augment defects and other abnormalities. The American Society of Plastic and Reconstructive Surgery (ASPRS) Ad-Hoc Committee on New Proce­ dures produced a report on 30 September 1987, regarding autologous fat transplantation (22). The conclusions were: 1. Autologous fat injection has a historical and scientific basis. 2. It is still an experimental procedure. 3. Fat injection has achieved varied results, and longterm, controlled clinical studies are needed before firm conclusions can be made regarding its validity. 4. Fat transplant for breast augmentation can inhibit early detection of breast carcinoma and is hazardous to public health. Coleman and Saboeiro (23) reported success in fat transfer to the breast and concluded that it should be considered as an alternative to breast augmentation and reconstruction procedures. Two of 17 patients had breast cancer diagnosed by mammography, one 12 months and the other 92 months after fat transfer to the breast. Now fat transfer to the breast area is being used outside the breast itself, into the pectoralis major muscle and behind and in front of the muscle. The fat is also being used to augment tissues around the breast following treatment for breast cancer. Although most of the fat transfer procedures are for augmentation of tissues, there has been a surge of the use of fat for non-cosmetic procedures.

M. A. Shiffman

References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   2. Czerny V. Plastischer ersatz der brustdruse durch ein lipoma. Chi Kong Verhandl 1895;2:126.   3. Lexer E. Freie fettransplantation. Deutsch Med Wochenschr 1910;36:640.   4. Verderame P. Ueber fettransplantation bei adharenten knochennarben am orbitalrand. Klin Monatsbl fur Augenh 1909; 47:433–442.   5. Bruning P. Cited by Broeckaert, TJ, Steinhaus, J. Contribution e l’etude des greffes adipueses. Bull Acad Roy Med Belgique 1914;28:440.   6. Tuffier T. Abces gangreneux du pouman ouvert dans les bronches: Hemoptysies repetee operation par decollement pleuro-parietal; guerison. Bull et Mem Soc de Chir de Paris 1911;37:134.   7. Straatsma CR, Peer LA. Repair of postauricular fistula by means of a free fat graft. Arch Otolaryngol 1932;15:620–621.   8. Cotton FJ. Contribution to technique of fat grafts. N Engl JMed 1934;211:1051–1053.   9. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18(4):233–250. 10. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217–230. 11. Peer LA. Transplantation of Tissues, Transplantation of Fat. Baltimore, Williams & Wilkins, 1959. 12. Fischer G. The evolution of liposculpture. Am J Cosm Surg 1997;14(3):231–239. 13. Fischer G. Surgical treatment of cellulitis. Third Congress of the International Academy of Cosmetic Surgery, Rome, 31 May 1975. 14. Fischer G. First surgical treatment for modeling body’s cellulite with three 5 mm incisions. Bull Int Acad Cosm Surg 1976;2:35–37. 15. Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosm Surg 1977;2(4):40–43. 16. Bircoll M. Autologous fat transplantation. The Asian Congress of Plastic Surgery, February 1982. 17. Illouz YG. The fat cell “graft”: A new technique to fill depressions. PlastReconstrSurg 1986;78(1):122–123. 18. Johnson GW. Body contouring by macroinjection of autologous fat. Am J Cosm Surg 1987;4(2):103–109. 19. Bircoll MJ. New frontiers in suction lipectomy. Second Asian Congress of Plastic Surgery, Pattiyua, Thailand, February 1984. 20. Krulig E. Lipo-injection. Am J Cosm Surg 1987;4(2):123–129. 21. Newman J, Levin J. Facial lipo-transplant surgery. Am J Cosm Surg 1987;4(2):131–140. 22. American Society of Plastic and Reconstructive Surgery Committee on New Procedures. Report in autologous fat transplantation September 30,1987. Plast Surg Nurs 1987; Winter:140–141. 23. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg 2007;119(3): 775–785.

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History of Autologous Fat Transplant Survival1 Melvin A. Shiffman

2.1  Introduction The survival of free fat used as an autograft is operator dependent and requires delicate handling of the graft tissue, careful washing of the fat to minimize extraneous blood cells, and installation into a site with adequate vascularity. There is evidence that fat cells will survive and that filling of defects is not from the residual collagen following cell destruction. There is some loss of fat after transplant, and most surgeons tend to overfill the recipient site.

2.2  Historical Review Verderame (1) reported that autogenous fat grafts in ocular surgery became reduced in size and advised the use of a larger transplant than that seemed necessary to fill the defect. Lexer (2) claimed that manipulation and tearing of the graft at the time of transfer would cause a great degree of graft shrinkage. Kanavel (3) felt that graft survival was improved by not using suture to secure the graft, careful hemostasis, and aseptic technique. He transplanted sheets of fat varying from 0.25 to 1 in. in thickness to prevent adhesions and contractures and lessen deformity of tendons, nerves, blood vessels, and joints. He felt that fat can be transplanted into any Reprinted with permission of Lippincott Williams & Wilkins.

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M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

ordinary field with the assurance that it will not act as a foreign body. Clinically it appears to live, become a part of the structure in which it is placed, and persists for many months and probably years. Davis (4) concluded that omentum, transplanted freely beneath the skin in a mass, 1 in. in diameter, maintains the greater part of its bulk. Lexer (5) reported excellent clinical results with very large fat grafts but stated that up to 66% of the fat autografts were absorbed and significant overcorrection should be used. He stated that multiple small grafts would turn to scar, while larger grafts would remain fatty tissue. Mann (6) performed free transplant of omentum fat and stated that it remained seemingly viable for as long as 1 year and retained a small percentage of its fat. Neuhof (7) examined available experimental and clinical evidence and concluded that: 1. Transplanted autologous fat undergoes practically some changes as transplanted bone. 2. The transplant dies and is replaced either by fibrous tissue or by newly formed fat. 3. Newly formed fat occurs through the activity of a large wandering histocyte-like cell, which takes on fat and becomes a fat cell. Guerney (8) noted that autogenous fat grafts should be transplanted in larger bulk than required since only 25–50% of the graft survives 1 year after transplantation. He studied transplanted, 1.7 mm3 (average size), fat grafts over a period of 12 months in rats and concluded that: 1. Liberation of fat by contiguous cells probably gives rise to fatty cysts. 2. Phagocytosis of liberated fat was assisted by polymorphonuclear leucocytes. 3. The percentage of normal fat in any surviving graft gradually increased throughout the year.

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

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4. A certain portion of the transplanted tissue gained an adequate blood supply early and continued to survive, while the remainder of the graft degenerated and was gradually eliminated from the site of the implant without evidence of gross scar. 5. Crushed grafts eventually disappeared attesting to the devastating effect of trauma on the vitality of a graft. 6. Single pieces of fat remain viable for at least 1 year, while grafts of a similar size cut into smaller pieces may last as long as 6 months, but the majority disappear by the third month. 7. Absolute hemostasis is essential since even a slight hemorrhage jeopardizes the viability of the graft. 8. Although slight infection results in only a small loss of tissue, gross infection leads to a loss of the whole graft. 9. Phagocyte cells do not use their fat to form new fat cells during the first year after transplantation. Hilse (9) showed histologically that free fat transplants regenerate fatty tissue without any exception. He referred to the histocyte filled with fat as a “lipoblast.” Green (10) used fat and fat-fascia autografts in the treatment of osseous defects secondary to osteomyelitis. He presumed that transplanted fat would become connective tissue and then bone, closing the defect. Wertheimer and Shapiro (11) studied fat physiology and determined that fat develops from primitive adipose cells the structure of which is like that of the fibroblasts of connective tissue. Peer (12) implanted autogenous fat (single piece compared to a piece cut into 20 segments) into the rectus muscle. Grafts were removed at intervals from 3 to 14 months. Grossly all grafts were surrounded by a connective-tissue capsule and, upon sectioning, the bulk of the graft contained fatty tissue. Single grafts (the size of a walnut) lost 45% of their weight while multigrafts lost 79% of their weight. He concluded that the fat grafts appeared like normal fat tissue 1 year or more after transplantation. Bames (13) noted that circulation in grafts is established in about 4 days after transplantation by anastomosis between the host and graft blood vessels. Traumatized fat grafts lose much more weight and volume than gently handled transplants (50% loss after 1 year). Normal appearing adipose cells were present in all the transplants. Dermal-fat grafts provide a readily available transplantation material for establishing normal contour in small breasts instead of foreign implants.

M. A. Shiffman

Hansberger (14) proposed that histocytes phagocytose the lipid and do not replace graft fat. After the graft of mature autotransplanted fat goes through initial ischemia, fat cells either necrose or dedifferentiate into immature cells. Under suitable conditions, the immature fat cells revert to mature adipocytes. Schorcher (15) reported using autogenous free fat transplantation to treat hypomastia. He noted that the connective elements remained intact with fat shrinkage to 25% of the original size by 6–9 months. He believed that if the graft was in several pieces, it would receive better nourishment from the recipient site. Van and Roncari (16, 17) demonstrated conversion of adipocyte precursors into adult adipocytes, both in vitro and in vivo, in rats. Saunders et al. (18) studied fat autograft survival and observed initial adipose tissue breakdown followed by revascularization. There is early breakdown of fat cells with formation of cyst like lipid deposits and infiltration by host histocytes. Illouz (19) opined that the human body is an excellent culture medium and that the fat cells apparently survive by intercellular lipolysis and osmosis until they are revascularized. The area to be augmented should be over corrected by 30% because approximately 30% necrosis of fat cells results when using the wet technique. Illouz (20) reported that fat transplantation in one patient biopsied 9 and 16 months later, showed normal fat cells. Asken (21) found that 90% of fat extracted by liposuction appears viable, assuming it is not traumatized either by handling or by high suction pressure. Damage incurred by the adipocytes is inversely related to the diameter of the instrument used for harvesting and injection. Campbell et al. (22) noted, both morphologically and biochemically, that adipocyte integrity and metabolism remain intact when subjected to liposuction. Johnson (23) examined liposuctioned fat and noted that 90% or more of the fat cells remained viable. He found that there was 75–85% of original fat present 3 months after transplantation. Agris (24) claimed that trauma and desiccation injured transplanted fat cells. Bircoll (25) stated that the ASPRS report (26) of 30% survival and Peer’s report (27) of 50% survival of autologous fat transplantation were based on the older technique of bulk fat transfer. Biopsies show 80% survival of fat after 1 year and an additional bulk of 10–20% of fibrous tissue. Fat transplants must be placed into the fatty subcutaneous tissue. Billings and May (28) analyzed the histology of free fat grafts and noted the following:

2  History of Autologous Fat Transplant Survival

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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 cells may increase, through differentiation of existing preadipocytes, when fat cells reach a “critical size.” Illouz (30) reported that fibroblast-like precursor cells are able to multiply and give rise to fibroblasts or cells that resemble fibroblasts. When these cells are stimulated to absorb fat vacuoles with insulin or dexamethasone, they do not because adipocytes. He noted that adipocytes are very fragile and have a short life span outside the body. The cells live longer if mixed with normal saline and kept at a moderate temperature. They do not tolerate excessive manipulation, refrigeration, or major trauma such as grinding. Hudson et al. (31) demonstrated a greater cell size and lipogenic activity (using measurement of activity of lipogenic enzyme adipose tissue lipoprotein lipase [ATLPL]) in the gluteal – femoral area compared to the abdomen. Facial fat was found to have small cells with almost no ATLPL activity. This may have implications for donor site suitability. Nguyen et al. (32) compared suctioned fat, aspirated fat, and excised fat 9 months after implantation. Suctioned fat was obtained by using 1 atm negative pressure and on microscopy, only 10% of the fat cells were found with intact cell membrane. In all the grafts, fat was replaced with fibrosis, and only a small number of surviving adipocytes were still present. Kononas et al. (33) compared the loss of fat following transplant between surgically excised fat cut into small pieces and suctioned fat which was centrifuged. Weight loss was 59% for excised fat and 67% for suctioned fat. Ersek (34) used a wire whisk to agitate harvested fat and then strained it. He reported disappointing results even with repeated injection

and concluded that little, if any, autologous fat survives in its new site. Courtiss et al. (35) reported marginal success in fat grafting of two patients with postliposuction depressions. Asaadi (36) reported 5-year successful retention of fat transplanted to a right trochanteric post-traumatic depressed scar. Samdal et al. (37) measured blood flow and the amount of surviving fat following needle abrasion of the recipient site in rats. Abrasion was performed by a criss-cross pattern with 20 strokes using an 18 gauge needle in the subcutaneous tissue prior to transplant and compared this to controls without abrasion. They found that the mean weight of the fat transplant had shrunk to 44.6% of the original weight in the abraded group and 33.5% in the control group. The mean blood flow in fat was 0.165 mL/min/g in normal fat, 0.120 mL/min/g in the controls, and 0.187 mL/min/g in the abraded group. Microscopic examination of the transplanted fat varied from oil cysts, connective tissue, and inflammatory cells in some specimens and completely normal fatty tissue in others. Fat survival varied from 0–90%. They concluded that fat transplant survival was unpredictable. Eppley et al. (38) reported that the addition of basic fibroblast growth factor delivered by dextran beads to fat grafts results in a larger weight maintenance of fat at 1 year than controls. Group A Group B Group C

Group D

Fat alone Fat with dextran beads Fat with dextran beads soaked with cytochrome C (nonmitogenic control solution) Fat with dextran beads soaked with basic fibroblast growth factor

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M. A. Shiffman

Group

Weight retention after 12 months (%)

A B C D

48.8 79.6 75.2 93.8

Histologically, he noted extensive interlacing collagen formation between the adiposites that provide support for the known effects of basic fibroblast growth factor on mesenchymal cell lines. There was an increased uniformity in adipocyte size seen in 1 year grafts compared to 1 month grafts which may indicate a possible maturation of these more “immature” cells. Whether this represents repair of damaged adipocytes, preadipocyte differentiation, conversion of infiltrating macrophages or fibroblasts, or entrapped lipid material is speculative. Carpaneda and Ribeiro (39) examined fat 2 months after transplantation and noted viable tissue only in the peripheral zone of 3.5 mm diameter cylindrical grafts. There was 60% loss of grafted tissue which occurred closer to the center. They reported, in 1994 (40), that graft viability depends on the thickness and geometric shape and is inversely proportional to the graft diameter if the diameter is greater than 3 mm. The maximum percentage of viability is 40% when the graft is no greater than 3.0 mm thick. Niechajev and Sevchuk (41) reported 50% fat survival over 3.5 years after single fat transplantation with 50% overcorrection. They found that fat obtained under maximum negative pressure (−0.95 atm) results in partial breakage and vaporization of the fatty tissue. About two-thirds of the fat withstood the trauma of aspiration. Low pressure (−0.5 atm) resulted in smaller cell size (29% smaller than with aspiration at −0.95 atm) and they assumed that high pressure causes mechanical distention of the adipocytes which increases the risk of and sometimes causes cell breakage. Courtiss (42) stated that fat grafting remains controversial and poorly understood and that “some surgeons have some impressive results, but most of us have many disappointing results.” Fagrell et al. (43) examined fat 6 months after implantation in the ears of rabbits. The fat implanted was obtained by: 1. Fat cylinder retrieved with 4.5 mm internal diameter syringe pushed into the fat and pulling the piston back. 2. Excised fat, 1 mg in weight. 3. Aspirated fat using 2 mm (14 gauge) cannula and syringe.

The tissue was examined by light microscopy and ­computer-assisted image analysis. There was no difference between the weight of the 6 month excised specimen (no weight loss) between the fat cylinder and excised fat, but there was a 59% loss of weight of the aspirated fat. The conclusion was that fat aspiration is traumatic and breaks up the cells. However, there was histologic evidence of viable fat cells in all transplants. Jones and Lyles (44) harvested fat with a 60 mL syringe, 3.0 mm pyramid cannula, and locked the plunger at 35 mL. The harvested fat was washed three times with normal saline and gently agitated. Cell cultures were prepared and maintained for 1 day to 2 months. Microscopy disclosed maintenance of mature adipose cells without dedifferentiation into a precursor phenotype. There was very little evidence of cellular damage or debris. Using photographs over a 6 year period of time, Coleman (45) demonstrated long-term survival of liposuctioned fat transplanted into the nasolabial fold. He stated that fat can migrate as the pressure of excess tissue forces the transplanted fat to shift and that fat can die from inadequate nutrition and oxygen from competition with other transplanted parcels of fatty tissue. Placement of fat into multiple tunnels allows closer location to nutrition. He concluded that fat survival is technique dependent and the primary reason for failure of long-term correction of the nasolabial fold is initial inadequate correction. Sattler and Sommer (46) found that autologous fat, dried over sterile swabs and frozen at −20°C (lower temperatures down to −70°C are preferable) up to 2 years and then thawed at room temperature, contains only fat cells and no fibrous debris. Ullmann et al. (47) added Cariel, a modified serum-free cell culture medium (MCDB 153), to aspirated human fat prior to reinjection into mice. Cariel contains essential and nonessential amino acids, vitamins, inorganic salts, trace elements, buffers, thyroxin, growth hormone, insulin, and sodium selenite. There was 46% of the weight of the fat remaining after 15 weeks in the group with Cariel compared to 29% in the control without Cariel. They concluded that the addition of nutrients enriched with anabolic hormones enabled the survival and take of more adipose cell in the graft. United States Patent (Lindenbaum) Composition and methods for enhancing wound healing. Patent No. 5461030. Date of patient: 24 October 1995.

2  History of Autologous Fat Transplant Survival

References   1. Verderame P. Ueber fettransplantation bei adharenten knochennarben am orbitalran. Klin Montsbl f Augenh 1909; 7:433.   2. Lexer E. Ueber freie fettransplantation. Klin Therap Wehnschr 1911;18:53.   3. Kanavel AR. The transplantation of free flaps of fat. Surg Gynecol Obstet 1916;23:163–176.   4. Davis CB. Free transplantation of the omentum, subcutaneously and within the abdomen. J Am Med Assoc 1917;68: 705–706.   5. Lexer E. Fatty tissue transplantation. In: Die Transplantation, Part I. Stuttgart, Ferdinand Enke, 1919, pp. 265–302.   6. Mann FC. The transplantation of fat in the peritoneal cavity. Surg Clin N Am 1921;1:1465–1471.   7. Neuhof H. The Transplantation of Tissues. New York, D. Appleton, 1923, p. 74.   8. Guerney CE. Experimental study of the behavior of free fat transplants. Surgery 1938;3:679–692.   9. Hilse A. Histologische ergebuisse der experimentellen freien fettgewebstronsplantation. Beitr 2 Path Anal U Z Allg Path 1928;79:592–624. 10. Green JR. Repairing bone defects in cranium and tibia. South Med J 1947;40:289. 11. Wertheimer E, Shapiro B. The physiology of adipose tissue. Physiol Rev 1948;28:451. 12. Peer LA. Loss of weight and volume in human fat grafts: With postulation of a “cell survival theory.” Plast Reconstr Surg 1950;5:217–230. 13. Bames HO. Augmentation mammoplasty by lipotransplant. Plast Reconstr Surg 1953;11(5):404–412. 14. Hansberger FX. Quantitative studies on the development of autotransplants of immature adipose tissue of rats. Anat Rec 1995;122:507. 15. Schorcher F. Fettgewebsver pflanzung bei zu kneiner brust. Munchen Med Wochenschr. 1957;99(14):489. 16. Van RL, Roncari DA. Complete differentiation of adipocyte precursors: A culture system for studying the cellular nature of adipose tissue. Cell Tiss Res 1978;195(2):317–329. 17. Van RL, Roncari DA. Complete differentiation in vivo of implanted cultured adipocyte precursors from adult rats. Cell Tiss Res 1982;225(3):557–566. 18. Saunders MC, Keller JT, Dunsker SB, Mayfield FH. Survival of autologous fat grafts in humans and mice. Connect Tiss Res 1981;8(2):85–95. 19. Illouz YG: New applications of liposuction. In Illouz YG (ed), Liposuction: The Franco-American Experience. Beverly Hills, CA, Medical Aesthetics, 1985, pp. 365–414. 20. Illouz YG. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 21. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosm Surg 1987;4:111–121. 22. Campbell GL, Laudenslager N, Newman J. The effect of mechanical stress on adipocyte morphology and metabolism. Am J Cosm Surg 1987;4:89–94. 23. Johnson GW. Body contouring by macroinjection of autogenous fat. Am J Cosm Surg 1987;4(2):103–109. 24. Agris J. Autologous fat transplantation: A 3-year study. Am J Cosm Surg 1987;4(2):95–102.

9 25. Bircoll M. Autologous fat transplantation: An evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosm Surg 1988;5(4) 283–288. 26. ASPRS Ad-Hoc Committee on new Procedures: Report on Autologous fat transplantation. Plast Surg Nurs 1987 Winter; 7(4):140–141. 27. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18(4):233–250. 28. Billings E Jr, May JW. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381. 29. Markman B. Anatomy and physiology of adipose tissue. Clin Plast Surg 1989;16(2):235–244. 30. Illouz YG. Fat injection: A four year clinical trial. In Hetter GP (ed), Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy, Second Edition, Boston, Little Brown, 1990, pp. 239–246. 31. Hudson DA, Lambert EV, Block CE. Site selection for fat autotransplantation: Some observations. Aesthetic Plast Surg 1990;14(3):195–197. 32. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argernt LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386. 33. Kononas TC, Bucky LP, Hurley C, May JW Jr. The fate of suctioned and surgically removed fat after reimplantation for soft-tissue augmentation. A volume and histologic study in the rabbit. Plast Reconstr Surg 1993;91(5):763–768. 34. Ersek RA. Transplantation of purified autologous fat: A 3-year follow-up is disappointing. Plast Reconstr Surg 1991;87(2):219–227. 35. Courtiss EH, Choucair RJ, Donelan MB. Large-volume suction lipectomy: An analysis of 108 patients. Plast Reconstr Surg 1992;89(6):1068–1079. 36. Asaadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg 1993;91(4): 755–756. 37. Samdal F, Skolleborg KC, Berthelsen N. The effect of preoperative needle abrasion of the recipient on survival of autologous free fat grafts in rats. Scand J Reconstr hand Surg 1992;26(1):33–36. 38. Eppley BL, Sidner RA, Plastis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6):1022–1030. 39. Carpaneda CA, Ribeiro MT. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17(1):43–47. 40. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 41. Niechajev I, Sevchuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 42. Courtiss EH. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg 1994;94:137–138; discussion 137–138. 43. Fagrell D, Eneström S, Berggren A, Kniola B. Fat cylinder transplantation: An experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996; 98(1):90–96.

10 44. Jones JK, Lyles ME. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosm Surg 1997; 14:275–279. 45. Coleman SR. Long-term survival of fat transplants: Con­ trolled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425.

M. A. Shiffman 46. Sattler G, Sommer B. Liporecycling: Immediate and delayed. Am J Cosm Surg 1997;14:311–316. 47. Ullmann Y, Hyams M, Ramon Y, Beach D, Peled IJ, Linderbaum ES. Enhancing the survival of aspirated human fat injected into mice. Plast Reconstr Surg 1998; 101(7): 1940–1944.

Principles of Autologous Fat Transplantation Melvin A. Shiffman

3.1  Introduction The introduction of liposuction for fat reduction and body contouring has developed into transplantation of the extracted fat for augmentation of defects or for cosmetic purposes. There has been a controversy concerning the manner of collecting, injecting, and cleansing the fat and the effectiveness of the fat transfer. Some physicians have been disappointed with the long-term results of fat transplantation. The process of fat transplantation has not yet been standardized, and there is a need to analyze some of the methods and results.

3.2  Fat Transplant Survival Vitamin E is a necessary factor in the maintenance of fat tissue (1) while insulin increases the metabolic activity of fat cells (2) and retards lipolysis (3–7). Hiragun et al. (8) theorized that insulin may induce fibroblasts to pick up lipid lost from lipolysis and become adipocytes. Skouge (3) felt that fat cells from an area of ­relatively poor vascularity will be more hardy, have decreased metabolic needs, and increase survival. Asken (9), however, stated that the more fibrous areas, such as upper abdomen, are not ideal for donor sites. Fat characteristics may be helpful in determining which area of fat is more likely to be retained. The adipocytes with alpha 2 receptors are antilipolytic with poor response to diet and appear more likely to survive with

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

little change from weight loss or weight gain in comparison with adipocytes with beta 1 receptors (Table 3.1). Survival of adipocytes depends on the instrumentation used for harvesting and injecting the fat. Damage is inversely related to the diameter of the instrument to extract and inject fat (10). The pressure generated in injecting fat increases as a function of decreasing needle diameter (from 16 to 22 gauge) (11). There is some decrease in the metabolic activity of fragments that are passed through 20-gauge needles or smaller (Table 3.2). However, the size of the extracted particles is not de­­ scribed. If the extraction of fat is with a cannula that is 20 gauge, it is doubtful that the 20-gauge needle would cause damage to the adipocytes. The presence of blood in the fat injected stimulates macrophage activity to remove the cells. Washing the cells in a physiologic solution prior to injection will solve the problem (12–14). Skouge (3) raised the question of whether washing decreases the viability of fragile adipocytes. Campbell et al. (11) concluded that adipocyte integrity and metabolism of fat fragments subjected to mechanical manipulation by liposuction using wall suction remain intact. Illouz (12) biopsied the areas of fat injection and found normal fat cells. McCurdy (15) analyzed fat cell survival and concluded that the technical factors to accomplish the goal of 40–50% transplanted adipocyte survival include: 1. Low vascularity of donor site 2. High vascularity for recipient site 3. Low pressure technique of aspiration of fat 4. Filtering and washing harvested adipocytes 5. Use of ³2 mm cannula for injection to minimize adipocyte injury 6. Multilayered deposition of fat 7. Overcorrection of the recipient site

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

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M. A. Shiffman

Table 3.1  Fat characteristics (8) Lipolysis Response to diet Region of fat

Alpha 2 receptors

Beta 1 receptors

Antilypolytic Poor Abdominal, trochanteric (genetic fat)

Lipolytic Good Facial, arms, upper torso

Berdeguer (23): Clinical indications for fat trans­ plantation

Table 3.2  Needle size and cell survival (11) Needle gauge Pad integrity Cell morphology Nuclear morphology Fat globule

16

18

20

22

+ + + +

o + + +

− o o +

− − +

+ = 75% or more without cell damage o = 25–75% cell damage − = >75% cell damage

Because of the problem of resorption of fat with fat transplantation, 30–50% overinjection is ordinarily used (16–21). Asadi and Haramis (16) determined that subdermal injection is important for long-term results.

3.3  Indications for Fat Transplantation There have been two papers that relate to the indications for autologous fat transplantation. Skouge (22): Indications for fat transplantation • Facial −− Aging changes −− Melolabial grooves −− Central cheek depressions −− Subcommissural depressions −− Flattened upper lip −− Glabella −− Diffuse age-related lipoatrophy • Cosmetic −− Lip augmentation −− Chin augmentation −− Malar augmentation • Scars −− Traumatic −− Lipoatrophy, acne −− Idiopathic lipodystrophy −− Facial hemiatrophy

• Nonfacial −− Rejuvenation of the hands −− Body contour defects −− Depressions, liposuction induced −− Breast enlargement −− Traumatic scars

(a)  Depressed scars – face and body 1.  Postsurgical 2.  Posttraumatic (b)  Aging skin with loss of supportive tissue 1.  Glabellar furrows 2.  Upper lip 3.  Melolabial folds 4.  Hollow cheeks 5.  Dorsal hands (c)  Aesthetic enhancement 1.  Cheek augmentation 2.  Chin augmentation 3.  Breast augmentation 4.  Leg contour surgery (d)  Congenital defects 1.  Hemifacial atrophy 2.  Soft-tissue defects of the body In analyzing these lists, a simpler and more useful classification can be devised: Indications (Shiffman) 1. Fill defects (a)  Congenital (b)  Traumatic (c)  Disease (acne) (d)  Iatrogenic 2. Cosmetic (a)  Furrows (wrinkles) (b)  Refill Lost Supportive Tissue (aging) (c)  Enhancement 3. Non cosmetic (a) Migraine headaches, clival chordoma surgery, congenital short palate, vocal cord paralysis, lumbar laminectomy, sulcus vocalis, vocal cord scar, hemifacial atrophy, myringoplasty, eye socket recon­struction, frontal sinus fracture, temporomandibular joint reconstruction). Some of these procedures need fat transfer to prevent scarring.

3  Principles of Autologous Fat Transplantation

3.4 Complications of Fat Transplantation Injection of small globules will prevent cyst formation. Johnson (24) showed that one, three, and five cc injections resulted in small cysts, but 10 cc injection had macroscopic cyst formation. Oil cysts develop through the confluence of necrotic fat cells having a lining of macrophages, and resorption may take years, thus giving a false impression of a successful transplantation (25). Sterility of fat retrieval and injection must be maintained. Infection has not been reported (22). Bruising, temporary swelling, and tenderness may result from fat transplantation (22). Teimourian (26) reported that a patient upon injection of fat into the glabellar frown lines complained of pain and loss of vision in one eye. There was central retinal artery thrombosis, probably secondary to fat particle embolism. Calcifications have only been reported in fat transplantation to the breast for augmentation. This does not appear to be a significant risk since the timing of the appearance, the position, and the character of the calcifications will indicate the etiology. The most important problem encountered is fat resorption. Trauma to the cells, desiccation during transfer, and the presence of blood are contributing factors. At least an 18-gauge needle should be used to reinject fat. Ersek (27) reported that very little autologous fat survives but his use of a whisk in the cleansing process probably destroyed most of the fat cells.

3.5 Technique of Autologous Fat Transplantation The lack of standardization of fat collection and transplantation allows a wide range of methods with varied results. Following are methods utilized by certain cosmetic surgeons, which the author obtained by personal commu­ nication: Billie (28) “I do have patients whose cases go back to over 10 years, at this point. I have had good fortune over all

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with non-smokers and actually a moderate amount of success among smokers. I have found that the younger the patients are, the better they seem to do. We placed it at multiple sites, including defects in legs from traumatic events such as automobile accidents or recluse spider bites, the nasal labial furrows in aging patients. Over the years, I have washed the fat, sometimes not washed the fat, added insulin, sometimes not added insulin, tried everything and currently even utilizing a 4-mm cannula to remove the fat, catching it in the sterile in-line trap, not washing it and reapplying it utilizing a 16-gauge fat grafting needle with a 10-mL syringe apparatus.” Fragen (29) “I have found that autologous fat transplantation is a very effective part of my facial rejuvenation surgery, provided I give the patients a detailed explanation of the limited nature of the procedure and the fact that it is always somewhat temporary. Depending on the patient and the location to where the fat is transferred, the fat survives for a variable period. I have found that transferring fat under skin grafts, scars, and on top of semirigid or rigid surfaces improves the viability of the fat transfer. For example, if one transfers fat under the skin post mastectomy, it seems to stay there and offers some padding. Putting it under burn scars will help increase the padding of the burn scar and make the skin grafts over it more pliable and flexible. If fat is transferred to a lip, it seems to survive there the least, because of the active nature of the lip. My method of transfer is very simple. I like to call it a closed system. Essentially what is done is the area for fat harvesting is prepped and draped and infiltrated with a Klein solution. The fat is then harvested with a 14-gauge blunt cannula on a 10-cc syringe. If there appears to be excess saline, the excess saline is decanted. If there is excess bloody tissue, then the specimen is washed in saline and again decanted. If, as is usual, essentially pure fat is removed from the donor site, then it is maintained within the syringe with the blunt 14-gauge cannula. A small stab incision is made near the site for fat transfer, and the blunt cannula is then placed into the donor area. Several tunnels are made with the blunt cannula so that the fat is not squeezed into the area, but rather easily injected into the donor site. Then, the fat is transferred to the donor site. Both sites are prepared sterilely. If the patient is under general anesthesia then usually no anesthesia is used for the recipient site. If

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this is done under local anesthesia, a small amount of 1% Xylocaine with adrenaline is infiltrated into either the lips or the glabella or whatever site we are transferring the fat to. I usually over-fill the graft site by approximately 50%, and I tell patients that the swelling will last 3–5 days. I routinely do fat transferring on face lift patients. I do somewhere around ten or more face lifts per month, and I would guess that 80% of those have a fat transfer associated with it. Untoward effects include bruising, short-term swelling, occasional lumpiness, and stimulation of fever blisters. The lumping has never been a problem, in that the fat can easily be compressed, even months later. Once a patient had a small fat cyst that was easily removed. It is my feeling that fat injected into the lower portion of the nasolabial fold, the lips, and the droll lines has a relatively short life span, with the ideal results being reached in approximately 2 weeks and slow disappearance over 2–4 months. In the glabella, I believe the fat will last six to more months and, in many cases, over a year. I think the area nearer the nose in the nasolabial fold will retain fat a little better. In that area also the fat will last 6–8 months. Fat injected under graft sites, scars, and over other hard prominences I think lasts for many months and I have several cases where the fat has lasted several years. The primary advantage of fat transfer is that it can very effectively camouflage cosmetic defects (such as thin upper lips with wrinkling, glabellar frown lines, drool line, etc) which are difficult to correct without other extensive procedures. In Palm Springs, we find many people who do not want to restrict their outdoor activities, such as tennis and golf. These patients accept the safe, though temporary, correction by fat transfer. Their biggest complaint is that the wonderful result they get is short-lived, but, until we find a safe, nonresorbable filler which the FDA will approve, we do not have a better alternative.” Tobin (30) “About 10 years ago, when liposuction surgery was first introduced, we began hearing recommendations for re-injection of fat. My initial experience with this procedure was to attempt to refine breast reconstruction cases by injecting small amounts of fat adjacent to implants or in patients on whom other surgeons had carried out flap reconstructions. We initially harvested the fat with a syringe and reinjected it using an old, mechanical injector that was designed initially to inject

M. A. Shiffman

Teflon into the vocal cords. In essence, we were injecting it through an 18-gauge needle with a very precise ratchet mechanism. The results were discouraging with rapid re-absorption. We felt that perhaps this was related to the fact that we were injecting into a scarred area. At about the same time, we began injecting fat into the face. My first experience with this procedure was to attempt to correct grooving in the cheeks that was caused by facial liposuction. We did not understand the risks that were involved when liposuction was carried out in this area. Many of us ended up with patients who had irregularities or waviness. Again, we used the same technique – namely aspiration with a syringe and re-injection through the Teflon gun. Again, the results were discouraging. Because of these failures, we essentially abandoned the technique. Sometime later, we heard about successes with injection of fat into the back of the hand and we attempted a few cases. By this time, we had stopped using the Teflon gun and were simply aspirating the fat with the syringe and transferring it to smaller syringes through a small transfer tube after which the fat was injected into the back of the hand. Our technique included aspiration of fat with a syringe, rinsing and straining with saline and then re-injection. Again, both we and our patients were disappointed with the results. About 3 years ago, after hearing of successes with the injection of separated fat, we were tempted to try again. Several surgeons had various techniques of morselizing the fat and injecting the fibrous portion. Often, this material was called autologous collagen, although I am not aware of any confirmation that the material was in any way similar to the bovine collagen that had become so popular under the trade name Zyderm. We utilized the technique recommended by Hilton Becker of Palm Beach. Kits were available which included syringes for transferring the material through a progressively smaller orifice. This resulted in the morse­lization of the material. Following this, the material was centrifuged and the collagenous component was obtained to be used for re-injection. The material was supposedly capable of being preserved by freezing and we attempted this as well. We probably treated about 25 patients with this process, carrying out multiple injections over a period of several months. As far as I can remember, we did not have even a single patient who was really pleased with the results and we have since then abandoned it.

3  Principles of Autologous Fat Transplantation

At present, our use of injectable fat is uncommon. When patients request for it, we explain the fact that the previous experiences have not been very positive, but we do offer it as an option. Occasionally, patients request it but once again, I have not seen any convincing evidence that there is any permanent augmentation. Obviously, I am perplexed by the reports and the literature by reputable surgeons who claim they see permanent results. Until I see a series of consecutive cases presented over a relatively long period of time, I will remain unconvinced but will attempt to be open minded.”

3.6  Insulin Some physicians have added insulin to the fat in preparation for transplantation (12, 31, 32). The theory is that insulin inhibits lipolysis. Sidman (33) found that insulin decreases lipolysis. Hiragun et al. (34) stated that theoretically insulin may induce fibroblasts to pick up the lipid lost and become adipocytes. Chajchir et al. (35) found that the use of insulin did not show any positive effect on adipocyte survival during transplantation compared to fat not prepared with insulin.

3.7  Centrifugation Some physicians centrifuge the adipose tissue to remove blood products and free lipids to improve the quality of the fat to be injected (31, 36, 37). Asken (9) stated that his “method of reducing the material to be injected to practically pure fat is to place the fat-filled syringe with a rubber cap (the plunger having been previously removed and kept in a sterile environment) into a centrifuge. The syringe is then spun for a few seconds at the desired rpm and the serum, blood, and liquefied fat collects in the dependent part of the syringe…” Toledo (36) reported that “for facial injection we spin the full syringes for 1 min… in a manual centrifuge (about 2,000 rpm), eject the unwanted solution, and transfer the fat…”

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Uebel (38) centrifuged autologous fat at 10,000 rpm for 10 min in order to obtain a “fat-collagen graft.” The centrifuged material on histologic examination showed cell residues, collagen fibers, and 5% intact fat cells. The material is absorbed at a slow rate and maintains the contour and volume for 18–24 months. A new graft procedure is always performed to achieve a more permanent result. Chajchir et al. (35) centrifuged 1 cc of bladder fat pad from mince (both at 1,000 rpm for 5 min and 5,000 rpm for 5 min) and injected it into the malar area subdermis. Microscopically, after 1–2 months there were macrophages filled with lipid droplets, giant cells, focal necrosis of adipocytes, and cyst like cavities of irregular size and shapes. After 112 months following injection no recognized adipocytes could be found. Total cellular damage was present in both groups. Brandow and Newman (39) found that centrifugation of harvested fat did not alter the microscopic structured integrity of cells. Spun and unspun samples were examined and were similar. Fulton et al. (40) found that centrifuged fat, 3 min at 3,400 rpm, works well for small volume transfers, but not for large volume transfers into breasts, biceps, or buttocks.

3.8  Ratchet Gun for Injection Neuman and Levin (41) designed a lipo-injector with gear driven plunger to inject fat tissue evenly into desired sites. Fat injected with excessive pressure in the barrel of a syringe can cause sudden injections of undesired quantities of fat which will pour into recipient sites. Agris (42) stated that a ratchet-type gun allows controlled accurate deposition of autologous fat. Each time the trigger is pulled, 0.1 cc is deposited. Neichajev (43) used a ratchet gun for free transplantation of fat harvested at −0.5 atm. pressure. EH noted only partial resorption of the fat but with significant improvement of the contour. Asadi and Haramis (44) described the use of a gun with disposable 10 mL syringe for fat injection. Niechajev and Sevc´uk (45) utilized a special pistol and a blunt typed cannula, with 2.3 mm internal diameter, to inject the fat. Berdeguer (23) used a lipotransplant gun to inject fat into areas to be enhanced.

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Fulton et  al. (40) stated that it is beneficial for a beginning surgeon i.e., a fresher to use a ratcheted pistol for injection as this gives a more uniform injection volume.

3.9  Severing Tethering Bands Several surgeons have suggested severing of tethering bands, usually with a needle, paddle shaped, or V shaped (“pickle-fork”) typed instrument, to allow the skin to lift more easily with injection of fat (36, 46–48). Recurrence of depressions was thought to be less likely.

3.10  Machine Liposuction “Liposuction harvesting of fat is traumatic and results in a graft composed of intact cells combined with cellular debris and free lipid” (49). Liposuction removal of autologous fat by −1 atm. suction was reported by Nguyen et al. (50) as showing microscopically 90% elongated, irregularly shaped, and ruptured adipocytes and only 10% unchanged, normal-appearing adipocytes. With the use of a 10-ml syringe for aspiration of fat, they found 95% unchanged adipocytes. May (51), in commenting of Nguyen’s study stated that “…one would have thought that aspiration could produce nearly the same degree of suction (1 atm.) as formal suctioning. If the degrees of negative pressure produced by these two techniques are similar, and if the cannulas are similar then the degree of cell damage should have been similar.” Niechajev (43) obtained fat for grafting using a vacuum pump with –0.5 atm. pressure. Using a ratchet gun for injection into the cheek, he noted only partial resorption of the fat over 1½–4 years (mean 3 years). Niechajev and Sevc´uk (45) reported 50% fat survival over 3.5 years after single fat transplantation with 50% overcorrection. They found that fat obtained under maximum negative pressure (–0.95 atm.) results in partial breakage and vaporization of the fatty tissue. About two-thirds of the fat withstood the trauma of aspiration. Low pressure (–0.5 atm.) results in smaller cell size (29% smaller than with aspiration at –0.95% atm.) and assumed that high pressure causes mechanical distention of the adipocytes which increases the risk of and sometimes causes cell breakage.

M. A. Shiffman

Elam et al. (52) noted more effective fat removal by lowering the negative suction pressure during liposuction. Negative pressures varied from 15 in. of mercury (–375 mm mercury) to 30 in. (–750 mm) (–760 mm = 1 atm.). Above 25 in. of mercury (–625 mm) an obvious amount of blood appears in the aspiration along with air bubbles. At maximum vacuum (–750 mm) the aspirate is a blood-tinged mixture of fatty globules with significant amounts of dark venous blood. The ideal liposuction vacuum pressure at sea level was felt to be a negative 20 in. of mercury (–500 mm).

3.11  Specific Principles Regional block is better than local anesthesia to prevent destruction of injected fat cells by local anesthetic in the region of the fat transfer. If local anesthesia is used, compress the area for 15 min to reduce swelling and distortion of the area prior to injection. Injection should be on withdrawing the needle to prevent accidental injection into vessels and over injection into an area that is fibrous causing resistance to the cannula insertion. Sharp needles should not be used to inject fat into the recipient site. Recently, small cannulas have been devised with relatively blunt tips that can be used for reinjection without the problem of bleeding in the recipient area. Blood in the donor fat should be removed by decanting with physiologic solution. Blood, as is infection, is the enemy of fat and will result in a major loss of the transferred fat.

References   1. Meschik Z. Vitamin E and adipose tissue. Edinburgh Med J 1944;51:486.   2. Katoes AS Jr, et  al. Perfused fat cells: effects of lipolytic agents. J Biol Chem 1933;248:5089.   3. Skouge J.W. Autologous fat transplantation in facial surgery. Presented at American Academy of Cosmetic Surgery: Controversies in Breast and Facial Augmentation, Phila­ delphia, PA, 7–9 Aug 1992.   4. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anal Rec 1956;124(4):723–739.   5. Smith U. Human adipose tissue in culture studies on the metabolic effect of insulin. Diabetologia 1976;12(2):137–143.   6. Solomon SS. Comparative studies of the antilipolytic effect of insulin and adenosine in the perfused fat cell. Horm Metab Res 1980;12(11):601–604.

3  Principles of Autologous Fat Transplantation   7. Solomon SS, Duckworth WC. Effect of antecedent hormone administration on lipolysis in the perfused isolated fat cell. J Lab Clin Med 1976;88(6):984–994.   8. Hiragun A, Sato M, Mitsui H. Establishment of a clonal cell line that differentiates into adipose cells in vitro. In Vitro 1980;16(8):685–693.   9. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosmet Surg 1987;4(2):111–121. 10. Dolsky RL. Adipocyte survival. Presented at the Third Annual Scientific Meeting of the American Academy of Cosmetic Surgery and The American Society of LipoSuction Surgery, Los Angeles, February 1987. 11. Campbell GL, Laudenslager N, Newman J. The effect of mechanical stress on adipocyte morphology and metabolism. Am J Cosmet Surg 1987; 4(2):89–94. 12. Illouz YG. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 13. Krulig E. Lipo-injection. Am J Cosmet Surg 1987;4(2): 123–129. 14. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg 1992;16(3):247–250. 15. McCurdy JA, Jr. Five years of experience using fat for leg contouring (Commentary). Am J Cosmet Surg 1995;12(3):228. 16. Asadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg 1993;91(4): 755–756. 17. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesthetic Plast Surg 1986;10(2): 115–117. 18. Chajchir A, Benzaquen I. Fat-grafting injection for soft tissue augmentation. Plast Reconstr Surg 1989;84(6):921–934.. 19. Chiu DT, Edgerton BW. Repair and grafting of dermis, fat, and fascia. In: McCarthy, J (ed), Plastic Surgery. Philadelphia, W.B. Saunders, 1990, p. 515. 20. Illouz YG. De l’utilization de la graisse aspiree pour combler les defects cutanes. Rev Chir Esthet Langue Fr 1985; 10(40):13. 21. Matsudo PK, Toledo LS. Experience of injected fat grafting. Aesthetic Plast Surg 1988;12(1):35–38. 22. Skouge J. The effectiveness and long term survival of transplanted fat. Presented at American Academy of Cosmetic Surgery, Philadelphia, 7–9 Aug 1992. 23. Berdeguer P. Five years of experience using fat for leg contouring. Am J Cosmet Surg 1995;12(3):221–229. 24. Johnson GW. Body contouring by macroinjection of autogenous fat. Am J Cosmet Surg 1987;4(2):103–109. 25. Smahel J. Fat cylinder transplantation: An experimental study of three different kinds of fat transplants. Plast Reconstr Surg 1996;98(1):97–98. 26. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361. 27. Ersek RA. Transplantation of purified autologous fat: A 3-year follow-up is disappointing. Plast Reconstr Surg 1991; 87(2):219–227. 28. Billie JD. Autologous fat transplantation. Personal Commu­ nication 3/6/96. 29. Fragen R. Autologous fat transplantation. Personal communication 3/19/96. 30. Tobin H. Fat transfer. Personal communication 3//5/96.

17 31. Ellenbogen R. Free autogenous pearl fat grafts in the face – A preliminary report of a rediscovered technique. Ann Plast Surg 1986;16(3):179–194. 32. Newman J. Preliminary report on “fat recycling” – Liposuction fat transfer for facial defects. Am J Cosmet Surg 1986;3: 67–69. 33. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anat Rec 1956;124(4):723–739. 34. Hiragun A, Sato M, Mitsui H. Establishment of a clonal line that differentiated into adipose cells in vitro. In Vitro 1980;16(8):685–693. 35. Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg 1993;17(2):113–115. 36. Toledo LS. Syringe liposculpture: A two-year experience. Aesthetic Plast Surg 1991;15(4):321–326. 37. Zocchi M. Produccion y utilizacion de Colegeno Autologo para el remodelaje facial. II Congreso Chileno de Cirugia Plastica, 1991. 38. Uebel CO. Facial sculpture with centrifuged fat-collagen. In: Hinderer VT (ed), Plastic Surgery, Vol. II. Amsterdam, Excerpta Medica, 1992, pp. 749–752. 39. Brandow K, Newman J. Facial multilayered micro lipo-­ augmentation. Int J Aesth Restor Surg 1996;4(2):95–110. 40. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865. 41. Newman J, Levin J. Facial lipo-transplant surgery. Am J Cosmet Surg 1987;4(2):131–140. 42. Agris J. Autologous fat transplantation: A 3-year study. Am J Cosmet Surg 1987;4(2):95–102. 43. Niechajev I. Autologous transplantation of fat (lipo-filling) for the improvement of the cheek contour, long-term results. In: Hinderer VT (ed), Plastic Surgery, Vol. II. Amsterdam, Excerpta Medica, 1992, pp. 747–748. 44. Asaadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg 1993;91(4):755–756. 45. Niechajev I, Sevc´uk O. Long term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 46. Fournier PF. Liposculpture: The Syringe Technique. Paris, Arnette, 1991. 47. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg 1992;16(2):141–153. 48. Grazer FM. Cellulite lysing. Aesth Surg 1991;11:11. 49. Eppley BL, Sidner RA, Platis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6):1022–1030. 50. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386. 51. May JW Jr. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques (Discussion). Plast Reconstr Surg 1990;85(3):387–389. 52. Elam MV, Packer D, Schwab J. Reduced negative pressure liposuction (RNPL): Could less be more? Int J Aesth Restor Surg 1997;5:101–104.

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

4.1  Introduction With an understanding of the subcutaneous fat anatomy, physiology, and metabolism/nutrition, the surgeon can gain familiarity with the interrelationship between these three aspects of subcutaneous fat as they relate to adipocyte mass, appearance, and liposculpture. With this knowledge, the surgeon should gain a deeper understanding of the impact of the surgical procedure that may lead to improved results following fat transfer. An appreciation of the importance of interstitial soluble protein is crucial because Klein’s solution dramatically dilutes its content and predictably, causes a temporarily pseudo-leaky membrane in that region. Using excess Klein’s solution can produce symptoms of acute congestive heart failure. When administered properly, Klein’s solution is safe in which the total body’s soluble protein reserve will re-equilibrate over a relatively short period of time. Until recently, the study of the lowly lipocyte was considered boring and therefore limited. Fat was viewed as an adynamic tissue that stored energy, improved insulation, and functioned as a shock absorber. The differences in fat distribution between the sexes are well recognized and have been the subject of discussion as well as artful renderings. Removal of fat by liposuction was thought the end of the line, producing a localized permanent reduction in number; however, nothing could be further from the truth. Adult stem cells are abundant within the fat mass, and in the face of excess calorie consumption, these stem cells

M. V. Kaminski () Finch University of Health Sciences, Chicago Medical School, 230 Center Drive, Vernon Hill, Chicago, IL 60061-1584, USA e-mail: [email protected]

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

4.2  Histology Fibroblast appearing preadipocytes are noted in the embryo as well as in adult subcutaneous fat tissue. The ultimate shape of a fat-laden mature adipocyte is that of a cygnet ring as the central lipid accumulation pushes the nucleolus to the periphery (Fig. 4.1). The fibroblast appearing preadipocyte is pluripotential. During calorie deprivation fat cells can also dedifferentiate back into the fibroblast appearance. The adult stem cell within the fat tissue has been stimulated to form muscle and bone.

Fig. 4.1  A spread preparation using Fankels combined orcein connective tissue stain that reveals rich microvasculature and adipocytes packed against each other. Ad adipocyte; C collagen; E elastin

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_4, © Springer-Verlag Berlin Heidelberg 2010

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Every lipocyte is surrounded by or touching a capillary (Fig. 4.1). These capillaries are highly sensitive to epinephrine that causes vasoconstriction. This is a phenomenon associated with Klein’s tumescent anesthesia that has made office-based liposuction a relatively nonbloody procedure, and safe outside of the hospital setting. No other additive in Klein’s formula is as important. This surgeon uses 2 mg of epinephrine per 1,000 mL of crystalloid rather than the recommended 1 mg. Total amount of tumescent solution with 2 mg of epinephrine per liter should be limited to 3 L or less per procedure.

4.3  The Interstitium The connective tissue of the interstitium is host to myriad cell types, including fibroblasts, adipocytes, macrophages (histiocytes), neutrophils, eosinophils, lymphocytes, plasma cells, mast cells, monocytes, and undifferentiated mesenchymal cells. These cells, either fixed or transient, interact with each other and the extracellular matrix components (i.e., collagen, elastic fibers, adhesion glycoproteins) and as mentioned a substantial amounts of soluble protein (1, 2). Within this integrated gel-sol assemblage are the vital components of the vasculature, initial lymphatics, and nervous system (lightly myelinated fibers to free nerve endings, myelinated fibers to encapsulated neural structures). The importance of the vasculature and lymphatics in maintaining homeostasis of protein and fluid concentration of the blood and interstitium is well documented and cannot be overstated. The neural components at a single anatomic site, although perhaps not vital, provide for the general sense of well-being. The presence of the above constituents within the interstitium, however, cannot be overlooked and may represent the seed medium for the growth of normal adipose tissue. Considering the cell biology of the anatomic site, liposuction procedures are traumatic, albeit transient, events. Even with the most careful technique, the architecture and physiology are altered dramatically, which sets in motion a cascade of systemic and cytokinemediated cellular responses. Providing a unified concept on the restructuring of this anatomic site after traumatic events is a challenge that needs to be met. The inventory of the components of the interstitium and how they interact is far from complete. Current techniques yield a heterogeneous material composed of liberated fat, locules of adipose cells, collagen fibers and septa, vessels and nerves, clots, ruptured

M. V. Kaminski and R. M. Lopez de Vaughan

cells, hemoglobin, inflammatory proteins, proteases, lipogenic enzymes, and electrolytes including calcium (3). Weber et al. (4) developed a concept of extracellular homeostasis. This concept is one of self-regulation of cellular composition and structure based on fibroblastderived angiotensin that regulates the elaboration of trans­forming growth factor-1. This is a fibrogenic cyto­ kine responsible for connective tissue formation at normal and pathologic sites. Biologic responses are found in various connective tissues, including adipose tissue. Given that the three-dimensional architecture is altered profoundly, it is astonishing that it can be reconstituted to normalcy in a relatively short period of time. Lipocytes are not islands unto themselves. They are surrounded by a sea of supportive cells, proteins, growth factors and electrolytes.

4.4  Physiology For the most part, the adipocytes are not rounded, bloated spheres. They have one or more flattened sides and are better described as polygonal and appear packed between the vasculature. This is because they are compressed by colloid osmotic pressure, which is generated by soluble protein in the interstitial space. Under these conditions, the cells are like peanuts sealed by vacuum in a bag. The interstitial proteins that surround cells create −7 mmHg pressure (5). Interstitial protein is reported as total protein (TP) when measured by a laboratory. Its three components are albumin, globulin, and fibrinogen. Albumin is the principle soluble protein and makes up at least 60% of TP (6). Because albumin is the smallest molecule that cannot pass easily through the semi permeable membrane of the capillary, it contributes most of the oncotic force, squeezing cells together. The number of particles in solution on one side of a semi permeable membrane, not their size, creates an oncotic force. To be specific, albumin is 69,000 Daltons (Da), whereas globulin is 150,000 Da, and fibrinogen is 400,000 Da. Thus, one gram of albumin has twice as many molecules as 1gram of globulin, and eight times that of 1 g of fibrinogen. To understand that this is oncotic pressure and not osmotic pressure, one should recall that if the particle in solution can pass back and forth across the semi permeable membrane, it cannot create an oncotic force. For example, if a glass funnel is covered with a semi permeable membrane whose pore size allows water, sodium,

4  The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition

and chloride to pass but not sucrose, and if that funnel is then partially filled with a sugar and salt water solution and placed upside down in a beaker of fresh water, after a period of time the sugar molecules on the funnel side of the membrane are responsible for drawing fluid into it. Because sodium and chloride easily traverse the membrane, they cannot create an oncotic force and will distribute equally on both sides of the membrane. In vivo, soluble proteins that surround adipocytes are dynamic. Even if it be slow, albumin molecules make a circuit from the heart across the capillary membrane through the interstitial space and return to the heart by way of lymphatic flow within 24–48 h.

4.5  Gross Anatomy There are three layer of subcutaneous fat: the apical, the mantle, and deep layers.

4.5.1  Apical Layer This layer, just beneath the reticular dermis (Fig. 4.2) is also called thecal or periadnexal layer in that it surrounds sweat glands and hair follicles.

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Slightly deeper, the apical layer also surrounds vascular and lymphatic channels. Depending on the quantity and depth of color of fruits and veggies in the diet this layer is rich in carotenoids and tends to be yellow in appearance. Because of the neural, vascular and lym­ phatic potential for damage this layer should be avoided during liposuction. Extensive disruption of these anatomical elements can lead to seroma, erythema, hyperpigmentation and even full thickness dermal necrosis. This was more of a problem in the past when larger diameter 8 and 10 mm cannulas were directed at the deep fat layer, but these complications have become rare in this era of 2 and 3 mm cannulas.

4.5.2  Mantle Layer Just beneath the adipocytes’ investing dermal structures is another anatomically organized layer of fat cells that is part of the superficial fat layer. It is called the mantle layer and is composed of more columnar shaped lipocytes. It is separated from the deep layer of fat by a fascia-like layer of fibrous tissue. The mantle is absent from the eyelids, nail beds, bridge of the nose and penis. This layer significantly contributes to the skin’s ability to resist trauma. It causes external pressure to be distributed across a larger field; much like a box spring mattress absorbs sitting pressure.

4.5.3  Deep Layer

Fig. 4.2  The general lipocyte distribution from the dermis to the muscular fascia. The apical and mantle layers represent the “no man’s zone” of liposuction. Damage to these layers may compromise the blood supply to the skin and predispose to postoperative complication such as seroma or dermal necrosis

This layer extends from the undersurface of the mantle layer to the muscle fascia below. Its shape and thickness depends on the sex, genes, and diet of the individual. This is the layer best suited for liposculpture. Here fat cells are arranged in pearls and pearls gathered into globules. These globules are then packaged like eggs in an egg crate between fibrous septa and then arranged between tangential and oblique fibrous planes. Histologically tangential planes are thicker and run parallel to the underlying muscle fascia, but they are of little consequence when performing liposuction. Oblique planes are thinner and interconnect the tangential fibrous layers. They hold fat globules in their

22

Fig. 4.3  Submantle fat is amenable to standard liposuction technique using very small canuulas. Removal of the buccal fat requires an intra-oral incision just lateral to the second molar

M. V. Kaminski and R. M. Lopez de Vaughan

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

relative positions. Though thinner, they are of a cosmetic consequence because the vertical arrangement of subcutaneous fat from skin to muscle fascia is the cause of cellulite.

4.6  Deep Fat of the Neck A wattle is produce by accumulation of excess of fat between platysma and the superficial layer of the deep cervical fascia and is superficial to the anterior bellies of the digastric muscles (Fig. 4.3). The fat immediately beneath the platysma is amenable to liposuction. How­ ever, the fat between the digastric muscles and beneath the superficial layer of the deep, or the investing fascia of the neck should not be removed. Doing so may result in a permanent depression. The buccal fat pad accounts for the chipmunk fascial features noted in some families. It extends anterior to the mandibular ramus into the cheek, deep into the subcutaneous musculoaponeurotic system (SMAS) buccinators. The buccal branch of C7 courses over and just lateral to the buccal fat pad.

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

brachioplasty. Loose skin of the posterior arm shrinks poorly. The patient who chooses liposuction without resection should understand that an excision may be required later. A middle aged to older individual who complains of loose skin following weight loss or due to senile laxity, will always require an excision of the redundant tissue. Preoperative notes should make clear the fact that these considerations were discussed in detail with the patient.

4.8  Abdomen 4.7  Upper Arm Fat Liposuction without brachioplasty is suitable for younger patients with minimal to moderate fat excess, who exhibit taut skin. It is generally limited to the posterior flap. This flap in layman’s terms produces a “kimono arm” deformity (Fig. 4.4). For the patient who is middle aged and has loose skin, liposuction may have to be accompanied by a

The subcutaneous fat of the abdominal wall is divided by two easily identifiable fascial layers: The superficial Campers fascia and the deeper Scarpas fascia. These layers are most easily observed in the lower abdomen. The deep fascia overlays the musculoaponeurosis and is continuous with the fascia lata of the thigh. It also covers the small arteries and veins along the surface of the anterior rectus sheath. Liposuction using small cannulas of 2–3.7 mm in diameter can be artfully performed

4  The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition

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

Fig. 4.5  The relationship of Camper’s fascia to Scarpa’s fascia. Scarpa’s fascia in the membranous layer of the subcutaneous tissue of the abdomen

between these fascial layers in the abdomen with impunity. However, care must be taken not to injure the vascular and lymphatic complexes within the mantle layer of fat just beneath the skin (Fig. 4.5).

4.9  Hips and Flanks

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

4.11  Lower Leg

In the area of the hips and flanks the subcutaneous fat is divided into two well-defined layers: the superficial and the deep. The superficial fascial system (SFS) encases the superficial fat. This fat is light yellow and dense, whereas the deeper fat is usually darker and less well structured. Zones of adherence are formed where the SFS connects to the underlying muscle fascia. The zones of adherence differ between men and women (Fig 4.6). In men, the attachment runs along the iliac crest, it confines the deep fat to the mid abdomen. The zone of

A subtle tapering from the thighs to the ankle is considered attractive. Thus, although a degree of fullness at the knee is normal it is usually identified as an area to be reduced during liposuction of the legs. The lateral knee should never be liposuctioned. It is also an area of insertion of thigh musculature (Fig. 4.8). No major arteries or nerves run within the subcutaneous fat. Rather, they run along or beneath the investing fascia of the superficial fat of the legs.

Fig. 4.6  The hip and flank region are distinctly male or female, specifically, the zones of adherence differ. Care should be taken to preserve these attachments during liposuction (after Pitman (7))

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

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M. V. Kaminski and R. M. Lopez de Vaughan

Fig. 4.8  The deep fat does not extend into the lower leg. Note the zone of adherence located at the lateral knee which has essential not fat (after Pitman (7))

4.12  Nutrition and Metabolism More often than not a patient will present with unwanted fatty deposits that are secondary to the over consumption of food. Stored fat is mobilized during calorie restriction through the activation of triglyceride lipase. Triglyceride lipase is a cyclic AMP dependant mobilizing enzyme. The hormonal signal to activate triglyceride lipase is glucagon and to some extent epinephrine. When the insulin glucagon ratio is in favor of insulin, fat cannot be mobilized. Insulin is secreted in response to circulating glucose levels. Thus, a meal that raises glucose will cause insulin secretion, the magnitude of which depends on the carbohydrate load and the refined vs. complex composition of the food consumed (Fig 4.9). Eating either fat or protein will not raise insulin. All fruits and veggies are predominantly carbohydrates. Fruits and veggies are complex carbohydrates which require more time to digest and absorb Compared to flour and sugar products which are refined carbohydrates. Regarding complex carbohydrates, the tighter the carbohydrates are configured the slower the digestion, absorption and the lower the maximum post parandial glucose will be. On the other hand, all refined carbohydrates such as sugar and flour products will dramatically elevate

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

blood glucose and insulin. It is therefore conceivable that someone who eats what he/she believes is a calorie restricted diet will never catabolize stored fat over a 24-h period. Such a diet might be a bagel and coffee for breakfast, a sweet roll at 10 a.m. on coffee break, a can of pop, a cheese sandwich for lunch, a pasta dinner, a soda pop with cake for dessert and fat free cookies while watching television. Even if small portions are chosen, the refined carbohydrate consumed will guarantee an elevated insulin throughout the day. The average soft drink contains more than nine packs of table sugar per can. Patients on this diet are perplexed by their inability to lose weight. When a physician tries to get refined carbohydates out of their diet it is not unusual for the patient to vigorously object because they claim that they suffer from hypoglycemia. They report that unless they are frequently treating themselves with refined carbohydrates they become severely symptomatic. They will complain of brain fog, tremor,

4  The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition

Blood glucose mg %

Pseudohypoglycemia 300

200 Symptomatic 115

Normal 75

Time

Fig. 4.10  The yo-yo hyperglycemia experienced by refined carb carboholics. It is the downward slope of the hyperglycemia curve that initiated the symptoms described as hypoglycemia by the patient. Note the blood sugar is never normal

and severe hunger pains which are quickly ameliorated by consumption of another form of a refined carbohydrate. Thus they are convinced that they are hypoglycemic or refined carbs would not treat their symptoms. The fact is that their blood sugar rapidly rises and then within 90–120 min begins to decline secondary to the insulin response. It is the downward slope of the serum glucose that triggers what they call a hypoglycemic episode. In fact their blood sugar remained above normal at all times (Fig. 4.10) (8). The potential for any given complex carbohydrate or refined carbohydrate to raise blood glucose in comparison to a 50-g dextrose meal is called the glycemic index (GI). All vegetables and fruits are complex carbohydrates but some have a higher GI then others. Keeping the GI below 55 for any given meal is recommended. The GI of anything made from flour or sugar is near 90 thus all baked goods and pasta should be avoided. Geletinization is a process that occurs during boiling where a complex carbohydrate vegetable with a low GI can be converted to a high GI food. During boiling gaps appear in the tight molecular structure that is quickly filled by a water molecule. This new configuration reduces the time of digestion increasing the rate of absorption and therefore increasing the GI. Over heating, especially over boiling is another consideration to be avoided in food preparation. Glycosolation refers to the combination of glucose and protein. This occurs naturally by simple contact. Neither heat nor an enzyme is necessary to create this

25

new molecule. Glycosolation irreparably damages the protein just as oxygen changes iron into rust. When the damaged glycosolated protein is replaced during a healing process as it floats free it is called a advanced glycosolation end (AGE) product. An AGE is recognized by the immune system as a foreign micro. The AGE binds to a receptor on white blood cells called receptors for advanced glycosolation end (RAGE) product which unregulated the immune response. This up regulation increases free radical production. Free radicals then promote all AGE-related disease processes. Inflammation is now known to be a major faction in Alzheimer, osteo and rheumation arthritis, coronary artery and renal disease, etc. Understanding this deepens the reason for advising obese patients who consume refined carbohydrate-carboholism, who present themselves for liposuction to get refined carbs out of their diet. Details of these nutritional concepts and other lifestyle guidance have recently been summarized by the author/surgeon (8). For almost two decades leptin was pursued as the holy grail in the control of obesity. It was considered the adipostat mediator. A specific adipostat may never be found because there are many factors that contribute to energy homeostasis. Since the introduction of fat free and low fat food the average American’s weight for any given age has increased 10 pounds. Adipocyte number is not as stagnant as previously thought. Decrease occurs via a process called apoptosis of both preadipocytes and adipocytes. Adipocytes may also dedifferentiate into preadipocytes. Adipocyte differentiation is the in vitro process by which differentiated fat cells revert morphologically and functionally to less differentiated cells (9, 10). The process has been observed in vitro. These adipocytes lost their cytoplasmic liquid and acquired a fibroblast morphology (11, 12). These dedifferentiated cells also display the gene expression patterns of preadipocytes (13). This is intriguing behavior in that preadipocytes exhibit stem cell-like qualities. Zuk (14) reported isolation of a population of stem cells from human adipocyte tissue. The cells were obtained from liposuction aspirate, and were determined to be mesodermal and mesenchymal in origin. In vitro these cells could differentiate into adipogenic, chondrogenic, osteogenic, and myogenic cells in the presence of proper induction factors (Table 4.1). Researchers from Duke University Medical Center have enthusiastically reported that adipocytes can

26

M. V. Kaminski and R. M. Lopez de Vaughan

Table 4.1  Representative factors secreted by adipocytes and their presumed functions (16) Secreted molecules and their targets Energy homeostasis   Agouti   Leptin   Lipoprotein lipase   Insulin like growth factor   IGF binding protein   Acylation stimulating Protein   TNF-a   apM-1 Cardiovascular   Angiotensinogen   ApoE   Cholesterol ester transfer protein (CETP)   Plaminogen activator inhibitor-1 (PEI-1)   Adiponectin Complement factors   Adipsin   Adipo Q/Acrp30   Complement factor B Other   VEGF angiogenesis   IL-6   Preadipocyte factor1 (pref 1)   Colony stimulating factor

Adipocyte specific

Ref.

No Yes No No No No No Yes

(1) (2) (3) (4) (5) (6) (7) (8)

No No No

(9) (10) (11)

No

(12, 13)

Yes

(14)

Yes Yes

(15) (16) (17)

No No No No

(18) (19) (20) (21)

become true stem cells (15). Their research exposed cells taken from human liposuction procedures to different cocktails of nutrients and vitamins, and, successfully reprogrammed 62% of them to grow into bone, cartilage, fat or nerve cells. Since nerve tissue is ectodermal, and not mesodermal in embryonic origin, these experiments confirm true stem cell potential. Since the publication of this pioneering study, other researchers have continued to use Adipose-derived stromal (stem) cells (ASC) that have been shown to be of great therapeutic use in preclinical studies in diverse fields, but a standard expansion method has not been established (15).

4.13  Fat’s Future The traditional concept of the adipocyte as simply a calorie storage cell has been shattered over the past few years. Fat is an exocrine, endocrine and apocrine organ and plays a role in immunity.

4.14  Conclusions Both the microscopic and gross anatomy of the fat mass should be appreciated by the liposuction surgeon. With this appreciation, a better result can be expected, especially in understanding the caveat not injury to the dermis during a procedure. The physiology keys are an appreciation for colloid osmotic pressure that is significantly reduced by Klein’s tumescent solution. This wash down of interstitial protein would enhance flow of the solution into the vascular space if it were not for the effect of epinephrine. Nevertheless using massive amount of tumescent solution can over-whelm the right heart and cause congestive heart failure. Current research emphasizes the fact that the fat mass is dynamic and that adipocytes can differentiate and dedifferentiate, is exciting in its application to redifferentiation into other cell types. Stem cells from lipo-aspirate make more sense than bone marrow or embryonic sources.

References   1. Fawcett OW. A Textbook of Histology. New York: Chapman and Hall, 1994.   2. Kessel RG. Basic Medical Histology. New York: Oxford University Press, 1998.   3. Lalikos JF, Li YQ, Roth TP, Doyle JW, Matory WE, Lawrence WT. Biochemical assessment of cellular damage after adipocyte harvest. J Surg Res 1997;70(1):95–100.   4. Weber KT, Swamynathan SK, Guntaka RV, Sun Y. Angiotensis II and extracellular matrix homeostasis. Int J Biochem Cell Biol 1999;31(3–4):395–403.   5. Guyton AC. Capillary dynamics and exchange of fluid between the blood and the interstitial fluid. In: Guyton AC (ed), Text Book of Medical Physiology, 7th ed. Philadel­ phia: WB Saunders, 1986, p. 348.   6. Kaminski MV, Haase T. Albumin and colloid pressure: Implications for fluid resuscitation. Crit Care Clin 1992;8(2): 311–322.   7. Pitman GH. Liposuction & Aesthetic Surgery. Quality Medical Publishing: St. Louis, 1993.   8. Kaminski MV, Lopez de Vaughan R. The Key to Successful Longevity: Book One Nutrition. July 2004.   9. Sugihara H, Yonemitsu N, Miyabara S, Yum K. Primary cultures of unilocular fat cells: characteristics of growth factors. Int J Obes 1994;31:42–49. 10. Cheng AY, Deitel M, Roncari DA. The biochemistry and molecular biology of human adipocyte reversion. Int J Obes 1994;18(Suppl. 2):112.

4  The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition 11. Van RL, Roncari DA. Complete differentiation of adipocyte precursors. Cell Tissue Res 1978;195(2):317–329. 12. Van RL, Bayliss CE, Roncari DA. Cytological and enzymological characterization of adult human adipocyte precursors in culture. J Clin Invest 1976;58(3):699–704. 13. Hauner H. Prevention of adipose tissue growth. Int J Obes 1994;18(Suppl. 2):147. 14. Zuk PA, Zhu M, Mizuno H, Huang J B.S., Futrell W, Katz AJ, Benhaim P, Lorenz HP, Hedrick MH. Multilineage cells

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from human adipose tissue: implications for cell-based therapies. Tissue Eng 2001;7(2):211–228. 15. Lott KE, Awad HA, Gimble JM, Guilak F. Clonal Analysis of Multipotent Differentiation of Human Adipose-Derived Adult Stme Cells. DukeMedNews 2004 Mar 8 News Release Available from: URL: http://www.dukemednews.org/news/ article.php?id = 7452.

5

Fat Cell Biochemistry and Physiology Melvin A. Shiffman

5.1  Introduction Fat cell biochemistry and physiology should be understood better by those surgeons doing liposuction and fat transfer. The fat cell is not just another item for us to remove or replace. The fat cell is a functioning hormonal unit of the body and affects other parts of the body as well as is affected by biochemical actions in the surrounding tissues and other parts of the body. We have not answered some questions regarding fat tissue when we do liposuction and transfer fat. For instance, what happens to the physiology of the body when a very large amount of fat is liposuctioned? What biochemical pathways may we disrupt when we lipo­ suction? A survey of the literature is presented in order to perhaps understand better what will be affected while doing autologous fat transfer.

5.2  Fat Cells It has been presumed that new adipose cells are not formed in adult adipose tissue (1–6). However, primitive reticular cells can differentiate into fat cells (7, 8). The preadipocytes (mesenchymal adipose cells), present in the connective network of the fat lobule, are destined to become mature adipose cells (7, 9, 10). The adipocyte is a metabolically active cell that functions to store energy for times of energy ­deprivation

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

or enhanced need (11). Atanassova (12) reported that preadipocytes in the subcutaneous tissues that were at different stages of differentiation were positive for S-100 protein. S-100 protein is expressed from the beginning of lipidogenesis and possibly acts as a factor regulating storage of lipids and formation of body fat. Ailhaud et al. (13) found that differentiation of adipose precursor cells can be divided into early and late events. Growth arrest at the G1/S boundary triggers the activation of early genes (pOb24 and lipoprotein lipase). The expression of both genes is primarily regulated at a transcriptional level. The expression of late markers, which leads to terminal differentiation and accumulation of neutral lipids, takes place after a limited number of mitoses of early-marker-expressing cells. Only terminal differentiation requires the presence of growth hormone and triiodothyronine as obligatory hormones and insulin as a modulating hormone, and results in the formation of triacylglycerol-filled nondividing cells. The terminal differentiation involves the cyclic AMP pathway, the diacylglycerol pathway, and a third pathway triggered by an insulin-like growth factor-1 (IGF-1) and insulin. It is proposed that a combination of mitogenic-adipogenic signals is required to trigger terminal differentiation of preadipose cells. There is a possible role of local and/or systemic growth factors in the differentiation of ­preadipocy­­tes into mature adipocytes (12, 14–22). Li et  al. (23) showed that adipocyte differentiation factor (ADF) in vivo may act as a cytokine paracrine agent to regulate the differentiation (adipogenic conversion) of preadipocytes. ADF causes a fourfold increase in triacylglycerol (triglyceride) content and a ninefold increase in glycerol-3-phospharte dehydrogenase (GPDH) activity, a marker of the late phase of differentiation of preadipocytes. According to Catalioto et al. (22) prostacyclin and PGF2 alpha (synthesized and secreted by

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_5, © Springer-Verlag Berlin Heidelberg 2010

29

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preadipocytes) appear to be autocrine mediators in the process of adipose con­version. Yokota et al. (24) noted that adiponectin, an ­adipocytederived hormone, is found in subcutaneous and bone marrow fat cells and has an inhibitory effect on adipocyte differentiation. Adiponectin can negatively and selectively influence lymphopoiesis. Adipocytes can con­tribute to the regulation of blood cell formation. Kawada et  al. (16) reported that in 3T3-L1 cells, vitamin C markedly increased the growth rate of preadipocytes at over 50 mM. Vitamin K3 slowed down the growth rate at over 0.1 mM. Vitamin B6 group and vitamin C significantly stimulated the differentiation and consequently increased the glycerophosphate dehydrogenase activity and triglyceride accumulation, to a concentration of over 10 mM. Vitamin A group, including beta-carotene, the vitamin D group, vitamin E, and the vitamin K group strongly inhibited the adipose conversion of 3T3-L1 cells at mM level. Carraro et al. (18) noted that a culture of adherent mature adipocytes contain rapidly proliferating fibroblast-like cells that are a substantially uniform subpopulation of adipocyte-precursor cells highly committed to differentiation. Between 36 and 48 h, such cells begin to accumulate lipid droplets, and by 150 h, they assume the morphology of small mature adipocytes (diameter 20–35 mm). Raclot (25) showed that the preferential hydrolysis of a substrate fraction enriched in the most polar triacylglycerols (TAGs) reflects the pattern of selective fatty acid mobilization and may be one of the regulating factors. Kajimoto et al. (26) claimed that there is an essential role of citrate export from the mitochondrial matrix to the cytosol at the early differentiation stage of 3T3-1 cells for their effective differentiation into fat cells. Vikman et al. (19) reported that GH-R mRNAs are present in rat adipose tissue from different fat depots. GH-R transcripts of the same estimated size were detected in isolated adipocytes and adipocyte precursor cells. There is a rapid and GH-dependent regulation of GH-R mRNA levels in adipose tissue. Ailhaud (27) noted that lipoprotein lipase (LPL) of adipose cells is present only in membrane compartments, mainly in the Golgi apparatus. LPL is a typical secretory protein which appears to be active as a homodimer. LPL is synthesized in the endoplasmic reticulum as an inactive monomer of Mr 51,000. A high-mannose, inactive mono­ mer of Mr 55,500 is then formed. An active homodi­ mer form, bearing two complex oligosaccharide chains

M. A. Shiffman

per monomer of Mr 58,000, forms in the Golgi apparatus. This mature form, present in secretory vesicles, can be secreted constitutively or after exposure to heparin. It is proposed that LPL is present in secretory vesicles in a potentially active, condensed, or “polymerized” form. This explains the activation of LPL. Peterfy et al. (28, 29) reported that two isoforms of lipin, lipin-alpha and lipin-beta, have distinct, but com­ plementary, functions in adipogenesis, with lipin-alpha playing a primary role in differentiation and lipin-beta being predominantly involved in lipogenesis. Variations in lipin levels alone are sufficient to induce extreme states of adiposity and may represent a mechanism by which adipose tissue and skeletal muscle modulate fat mass and energy balance. Benito et al. (20) showed that mammalian 3T3-L1 cells differentiate into adipocytes after continuous expo­ sure to pharmacological doses of insulin or physiologic doses of IGF-1. Expression of transfected ras oncogenes led to the differentiation of these cells into adipocytes in the absence of externally added insulin of IGF-1. Ras proteins participate in signal transduction pathways initiated by insulin and IGF-1 in these cells.

5.3  Lipolysis There are many substances that may regulate lipolysis, the decomposition or splitting up of fat. Natriuretic peptides (NP) that are known for ­regula­tion of blood pressure via membrane guanylyl cyclase (GC) receptors, are lipolytic in human adipose tis­sue (30). NP stimulate lipolysis and contribute to the regulation of lipid mobilization in humans. Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) stimulate lipolysis in human isolated fat cells (31). The action of ANP is mediated by activation of the adipocyte plasma membrane type A GC receptor (NPR-A), increase in intracellular guanosine 3'5'-cyclic monophosphate (cyclic GMP) levels, and activation of hormone sensitive lipase. ANMP plays a role in conjunction with catecholamines in the control of exercise induced lipid mobilization. Lafontan et al. (32) stated that the control of fat cell lipolysis by the catecholamines involves at least four different adrenoceptor (AR) subtypes: beta 1-, beta 2-, and beta 3-ARs and alpha 2A-adrenoceptors (alpha 2-AR). The physiological amines operate through differential

5  Fat Cell Biochemistry and Physiology

recruitment of these sites on the basis of their relative affinities. Beta 1-AR is always activated at the lowest norepinephrine levels. Van Harmelen et  al. (33) showed that acylationstimulating protein (ASP) and insulin inhibited basal and norepinephrine-induced free fatty acid (FFA) release by stimulating fractional FFA re-esterification and by inhibiting FFA produced during lipolysis. This is mediated by phosphodiesterase 3 (PDE3) and for ASP PDE4 might also be involved. Ryden et  al. (34) noted that tumor necrosis factoralpha (TNF-a) is a pleiotropic cytokine with a proposed role in obesity-related insulin resistance. This could be mediated by increased lipolysis in adipose tissue resulting in elevated FFA levels. Lipolysis was completely inhibited by blockers specific for p44/42 (PD98059) and JNK (dimetylaminopurine). These appear to be involved in the regulation of lipolysis. TNF-a induces apoptosis of human adipose cells (35) and prevents differentiation of human adipose precursor cells causing delipidation of newly developed fat cells (36). A common Gbeta (3) gene polymorphism (C825T) influences G protein receptor-mediated signal transduction and influences lipolysis (37). Large et  al. (38) showed that hormone-sensitive lipase (HSL) catalyzes the rate-limiting step in adipocyte lipolysis. HSL is a major determinant of the maximum, lipolytic capacity of human fat cells. HSL protein expression is, at least in part, caused by HSL mRNA expression. Decreased expression of HSL in the subcutaneous fat cells, which in turn causes decreased enzyme function and impaired lipolytic capacity of adipocytes, is present in obesity. Impaired expression of the HSL gene might explain the enzyme defect (39). Nonconventional partial beta 3-AR agonist, SR 12,177, was shown by Galitzky et al. (40) to activate lipolysis in fat cells through the interaction with beta 4-AR in human fat cells. Portillo et  al. (41) reported that the presence of beta1- and beta2-ARs has been clearly established in human fat cells.

5.4  Multilineage Cells in Fat There are primitive cells in accumulations of fat that are fibroblast-like that have the potential to have multilineage potential to form a variety of cells. Zuk et al. (42)

31 Table 5.1  Lineage-specific differentiation induced by media supplementation (51) Medium

Supplementation

Adipogenic

0.5 mM isobutyl-methylxanthine (IBMX), 1 mM dexamethasone, 10 mM insulin, 200 mM indomethacin, 1% antibiotic/ antimycotic 0.1 mM dexamethasone, 50 mM ascorbate2-phosphate, 10 mM b-glycophosphate, 1% antibiotic/antimycotic 6.25 mg/mL insulin, 10 ng/mL transforming growth factor-b1 (TGF-b1), 50 nM ascorbate-2-phosphate, 1% antibiotic/ antimycotic 0.1 mM dexamethasone, 50 mM hydrocortisone, 1% antibiotic/antimycotic

Osteogenic

Chondrogenic

Myogenic

took human adipose tissue, obtained by suction-assisted lipectomy, and this was processed to obtain a fibroblastlike population of cells or a processed lipoaspirate (PLA). PLA cells are of mesodermal or mesenchymal origin with low levels of contaminated pericytes, endothelial cells, and smooth muscle cells. Disruption of the blood supply during liposuction may result in the rele­ ase of pericytes, known to possess multilineage poten­ tial both in vivo and in vitro (43–45). PLA cells differentiate into adipogenic, chondrogenic, myogenic, and osteogenic cells in the presence of lineage-specific induction factors (Table 5.1). The multilineage differentiation observed in PLA may be, in part, due to the presence of pericytes. Adipose tissue is a source of adult multipotential stem cells that can differentiate along mesenchymal lineage. Cells tightly attached to mature fat cells can generate two fibroblastic cell populations with multiple but distinct potential of differentiation into adipocytes, osteoblasts, and chondrocytes (46).

5.5  Obesity Pausova (47) found that the presence of large rather than small adipocytes is associated with functional and structural abnormalities of the adipose tissue. These include increased production of bioactive mole­cules such as leptin, angiotensinogen, proinflammatory cyto­kines, and reactive oxygen species; insufficient capacity to accommodate excess energy-intake leading to ectopic fat storage in tissues and in turn insulin resis­tance and hyperinsulinemia; and augmented macrop­hage infil­ tration enhancing the production of pro-inflammatory

32

cytokines and reactive oxygen species. Such a “dysfunctional” adipose tissue may, in turn, induce ­activation of the sympathetic nervous system and renin-angiotensin-aldosterone system and oxidative stress and hence, promote the development of obesity-associated hypertension. Enlarged fat cells from obese subjects are characterized by insulin resistance and abnormal adrenergic regulation of lipolysis (48). Weight reduction decreased fat cell volume and basal and adrenergic-regulated lipolysis rates that were 20–40% lower than those in control women despite the fact that the percentage of body fat was almost identical in the two groups. Insulin-induced antilipolysis and lipogenesis were completely normalized after weight reduction. The adipocyte has long been suggested to be directly involved in the regulation of the body’s homeostasis. Human fat is a highly active endocrine tissue. EhrhartBornstein et al. (49) found that ecretory products from isolated human adipocytes strongly stimulate adrenocortical aldosterone secretion with a predominant effect on mineralocorticoid secretion. This may be responsible for obesity-related hypertension. Gottschling-Zeller et al. (50) reported that elevated levels of plasminogen activator factor inhibitor-1 (PAI-1) are characteristic of the obese state. Human fat cells release a substantial amount of PAI-1 in a depot-specific manner and transforming growth factor b1 (TGF-b1) particularly contributes to the regulation of PAI-1 secretion.

5.6  Diabetes In individuals who develop type 2 diabetes, fat cells tend to enlarge. DeFronzo (51) found that enlarged fat cells are resistant to the antilipolytic effects of insulin, leading to day-long elevated plasma free acid (FFA) levels. Chronically increased plasma FFA stimulates gluconeogenesis, induces hepatic and muscle insulin resistance, and impairs insulin secretion in genetically predisposed in-induced disturbances that are referred to as lipotoxicity. Enlarged fat cells have a dimin­ished capacity to store fat. When adipocyte storage capa­city is exceeded, lipid “overflows” into the muscle and liver, and possibly betacells of the pancreas, exacerbating insulin resistance and further impairing insu­lin secretion. Dysfunctional fat cells produce exces­sive amounts of insulin resistance

M. A. Shiffman

inducing inflamma­tory and atherosclerosis-provoking cytokines, and fail to secrete normal amounts of insulin-sensitizing cyto­kines. The adipocyte hormone adiponectin is negatively correlated with obesity and insulin resistance (52). Adiponectin acts as a regulator of adipocyte secretory function. The globular domain of adiponectin is gAcrp30. At least eight different cytokines were diminished in res­ ponse to gAcrp30. Lafontan (53) reported that several molecules secreted from adipocytes are involved in fat cell signaling to other tissues. Adipocyte products could initiate antagonistic effects on target tissues. Fat cells produce peptides that can elicit insulin resistance, such as leptin and adiponectin. Secretion of complement proteins, proinflammatory cytokines, procoagulant, and acute phase reactant proteins have been observed in adipocytes. The membrane receptor FAT/CD36 was found by Noushmehr et al. (54) to facilitate the major fraction of long-chain fatty acid (FA) uptake by muscle and adipose tissues. CD36 mediates a modulatory effect on insulin secretion. Sweeney et  al. (55) stated that insulin stimulates glucose uptake into muscle and fat cells by translocating glucose transporter 4 (GLUT4) to the cell surface, with input from phosphatidylinositol (PI) 3-kinase and its downstream effector Akt/protein kinase B. Input at the level of PI 3-kinase suffices for GLUT4 translocation but is insufficient to stimulate glucose transport. Insulin-dependent glucose influx in the skeletal muscle and adipocytes is believed to rely largely on GLUT4, but this has not been confirmed directly (56). Buren et al. (57) noted that chronic hyperglycemia promotes the development of insulin resistance. Insu­ lin resistance in fat cells from type 2 diabetes patients is fully reversible following incubation at physiological glucose concentrations. Cellular insulin resistance appears to be secondary to the hyperglycemic state. Hoffstedt et al. reported that deletion/insertion polymorphism in the calpain-10 gene (SNP-19) is associated with reduced beta (3)-AR function in obesity, which is also linked to type 2 diabetes, insulin resistance, and decreased thermogenesis. A common G to A polymorphism (UCSNP-43) in the Calpain 10 gene was found to be associated with type II (non-insulindependent) diabetes mellitus and variations in post absorptive and insulin stimulated glucose metabolism

5  Fat Cell Biochemistry and Physiology

in vivo (58). It is possible the Calpain 10 gene predisposes to diabetes by influencing the glucose metab­ olism. Impaired cellular expression of the docking pro­ tein,  IRS 1, and downstream signaling events in fat cells in response to insulin are associated with insulin resistance and Syndrome X (59). Bastelica et al. reported that elevated plasma plasminogen activator inhibitor (PAI) observed during insulin resistance has been connected with an excessive PAI-1 adipose tissue secretion mainly by visceral fat. PAI-1 production is mainly due to stromal cells, which are more numerous in the visceral than in the subcutaneous depot.

5.7  Hypertension The fat cell hormone leptin is implicated in the pathogenesis of hypertension and cardiovascular disease. Angiotensin (Ang II) and its metabolites stimulate leptin production in human adipocytes that is mediated through an extracellular-signal-regulated kinases 1 and 2-dependent pathway and includes the angiotensin II type 1 receptor subtype (60). The relationship between noradrenaline sensitivity and systolic blood pressure may be of importance in the early development of hypertension in humans (61).

5.8  Hematopoiesis Adipocytes are responsible for neuropilin-1 (NRP-1) expression suggesting that they may play a role in hematopoiesis by producing NRP-1 or that NRP-1 may regulate adipocyte activity (62).

5.9  Inflammatory Response Standard isolation procedures for isolating primary adipose cells from mouse adipose tissue triggers induction of many genes encoding inflammatory mediators including TNF-a, interleukin (IL)-1a, IL-6, multiple chemokines, cell adhesion molecules, acutephase proteins, type 1 IL-1 receptor, and multiple

33

transcriptions factors implicated in the cellular inflammatory response (63).

5.10  Traumatic Lipomas There is a genetic origin of lipomas with breakpoints in benign lipomas that may be at 12q13 or 12q14 (64). Lipomas are made up of clusters of rounded multilobulated masses of adipose tissue with a thin fibrous capsule. Various mesenchymal elements can be associated to form variants such as fibrolipomas, myolipomas, angiolipomas, and myxolipoma. Lipomas are multiple in 5% of patients (65, 66). Malignant transformation is unusual but liposarcoma and fibrosarcoma have been reported (67). There have been multiple reports of post traumatic formation of lipomas (67–75). Post traumatic lipomas arise more often in the female (12:1) arising 2–12 months following blunt trauma usually to the lower lumbar, gluteal, and trochanteric regions. The etiology of the lipomas was originally thought to be the result of herniation or relocation of deep adipose tissue secondary to fascial injury (68). Signorini and Campiglio (76) suggested other possible etiologic factors that include local or systemic factors, local inflammation, or products of degradation of hematomas inducing adipocyte proliferation. They also recommended liposuction as treatment for the lipomas. There is some evidence that the inflammatory processes capable of promoting lipomas formation in tendon sheaths and in synovial membranes following trauma (77) could also induce similar growth in the subcutaneous tissues after acute trauma (76).

5.11  Multiple Symmetrical Lipomatosis Multiple symmetric lipomatosis is an inherited disorder in which enlarging unencapsulated lipomas symmetrically develop in the subcutaneous tissues of the neck, shoulders, mammary, and truncal regions. In some cases it is associated with mitochondrial DNA abnormalities. Nisoli et al. (77) showed that the Beta(3)-adrenergic receptor is the functionally relevant adrenergic receptor subtype in brown adipocytes and its stimulation by

34

noradrenaline (NA) modulates the expression of genes such as uncoupling protein (UCP)-1 and inducible nitric oxide synthase (iNOS), involved in fat cell proliferation and differentiation. Trp64Arg mutation of the beta(3)-AR has been implicated in lower NA activity in adipose tissues. No association was found between beta(3)-AR gene poly­morphism and noradrenergic signaling in defects in MSL with or without mitochondrial DNA mutations (75).

5.12  Discussion There is a wide range of fat cell biochemistry and physiology that clinically involves medical problems such as diabetes, obesity, hypertension, and lipoma and lipomatosis. The physician who removes or decreases large amounts of fat in a patient through liposuction or other means (bariatric surgery or weight loss regimens) may affect, positively or negatively, some of the body fat functions. Understanding the potential problems may affect the way we surgically and medically approach the patient with body contouring problems.

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35 40. Galitzky, J., Langin, D., Verwaerde, P., Montastrue, J.L., Lafontan, M., Berlan, M. Lipolytic effects of conventional beta 3-adrenoceptor agonists and of CGP 12,177in rat and human fat cells: preliminary pharmacological evidence for a putative beta 4-adrenoceptor. Br J Pharmacol 1997;122(6):1244–1250. 41. Portillo, M.P., Rocandio, A.M., Garcia-Calonge, M.A., Diaz, E., Campo, E., Martinez-Blazquez, C. Errasti, J., del Barrio, A.S. Lipolytic effects of beta1, beta2, and beta3-adrenergic agonists in isolated human fat cells from omental and retroperitoneal adipose tissues. Rev Esp Fisiol 1995;51(4):193–200. 42. Zuk, P.A., Zhu, M., Mizuno, H., Huang, J., Futrell, J.W., Katz, A.J., Benhaim, P., Lorenz, H.P., Hedrick, M.H. Multi­ lineage cells from human adipose tissue: implications for cell-based therapies. Tissue Eng 2001;7(2):211–228. 43. Schor, A.M., Allen, T.D., Canfield, A.E., Sloan, P., Schor, S.L. Pericyte derived from the retinal microvasculature undergo calcification in vitro. J Cell Sci 1990;97(Pt 3):449–461. 44. Doherty, M.J., Ashton, B.A., Walsh, S., Beresford, J.N., Grant, M.E., Canfield, A.E. Vascular pericytes express osteogenic potential in vitro and in vivo. J Bone Miner Res 1998;13(5):828–838. 45. Diefenderfer, D.L., Brighton, C.T. Microvascular pericytes express aggrecan message which is regulated by BMP2. Biochem Biophys Res Commun 2000;269(1):172–178. 46. Miyazaki, T., Kitagawa, Y., Toriyama, K., Kobori, M., Torii, S. Isolation of two human fibroblastic cell populations with multiple but distinct potential of mesenchymal differentiation by ceiling culture of mature fat cells from subcutaneous adipose tissue. Differentiation 2005;73(2–3):69–78. 47. Pausova, Z. From big fat cells to high blood pressure: a pathway to obesity-associated hypertension. Curr Opin Nephrol Hypertens 2006;15(2):173–178. 48. Lofgren, P., Hoffstedt, J., Naslund, E., Wiren, M., Arner, P. Prospective and controlled studies of the actions of insulin and catecholamine in fat cells of obese women following weight reduction. Diabetologia 2005;48(11):2234–2242. 49. Ehrhart-Bornstein, M., Arakelyan, K., Krug, A.W., Scher­ baum, W.A., Bornstein, S.R. Fat cells may be the obesityhypertension link: human adipogenic factors stimulate aldosterone secretion from adrenocortical cells. Endocr Res 2004;30(4):865–870. 50. Gottschling-Zeller, H., Birgel, M., Rohrig, K., Hauner, H. Effect of tumor necrosis factor alpha and transforming growth factor beta 1 on plasminogen activator inhibitor-1 secretion from subcutaneous and omental human fat cells in suspension culture. Metabolism 2000;49(5):666–671. 51. DeFronzo, R.A. Dysfunctional fat cells, lipotoxicity and type 2 diabetes. Int J Clin Pract Suppl 2004;(143):9–21. 52. Dietze-Schroeder, D., Sell, H., Uhlig, M., Koenen, M., Eckel, J. Autocrine action of adiponectin on human fat cells prevents the release of insulin-inducing factors. Diabetes 2005;54(7):2003–2011. 53. Lafontan, M. Fat cells: afferent and efferent messages define new approaches to treat obesity. Annu Rev Pharmacol Toxicol 2005;45:119–146. 54. Noushmehr, H., D’Amico, E., Farilla, L., Hui, H., Wawrowsky, K.A., Miynarski, W., Doria, A., Abumrad, N.A., Perfetti, R. Fatty acid translocase (FAT/CD36) is localized on  insulin-containing granules in human beta-cells and mediates fatty acid effects on insulin secretion. Diabetes 2005;54 (2):472–481.

36 55. Sweeney, G., Garg, R.R., Ceddia, R.B., Li, D., Ishiki, M., Somwar, R., Foster, L.J., Neilsen, P.O., Prestwich, G.D., Rudich, A., Klip, A. Intracellular delivery of phosphatidylinositol (3,4,5)-triphosphate causes incorporation of glucose transporter 4 into plasma membrane of muscle and fat cells without increasing glucose uptake. J Biol Chem 2004;279(31):32233–32242. 56. Rudich, A., Konrad, D., Torok, D., Ben-Romano, R., Huang, C., Niu, W., Garg, R.R., Wijesekara, N., Germinario, R.J., Bilan, P.J., Klip, A. Indinavir uncovers different contributions of GLUT4 and GLUT1 towards glucose uptake in muscle and fat cells and tissues. Diabetologia 2003;46(5):649–658. 57. Buren, J., Lindmark, S., Renstrom, F., Eriksson, J.W. In vitro reversal of hyperglycemia normalizes insulin action in fat cells from type 2 diabetes patients: is cellular insulin resistance caused by glucotoxicity in vivo? Metabolism 2003; 52(2):239–245. 58. Hoffstedt, J., Ryden, M., Lofgren, P., Orho-Melander, M., Groop, L., Arner, P. Polymorphism in the Calpain 10 gene influences metabolism in human fat cells. Diabetologia 2002;45(2):278–282. 59. Smith U., Axelsen, M., Carvalho, E., Eliasson, B., Jansson, P.A., Wesslau, C. Insulin signaling and action in fat cells: association with insulin resistance and type 2 diabetes. Ann N Y Acad Sci 1999;892:119–126. 60. Skurk, T., van Harmelen, V., Blum, W.F., Hauner, H. Angio­ tensin II promotes leptin production in cultured human fat cells by an ERK1/2dependent pathway. Obes Res 2005;13(6): 969–973. 61. Hoffstedt, J., Reynisdottir, S., Lonnqvist, F. Systolic blood pressure is related to catecholamine sensitivity in subcutaneous abdominal fat cells. Obes Res 1996;4(1):21–26. 62. Belaid, Z., Hubint, F., Humblet, C., Boniver, J., Nusgens, B., Defresne, M.P. Differential expression of vascular ­endothelial growth factor and its receptors in hematopoietic and fatty bone marrow: evidence that neuropilin-1 is produced by fat cells. Haematologica 2005;90(3):400–401. 63. Ruan, H., Zarnowski, M.J., Cushman, S.W., Lodish, H.F. Standard isolation of primary adipose cells from mouse epididymal fat pads induces inflammatory mediators and

M. A. Shiffman down-regulates adipocyte genes. J Biol Chem 2003;278(48): 47585–47593. 64. Turc-Carel, C., Dal Cin, P., Boghosian, L., Leong, S.P., Sandberg, A.A. Breakpoints in benign lipomas may be at 12q13 or 12q14. Cancer Genet Cytogenet 1988;36(1):131–135. 65. Grandi, E., Trisolini, M.P. Tumors of the adipose tissue during 10 years of diagnostic activities (1979–1988). Pathologica 1990;82(1079):217–256. 66. Enzinger, F., Weiss, S. Soft Tissue Tumors. St. Louis, Mosby, 1983. 67. David, L.R., De Franzo, A., Marks, M., Argenta, L.C. Post­ traumatic pseudolipoma. J Trauma 1996;40(3):396–400. 68. Brooke, R.I., MacGregor, A.J. Traumatic pseudolipoma of the buccal mucosa. Oral Surg Oral Med Oral Pathol 1969; 28(2):223–225. 69. Meggitt, B.F., Wilson, J.N. The battered buttock syndromefat fractures. Br J Surg 1972;59(3):165–169. 70. Herbert, D.C., DeGeus, J. Post-traumatic lipomas of the abdominal wall. Br J Plast Surg 1975;28(4):303–306. 71. Rozner, I., Isaacs, G.W. The traumatic pseudolipoma. Austr N Z J Surg 1977;47(6):779–782. 72. Penoff, J.H. Traumatic lipomas/pseudolipomas. J Trauma 1982;22(1):63–65. 73. Dodenhoff, T.T. Trauma induced saddle bag: case report. Lipoplasty Newslett 1988;5:55. 74. Elsahy, N.I. Posttraumatic fatty deformities. Eur J Plast Surg 1989;12:208. 75. Cormenzana Olaso, P.S., Martinez Florez, A.E., Cecilia Gomez, J.A. Lipodistrofia post-traumatica. Cir Plast IberoLatinoamer 1992;18:47. 76. Signorini, M., Campiglio, G.L. Posttraumatic lipomas: where do they really come from? Plast Reconstr Surg 1998; 101(3):699–705. 77. Armstrong, S.J., Watt, I. Lipoma arborescens of the knee. Br J Radiol 1989;62(734):178–180. 78. Nisoli, E., Regianini, L., Bulbarelli, A., Busetto, L., Coin, A., Enzi, G., Carruba, M.O. Multiple symmetrical lipomatosis (MSL) may be the consequence of defective noradrenergic modulation of proliferation and differentiation of brown fat cells. J Pathol 2002;198(3):378–387.

6

White Adipose Tissue as an Endocrine Organ Kihwa Kang

6.1  Introduction White adipose tissue (WAT) is the main site of energy storage in mammals and provides the body’s thermal and mechanical insulation. Adipocytes store dietary sugar or fatty acids as a form of triglyceride in lipid droplets. When the body needs energy, as for fasting, these triglycerides are hydrolyzed and released into the blood stream to supply energy to other tissues. For a long time, WAT has been recognized only for energy storage until the discovery of leptin production by adipocytes (1). Since this finding, the perspective on the physiological role of WAT has begun to change and endocrine function of adipose tissue has begun to emerge. Following studies revealed that adipocytes can produce large numbers of peptide hormones and cytokines, called adipokines. These molecules affect energy metabolism in other tissues such as liver and muscle, as well as behaviors related to feeding through effects on neuroendocrine pathways. Some adipokines exhibit proinflammatory activities. For example, TNF-a and IL-6 are shown to cause insulin resistance. These findings indicate that WAT might be the main organ that plays an important role in obesity and obesity-induced metabolic disorders including type 2 diabetes.

K. Kang Department of Genetics and Complex Diseases, Harvard School of Public Health, 665 Huntington Avenue, Bldg 2, Rm 129, Boston, MA 02115, USA email: [email protected]

6.2 Role of White Adipose Tissue in Metabolism Adipose tissue is composed of mature adipocytes, fibroblasts, endothelial cells, preadipocytes, and immune cells. Different from other cell types, adipocytes can store lipids without compromising their cellular function. Lipoprotein lipase (LPL) and glucose transporters (GLUTs) are the major proteins responsible for the uptake of circulating energy sources in addition to de novo fatty acid synthesis in the cells. LPL breaks down triglyceride in circulating lipoprotein particles generating fatty acids, and GLUTs help in the uptake blood glucose. Inside the cells, fatty acids and glucose are either stored in a highly condensed form such as triglycerides, or are metabolized to generate cellular ATP. Among GLUTS, GLUT1 is responsible for basal glucose uptake and GLUT4 for insulin-stimulated glucose entry into cells. The expression of GLUT4 is highly correlated with insulin sensitivity (2). WAT is also important in endocrine function. In addition to release of fatty acids during fasting, adipocytes secrete multiple protein signals and factors called adipokines into the blood stream. The production of adipokines is regulated by the status of adipose tissue expansion and other physiological environment. Obese humans and animals have bigger adipocytes, increased adipose tissue mass, and a different method of producing adipokines. For example, proinflammatory cytokine TNF-a and satiety hormone leptin production are increased (3), while adiponectin level is decreased in obesity (4).

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K. Kang

a

sensitive to feeding and fasting statuses. For example, plasma level of leptin is increased after meals or in obesity. Circulating leptin binds to the leptin receptor at the hypothalamus in the brain, and subsequently activates the neuron for satiety (pro-opiomelanocortin (POMC)) and energy expenditure pathway, whereas it suppresses the neuron for appetite (neuropeptide-Y (NP-Y)) and energy conservation pathway. In support of this theory, mice lacking leptin (ob/ob) or leptin receptors (db/db) are severely obese due to loss of appetite regulation and energy control (1).

b

6.4  Adiponectin on Liver and Muscle

Fig. 6.1  Macropahges infiltrated into WAT. C57/B7 mice were fed normal chow diet (a) or high fat diet (b). Macrophages are accumulated around adipocytes and make crown like structure. Obesity increases macrophage content in WAT, which results in insulin resistance

Obesity not only increases proinflammatory adipokine production in adipocytes, but also induces macrophages infiltration into the tissue (5) (Fig. 6.1). This is one of the main causes of peripheral and systemic insulin resistance and metabolic syndrome. Although the mechanisms underlying accumulation of macrophages in adipose tissue in obesity are not clear, it is hypothesized that the removal of dead adipocytes caused by hypertrophy leads to this phenomenon.

6.3  Leptin on Brain Although leptin, a satiety hormone, is primarily produced by adipocytes, it exhibits its activity in the brain and peripheral organs. Its production and release are

Adiponectin, one of the most extensively characterized adipokines, is exclusively secreted by the adipose tissues. There are several forms of adiponectin including oligomers and multimers; the multimer forms of adiponectin are the major active hormones (6). Serum adiponectin binds to its receptor in the liver and muscle, and then activates cellular downstream proteins such as AMP-activated protein kinase (AMPK) and peroxi­ some proliferators-activated receptor a (PPARa). The main biological effect of adiponectin is the regulation of glucose and lipid metabolism in the liver and skeletal muscle. Many studies in humans and animals show that a lower adiponectin level is well correlated with obesity, insulin resistance, and diabetes (7). Further­ more, a lower adiponectin level is associated with higher blood pressure, proinflammatory state, and coronary artery disease (8).

6.5  Location of WAT Adipose tissues in different locations have different physiological and metabolic effects. Generally visceral adipocytes have higher lipolytic activity of catecholamines and less anabolic effect of insulin, which results in greater mobilization of free fatty acids from intra-abdominal depots than subcutaneous adipose tissue (9). Central obesity characterized by increased amounts of intra-abdominal fat or visceral fat is associated with insulin resistance, type 2 diabetes and atherosclerosis (10). By contrast, peripheral obesity with increased subcutaneous fat is associated with improved insulin sensitivity, a lower risk of developing type 2

6  White Adipose Tissue as an Endocrine Organ

diabetes, and dyslipidemia compared to the central obesity with increased visceral adipose tissue (11). Also, surgical removal of visceral fat has been reported to decrease blood insulin and glucose levels in humans (12), whereas removal of subcutaneous fat by liposuction did not result in improvement in any aspect of the metabolic syndrome (13), which suggests some beneficial effect of subcutaneous fat and adverse effects of visceral fat (14).

6.6  Adipokines and Inflammation WAT is a major secretory organ responsible for the release of over fifty adipokines. These adipokines appear to be involved in a wide range of physiological processes; classical cytokines/chemokines (e.g., TNFa, IL-6, IL-1b, MCP-1), growth factors (e.g., transforming growth factor-b; TGF-b), vascular haemostasis (e.g., PAI-1), regulation of blood pressure (e.g., angiotensinogen), lipid metabolism (e.g., RBP4, cholesteryl ester transfer protein), glucose homeostasis (e.g., adiponectin, resistin), angiogenesis (e.g., VEGF), and neuroendocrine control (e.g., leptin) (Table 6.1). The production of inflammation-related adipokines, including TNF-a, IL-6, MCP-1, and leptin, is increased in adipose tissue with obesity, implicating a chronic low-grade inflammation in obesity. In addition, the increased chemokine (MCP-1) production both in hypertrophic adipocytes and resident macrophages recruit additional macrophages. Macrophage recruitment in turn results in a proinflammation state in obese adipose tissue (15). Macropahges produce large amount of cytokines such as TNF-a, and IL-6, and these cytokines increase lipolysis and impair insulin signaling in adipocytes (16). When adipose tissue suffers insulin resistance states, circulating fatty acids and lipid levels go up, which makes other tissue such as liver, muscle, and pancreas accumulate more lipids. This ectopic lipid accumulation further increases whole body insulin resistance together with liver steatosis and muscle lipid accumulation. On the contrary, several adipokines appear to have an anti-inflammatory effect. Adiponectin inhibits phagocytic activity and TNFa production in macrophages, as well as increases human skeletal muscle bioenergetics, which results in antidiabetic effects (4). Recently it has  been reported that adipose tissue releases anti-

39 Table 6.1  Biological effect of adipokines Biological effect Adipokines Leptin Adiponectin

Satiety signal and energy expenditure Increases insulin sensitivity and antiinflammatory Resistin Decreases insulin sensitivity Visfatin Insulin-like activity RBP4 Not known but correlated to obesity and insulin resistance Angiotensinogen Regulates arterial blood pressure VEGF Stimulates vascular proliferation, angiogenesis Proinflammatory cytokines TNF-a Increases lipolysis and decreases insulin sensitivity IL-1b Proinflammatory IL-6 Increases lipolysis and decreases insulin sensitivity MCP-1 Chemokine and recruits more monocytes Anti-inflammatory cytokines IL-4 Reduced inflammation and increase tissue repair IL-13 Reduced inflammation and increase tissue repair Acute phage proteins PAI-1 Blocks fibrinolysis, vascular haemostasis Serum amyloid A Recruits immune cells CRP Binds to microbes and assists innate immunity RBP4 retinol-binding protein; VEGF vascular endothelial growth factor; TNF-a tumor necrosis factor-a; IL-1b interleukin-1b; IL-6 interleukin-6; MCP-1 monocyte chemoattractant protein-1; IL-4 interleukin-4; IL-13 interleukin-13; PAI-1 plasminogen activator inhibitor 1; CRP C-reactive protein

inflammatory cytokines such as interleukin-4 and interleukin-13 (17). These cytokines are known to be released by Th2 helper T cells to resolve inflammation and tissue repair. Adipocyte factors could activate macrophages both in proinflammatory (M1) and antiinflammatory (M2) program, and the balance of these programs through PPARd is critical for controlling insulin sensitivity. It is suggested that  adipose tissue releases these anti-inflammatory cytokines to control infiltrated macrophage activation and dampen proinflammatory responses. Several human studies showed that anti-inflammatory medication could be beneficial to obesity-induced insulin resistance (18). Thus, identification of adipokines and investigation of their physiological functions will be very important to understand the role of adipose tissue and to protect against obesityinduced metabolic disorders.

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6.7  Conclusions The incidence of obesity and obesity-related metabolic syndrome is increasing world-wide. WAT plays a central role in controlling body’s metabolic homeostasis and insulin sensitivity as a key endocrine and secretory organ. It is clear that there is extensive cross-talk between white adipocytes and other tissues through paracrine and endocrine functions. Understanding the biology of adipose tissue and the identification of adipokines will provide new insights into normal physiological regulation, as well as the pathogenesis and treatment of obesity, diabetes and disorders of lipid metabolism.

References   1. Zhang Y, Proenca R, Maffei M, Barone M, Leopold L, Friedman JM. Positional cloning of the mouse obese gene and its human homologue. Nature 1994;372(6505):425–432.   2. Abel ED, Peroni O, Kim JK, Kim YB, Boss O, Hadro E, Minnemann T, Shulman GI, Kahn BB. Adipose-selective targeting of the GLUT4 gene impairs insulin action in muscle and liver. Nature 2001;409(6821):729–733.   3. Hotamisligil GS, Shargill NS, Spiegelman BM. Adipose expression of tumor necrosis factor-alpha: Direct role in obesity-linked insulin resistance. Science 1993;259(5091):87–91.   4. Civitarese AE, Ukropcova B, Carling S, Hulver M, DeFronzo RA, Mandarino L, Ravussin E, Smith SR. Role of adiponectin in human skeletal muscle bioenergetics. Cell Metab 2006;4(1):75–87.   5. Xu H, Barnes GT, Yang Q, Tan G, Yang D, Chou CJ, Sole J, Nichols A, Ross JS, Tartaglia LA, Chen H. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest 2003;112(12): 1821–1830.   6. Kadowaki T, Yamauchi T. Adiponectin and adiponectin receptors. Endocr Rev 2005;26(3):439–451.

K. Kang   7. Maeda N, Shimomura I, Kishida K, Nishizawa H, Matsuda M, Nagaretani H, Furuyama N, Kondo H, Takahashi M, Arita Y, Komuro R, et al. Diet-induced insulin resistance in mice lacking adiponectin/ACRP30. Nat Med 2002;8(7): 731–737.   8. Huang KC, Chen CL, Chuang LM, Ho SR, Tai TY, Yang WS. Plasma adiponectin levels and blood pressures in nondiabetic adolescent females. J Clin Endocrinol Metab 2003; 88(9):4130–4134.   9. Arner P, Hellström L, Wahrenberg H, Brönnegard M. Betaadrenoceptor expression in human fat cells from different regions. J Clin Invest 1990;86(5):1595–1600. 10. Wang Y, Rimm EB, Stampfer MJ, Willett WC, Hu FB. Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. Am J Clin Nutr 2005;81(3):555–563. 11. Tanko LB, Bagger YZ, Alexandersen P, Larsen PJ, Christiansen C. Central and peripheral fat mass have contrasting effect on the progression of aortic calcification in postmenopausal women. Eur Heart J 2003;24(16):1531–1537. 12. Thörne A, Lönnqvist F, Apelman J, Hellers G, Arner P. A pilot study of long-term effects of a novel obesity treatment: Omentectomy in connection with adjustable gastric banding. Int J Obes Relat Metab Disord 2002;26(2):193–199. 13. Klein S, Fontana L, Young VL, Coggan AR, Kilo C, Patterson BW, Mohammed BS. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med 2004;350(25):2549–2557. 14. Tran TT, Yamamoto Y, Gesta S, Kahn CR. Beneficial effects of subcutaneous fat transplantation on metabolism. Cell Metab 2008;7(5):410–420. 15. Kanda H, Tateya S, Tamori Y, Kotani K, Hiasa K, Kitazawa R, Kitazawa S, Miyachi H, Maeda S, Egashira K, Kasuga M. MCP-1 contributes to macrophage infiltration into adipose tissue, insulin resistance, and hepatic steatosis in obesity. J Clin Invest 2006;116(6):1494–1505. 16. Cawthorn WP, Sethi JK. TNF-alpha and adipocyte biology. FEBS Lett 2008;582(1):117–131. 17. Kang K, Reilly SM, Karabacak V, Gangl MR, Fitzgerald K, Hatano B, Lee CH. Adipocyte-derived Th2 cytokines and myeloid PPARdelta regulate macrophage polarization and insulin sensitivity. Cell Metab 2008;7(6):485–495. 18. Fleischman A, Shoelson SE, Bernier R, Goldfine AB. Salsalate improves glycemia and inflammatory parameters in obese young adults. Diabetes Care 2008;31(2):289–294.

Part Preoperative

II

7

Preoperative Consultation Melvin A. Shiffman

7.1  Introduction Every patient considered for autologous fat transplantation should have a proper history. A physical examination as well as a discussion on the pros and cons of having fat transfer and viable alternative methods of resolving the patient’s problem is also necessary.

7.2  Initial Conference The patient should be able to state the problem that is to be treated, how it occurred, and how long it has been present. Previous attempts to correct the problem should be explored (what was done, how, when, and where) and prior records obtained if at all possible. This is important in case temporary or permanent fillers have been used or if there is possibly excessive scar in the area to be treated. Explore the patient’s past history and family history for diabetes, heart disease, cancer, bleeding problems, and thromboembolism. Obtain a list of all medications the patient is taking including dosage and frequency.

7.3  Physical Examination The specific defect or deficit that the patient is complaining about should be carefully examined and measurements taken if possible. The overlying skin should

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

be examined for scars and hypo or hyperpigmentation. Palpation is performed to determine if there are any deep tissue attachments, induration, and/or masses. If general anesthesia or intravenous sedation is to be used, examination of the heart and lungs should be performed. The fat tissue depth in the areas where fat will be removed for transfer should be determined for adequacy of the amount of fat that will be utilized and, if necessary, frozen and stored. Preoperative photos should be taken for future reference.

7.4  Discussion with the Patient For informed consent, the discussion with the patient should include the procedure contemplated, viable alternatives, and possible (material) risks and complications of each. In one jurisdiction the judge stated that the informed consent is personal to the cosmetic surgery patient. In that instance all possible risks and complications have to be discussed with the patient. Medical records should include when this discussion took place and the possible risks and complications discussed. The surgeon should be involved at some time in this discussion. It may be convenient for staff personnel to perform most of the discussion but the physician should establish some rapport with the patient to show interest and compassion concerning the procedure and its possible complications. Fat transfer may seem like a simple procedure to the physician, but it is important for the patient to understand the need for possible further fat injections because of absorption as well as future loss of fat through the aging process, and possible risks of the procedure. One has to be careful with the patient who is to have injection of fat into the glabella or nasal area. This

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patient must be informed of the possibility of blindness and/or central nervous system injury.

M. A. Shiffman

7.7  Written Instructions Preoperative and postoperative instructions should be given both orally and in writing.

7.5  Laboratory Studies If there is minimal fat to be removed and injected and local or local tumescent anesthesia is used, there is little need for lab studies. However, if the fat transfer is in addition to extensive liposuction or other procedure requiring general anesthesia or deep sedation, there may be need for at least a CBC (complete blood count). Diabetics should have their blood sugar levels evaluated preoperatively and postoperatively as well as when infection or necrosis occurs.

7.8  Postoperative The patient should be seen on the first or second postoperative day to evaluate for possible hematoma or infection as well as to adjust any dressings that have been applied.

7.9  Conclusions 7.6  Radiologic Studies Radiologic studies are not usually necessary. If the patient is to have a general anesthetic and is over the age of 50, chest X-ray may be recommended (as well as an electrocardiogram). If fat is to be injected around the breast, mammogram is usually necessary preoperatively and 6–12 months postoperatively.

The patient should receive enough information about the procedure in order to make a knowledgeable decision as to whether or not to have the procedure. The physician should establish rapport with the patient by being involved in the discussion about the procedure and its possible risks and complications.

Part Techniques for Aesthetic Procedures

III

8

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

8.1  Introduction The indications for autologous fat grafting (AFG) have gradually changed since the procedure gained popularity in the mid 1980s (1–4). The evaluation of results and critical comparisons with alternative methods has in many respects become more difficult. The initial cosmetic uses of AFG was generally limited to facial furrows – particularly to nasolabial folds, lateral oral commissural folds and glabellar frown lines – to the hands, and to a very limited extent, to the breasts. While the idea of fat grafting for breast augmentation gained a few early adepts, vehement opposition by plastic surgeons and to some extent by the medical establishment has largely rendered this application untenable from a medical legal position. Given the very limited worldwide choice of fillers in the mid-1980s, and even more so in the US, where collagen was the only FDA-approved injectable filler until December 2003, AFG was a clear-cut choice for those patients in need of more than 1–2 mL of collagen and who were willing to accept variability in long-term results and the longer down time associated with AFG. In fact, as AFG injecting needles became smaller and smaller from the 14–16 gauge used early on to the 18–20 gauge more commonly used now, the finesse and precision of the technique vastly improved, and the immediate posttreatment AFG appearance more closely approached results with commercial fillers. However, the unpredictability and variability of the duration of

S. Eremia Cosmetic Surgery Unit, Division of Dermatology, UCLA, Brockton Cosmetic Surgery Center, 4440 Brockton, Suite 200, Riverside, CA 92501, USA e-mail: [email protected]

the results were probably the biggest obstacles for AFG becoming the gold standard facial filler, particularly in the absence of serious competition. Lack of standardized harvesting, processing, and injection techniques, and lack of sound scientific studies to evaluate the duration of results were additional obstacles. The author (5) designed and carried out one of the first and few studies to objectively compare AFG to Zyplast collagen. The results confirmed the largely accepted opinion in the late 1980s, that AFG was at least equal to, and somewhat superior to, collagen during the first 6–9 months, but where the great majority of patients lost correction by 12–15 months. A followup study of 131 patients who underwent two or more AFG treatments confirmed that for most patients repeated injections of AFG did not achieve longer-term or permanent correction, when measured against baseline and the last treatment (6). These studies, though well designed, should be considered flawed today, because of improved injection techniques now being used. The patients in these two studies were fat grafted with 3–5 mL syringes fitted with 14–16 gauge needles. Due in great part to the work by Coleman (7–9), the switch to 1mL syringes fitted with smaller 18–19 gauge injection cannulas/needles has – confirmed by the author’s own personal experience – resulted in vastly improved duration of results. Other early pioneers such as Ersek (10, 11) noted improved results with improved techniques. While no precise guidelines for AFG have been defined, the author considers the application of certain basic minimum principles of the four components of AFG as a generally accepted “modern” technique. 1. Harvesting This should be as atraumatic as possible, to preserve the maximum amount of viable adipocytes. A low

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pressure aspiration system, usually by syringe, using a blunt harvesting cannula is the generally accepted norm. There is no true consensus as to donor site selection or use of anesthetics. 2. Processing The concept of processing the aspirated fat for reinjection ranges from very basic techniques of washing and concentrating the fat to separate the viable fat strands from any debris, to more complex methods which may include the use of various additives and extensive centrifugation. While there have been multiple studies advocating the benefits of various techniques to maximize the percentage of viable adipocytes to be reinjected, there appears to be some consensus that gentle processing, minimal washing, and the use of short time, low power centrifugation, or at least gravity separation of the fat, result in a relatively high percentage of viable fat cells ready for reinjection (12, 13). 3. Storage Harvesting extra fat for freezing and future reinjection, can render AFG far more competitive with commercial fillers, by eliminating the relatively traumatic, and certainly time consuming steps of harvesting and processing the fat. Significant controversy exists as to the viability and long term effectiveness of frozen fat. Sophisticated methods of freezing the fat, use of special additives, and good thawing technique have been demonstrated in various studies to improve the percentage of viable adipocytes following thawing (14, 15). Crude methods of freezing, storage, and thawing, are likely to result in relatively low percentage of viable adipocytes being reinjected. Nevertheless, the reinjection of nonviable adipocytes will result in short term correction, and in some patients may also induce a certain amount of tissue fibrosis. 4. Injection The use of a 1-mL syringe no greater than an 18 gauge injection needle or cannula, to precisely place small amounts, thin layers or strands of fat, with multiple passes if necessary, in the desired location, should be virtually considered the standard of care. Significant overcorrection should be avoided. Touch-ups, which are needed for many patients, are preferable to difficultto-fix long-lasting overcorrections. Using these types of “modern” techniques, most experienced AFG users report about 40% good long

S. Eremia

term results, which is also the author’s experience over the past 8–10 years. Unfortunately there is a great lack of newer, sound scientific studies that evaluate results of AFG. It is troubling that no side by side studies are being performed to compare AFG to various other available fillers. For areas such as the nasolabial folds this should be relatively simple and safe to do. Though attempts to set current guidelines for use of AFG may be rendered somewhat more difficult by lack of scientific studies to support them, it is nonetheless possible to endeavor to formulate them based on reported general experience. For purposes of guidelines it is best to divide use of AFG into several categories. 1. Correction of superficial furrows such as the nasolabial fold, oral commissural folds, and glabellar frown lines. For correction of these areas AFG are generally placed superficially in the subdermal area, and competes primarily against an increasing array of intradermal injections of temporary or permanent commercial fillers, such as crosslinked collagen and nonanimal hyaluronic acid (HA), Calcium hydroxyl-apatite, poly-l-lactic acid, polymethylmethacrylate beads, silicone, etc. Caution should be exercised with any filler agent for the glabellar area, as tissue necrosis and more rarely blindness have been reported with filler injections; neurotoxin injections or neurolysis provide excellent alternatives. The evaluation and interpretation of results for these areas are relatively straightforward. Results should be analyzed: (a) In the 1–7-day immediate postinjection period to determine swelling, bruising, overcorrection, all of which impact down time and patient acceptance vs. competing alternatives. (b) In the relative short term – 3–6-month period. (c)  In the intermediate term – 6–12-month period. (d) In the long term – 12–24-month period and beyond. For short-term evaluation, visual examination and descriptive records supported by photographs should suffice. For longer-term evaluation, optical profilometry would yield the most objective results, complemented by high-quality standardized photographs, which may be sufficient as a stand-alone evaluation standard. MRI has also been used but is somewhat impractical (16).

8  Guidelines for Autologous Fat Transfer, Evaluation, and Interpretation of Results

The guidelines for selecting AFG over available commercial fillers are not easy to set. It is difficult to justify AFG for treatment of relatively shallow nasolabial and commissural folds which can be adequately corrected with less than 1 mL of HA, or other equivalent commercial filler. However for deeper folds, where 2–3 mL of temporary commercial fillers may be needed, or there is serious consideration of use of the more expensive and riskier long term or permanent fillers, AFG should be seriously considered: (a) As a cost-efficient alternative to temporary fillers. (b) As a complement to temporary fillers, combining and layering AFG with intradermal fillers. (c) As a possibly safer, though less predictable, alternative to permanent fillers. The planned use of AFG for larger volume correction in other areas of the face and body, and the availability of state of the art, approved (in states or countries that require it), fat tissue storage capabilities, further improves the economics of AFG selection over commercial fillers. 2. Volume correction of the aging face – larger volume, deeper placement of AFG. The realization of the importance of volume shifting and loss during the ageing process, and its effect on appearance has helped establish AFG as an important technique in modern aesthetic surgery. While commercial injectable fillers for deeper, larger volume augmentation are becoming increasingly available, they have yet to establish the level of safety, and cost effectiveness, that have made them so popular for treatment of superficial furrows. The use of AFG for re-establishing youthful facial contours, through volume restoration, became possible in good part due to the work of Coleman – the premier advocate for use of smaller injection cannulas/needles fitted to 1-mL syringes. Berman (17) should be credited for some pioneering work demonstrating the effectiveness of AFG placed in deeper facial planes to restore desirable contours. Coleman, Berman, and most other advocates of widespread use of fat grafts to increase the volume of the face (temporal forehead, brows, inferior orbital rims, malar areas, perioral areas including lips and chin, etc.), focused more on fat grafting technique, and placing the fat where it seemed to be both needed and accessible, be it supraperiosteal, sub- or perimuscular, or subcutaneous. In 1999 Amar (18, 19) presented a

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very specific technique (FAMI – fat augmentation by muscle injection) for injecting small quantities of fat only along the facial muscle sheaths. While theoretically elegant, it is difficult to master, and has not gained widespread acceptance. Today, most experienced users of AFG for volume restoration place the fat in various planes – be it periosteal, perimuscular, or within existing deeper fat compartments – based on the perceived needs of the individual patient. Unfortunately, sound scientific studies examining not just differences in techniques, but even something as basic as average duration of results, are sorely lacking. It is clear though, both from the increasing popularity of AFG for contour improvement and volume restoration, confirmed by the author’s own experience, that AFG can yield excellent 6–12-month results, and in some patients, much longer-term results when judiciously placed in deeper planes. The alternatives to AFG for volume restoration include surgical repositioning of ptotic fat compartments, permanent, hard, cheek, chin, and extended jowl implants, larger particle HA’s, subperiosteal placement of hydroxyl-apatite, and poly-l-lactic acid, and BioAlkamid (a non-resorbable Alkyl-amide polymeric material that after injection quickly becomes encapsulated, not yet available in the US). Guidelines for selecting AFG over other alternatives can be only general, and to a great extent subject to physician and patient preferences. The risk profile for AFG compares favorably to surgery, and in terms of infection, it is equal to favorable when compared to hard implants. When compared to injectable fillers, AFG has a cost advantage, especially when larger volumes are needed to treat multiple areas. AFG also has a longevity advantage vs. temporary fillers, in that at least some patients treated with AFG maintain longer-term correction, and AFG has a somewhat lower safety profile compared to HAs and Ca hydroxyl-apatite, and equal to a better safety profile than products like Sculptra or Bio-Alkamid. HAs and hydroxyl-apatite are simpler to use and have less down time. Evaluation and interpretation of results of volume restoration with AFG are a little more difficult, given more reliance on subjective evaluations. Blinded examination of serial, standardized photographs is probably the only practical tool. Patient satisfaction surveys are exceedingly subjective. The combination with other procedures, frequent use of touch up injections, the difficulty of standardizing photographs

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covering multiple cosmetic regions of the face, are additional obstacles. Imaging studies are available to examine thickness of fat layers and compartments. Both MRI and high resolution ultrasound can distinguish fat from surrounding tissues, but these methods have not proven very useful or practical for following the fate of the grafted fat or the longevity of results. The actual viability of grafted fat remains subject of some controversy, with some of the improvements also attributed to tissue fibrosis. Nevertheless, it is the general consensus that at least some of the grafted fat does survive. This is supported by a multitude of animal studies. In vitro and in vivo animal studies have demonstrated the fact that injected fat cells are viable, and as previously discussed, the percentage of viable fat cells leaving the injection needle can be dependent on the handling of the fat cells up to that point. 3. Volume correction of the ageing hands. Fournier (20), the tireless, initial truly world wide promoter of AFG, was already using fat on the dorsum of the hand, as early as 1984–1985, when the author first became well acquainted with him. Problems with ecchymoses, limited duration of results, and general, if somewhat unsubstantiated fear of potentially very serious infections, limited the popularity of this technique for many years. More recently the technique, which has been modernized to include better preparation of fat, smaller injection syringes and cannulas, and smaller volumes of fat injected, has gained some popularity. Butterwick (21) has been in good part responsible. Her work included scientific studies, examining results with both fresh and frozen/thawed stored fat, and attempted to objectively measure correction and longevity, with albeit somewhat crude, volumetric measurements. The recent usage of both polylactic acid (Sculptra) and hydroxyl-apatite (Radiesse) for the dorsum of the hand provides additional alternatives to AFG. Guidelines for selecting any of these methods over another are still premature, as comparative studies – hopefully side-by-side studies – are needed. Volumetric evaluation of results is possible, though technically not so easy to perform with the level of accuracy needed. Photographic documentation, and patient and blinded evaluator assessment particularly in bilateral comparative studies, or unilateral single filler agent studies, should be performed to determine both level of improvement and longevity.

S. Eremia

4. Correction of localized fat loss. Aggressive liposuction in the early 1980s, with cannulas as large as 8–10 mm, led to a multitude of iatrogenic irregularities and defects, and initial crude attempts were made to correct them by injecting some of the aspirated fat. Surprisingly some of the fat seemed to survive, and over time and with improved AFG techniques, many anecdotal reports of relatively successful treatment of iatrogenic, traumatic, and congenital fat defects have surfaced. AFG has not been very successful in the treatment of most acquired forms of fat atrophy, and has been particularly disappointing in HIV-related lipodystrophy. Given the relatively large volumes of filler needed for most of these cases, fat is a natural first choice – with the exception of HIV-related fat loss – where Sculptra has proven to be particularly effective and should be considered first. One interesting application of AFG is the correction of overly aggressive neck liposuction, which can leave unsightly platysmal muscle bands attached to the dermis that are highly visible. A variation of the FAMI technique is applicable in these cases, where tight adherence of the muscle fibers to the dermis makes it a bit difficult to inject the fat strictly in the subdermal plane. The subsequent addition of neurotoxin injections can yield even better results. Evaluation and interpretation of results for treatment of localized fat loss is relatively straight forward with quality photographs.

8.2  Conclusions Autologous fat has often been referred to as the almost ideal filler. Nevertheless, its use remains relatively limited compared to commercial fillers. It also appears that surgically trained and oriented cosmetic practitioners are far more likely to use fat, and often as a complement to other surgical procedures such as face–neck lifts and blepharoplasty. In sheer numbers, less surgically aggressive dermatologists, and now a wide array of nonsurgically trained “cosmetic practitioners” – not to mention nonphysician “extenders” such as physician assistants and nurse practitioners, and even simple registered nurses – inject the bulk of commercial fillers. Establishment of guidelines of use and criteria for evaluation and interpretation

8  Guidelines for Autologous Fat Transfer, Evaluation, and Interpretation of Results

of both short and longer term results can be very helpful. However, until scientific studies can demonstrate the effectiveness and superiority of AFG as a filler, that is not likely to change. Unfortunately the focus in recent AFG research seems to target the best methods to achieve the highest possible viability of fresh and even more so frozen fat. That is of course very important and those researchers should be commended for innovative methods and well-designed studies. But until well-designed studies demonstrate the effectiveness and safety of AFG, much in the way as it would be necessary to obtain FDA approval for a new filler, it is unlikely that AFG will gain the popularity and stature it likely deserves.

References   1. Kaufman MR, Bradley JP, Dickinson B, Heller JB, Wasson K, O’Hara C, Huang C, Gabbay J, Ghadjar K, Miller TA. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results. Plast Reconstr Surg 2007;119(1):323–331.   2. Hanke CW. Fat transplantation: indications, techniques, results. Dermatol Surg 2000;26(12):1106.   3. Newman J, Ftaiha Z. The biographical history of fat transplant surgery. Am J Cosm Surg 1987;4:85.   4. Bucky LP, Perec I. The science of autologous fat grafting: views on current and future approaches to neoadipogenesis. Aesthetic Surg J 2008;28:313–321.   5. Gormley DE, Eremia S. Quantitative assessment of augmentation therapy. J Dermatol Surg Oncol 1990;16(12):1147–1151.   6. Eremia S, Newman N. Long-term follow-up after autologous fat grafting: analysis of results from 116 patients followed at least 12 months after receiving the last of a minimum of two treatments. Dermatol Surg 2000;26(12):1150–1158.

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  7. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367.   8. Coleman SR. Structural Fat Grafting. St. Louis, MO, Quality Medical Publishing, 2004.   9. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119. 10. Ersek RA. Transplantation of purified autologous fat: a 3 year follow-up is disappointing. Plast Reconstr Surg 1991; 87(2):219–227. 11. Ersek RA, Chang P, Salisbury MA. Lipo layering of autologous fat: an improved technique with promising results. Plast Reconstr Surg 1998;101(3):820–826. 12. Shiffman MA, Mirrafatti S. Fat transfer techniques: the effect of harvest and transfer methods on adipocyte viability and review of the literature. Dermatol Surg 2001;27(9):819–826. 13. Smith P, Adams WP, Jr, Lipschitz AH, Chau B, Sorokin E, Rohrich RJ, Brown SA. Autologous human fat grafting: effect of harvesting and preparation techniques on adipocyte graft survival. Plast Reconstr Surg 2006;117:1836–1844. 14. Matsumoto D, Shigeura T, Sato K, Inoue K, Suga H, Kato H, Aoi N, Murase S, Gonda K, Yoshimura K. Influences of preservation at various temperatures on liposuction aspirates. Plast Reconstr Surg 2007;120(6):1510–1517. 15. Piasecki JH, Gutowski, KA, Lahvis GP, Moreno KI. Purified viable fat suspended in Matrigel improves volume longetivity. Aesthetic Surg J 2008;28:24–32. 16. Horl HW, Feller AM, Biemer E. Technique for liposuction fat reimplantation and long term evaluation by magnetic resonance imaging. Ann Plast Surg 1991;26(3):248–258. 17. Berman M. The aging face: a different perspective on pathology and treatment. Am J Cosm Surg 1998;15:167–172. 18. Amar RE. Adipocyte microinfiltration in the face or tissue reconstruction with fat tissue graft. Ann Chir Plast Esthet 1999;44(6):593–608 (French). 19. Butterwick KJ. Fat autograft muscle injection (FAMI): new technique for facial volume. Dermatol Surg 2005;31(11 Pt 2): 1487–1495. 20. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000;26(12):1117–1128. 21. Butterwick KJ. Lipoaugmentation for the aging hands: a comparison of the longevity and aesthetic results of centrifuged vs. non-centrifuged fat. Dermatol Surg 2002;28(11):1184–1187.

9

Face Rejuvenation with Rice Grain-Size Fat Implants1 Giorgio Fischer

The Plastic Surgeon is undoubtedly the greatest of all contemporary artists. He paints on living canvas and sculpts in human flesh. C.H. Willi

9.1  Introduction Augmentation and restoration of different parts of the body has been the cosmetic surgeons’ primary goal for centuries. Various alloplastic, allogenic, and xenograft materials have been used with this intent. The perfect filler has not been invented yet, but I believe that fat is the best material we can use. No allergic reaction has ever been reported in literature with the use of autologous fat. Facial enhancement for young women or rejuvenation for elder women with rice grain-size fat parcels is, according to me, one of the greatest inventions of the century. Along with the aging process comes the loss of fat which consequently affects the texture of the face skin itself. It is only by cosmetic surgery that we are able to give back vitality and new skin texture to an elderly looking face.

9.2  History After the invention of liposuction together with my father, Arpad, in 1974, I was confronted with the problem of having to correct depressed areas where too

Reprinted with permission of Lippincott Williams and Wilkins.

1

G. Fischer Via della Camiluccia, 643, 00135 Rome, Italy e-mail: [email protected]

much fat had been taken out. The corrections were made by filling the depressions with adipose tissue taken through a cannula from the patient. The areas were frequently overfilled. More than 50% of the graft was lost. For many years I did not realize the mistake I was making. Today the technique I use differs very much from these first attempts. It is only about 12 years ago that my interest in facial rejuvenation with the use of autologous fat was rekindled. Fournier and I were in London and we came across a book that changed my career. The book was entitled THE FACE and its improvement by aesthetic plastic surgery and was written by Charles H. Willi in 1926 (Fig. 9.3). Over 90 years ago Willi described the use of autologous fat delivered with a syringe for the correction of face lines and the loss of tissue. This technique employed by Willi represents the method that is most similar to our current approach (Fig. 9.1). Around 1985 the author had begun to augment the zygomatic and malar regions with autologous fat and to fill deep nasolabial folds. At that time overfilling the areas was to compensate early graft loss. As a result, more than 50% of the graft was lost. By 1992, with better understanding of grafting tech­ niques and physiology of adipose tissue, the author began to harvest adipose tissue with small syringes and a sharp needle and the processing technique was abandoned. Since less fat was transferred, there was a great increase in long-term survival and a decrease in early graft loss. The larger the graft, the less chances it has to survive and this is because the implants survive by imbibitions. If the graft is too large, the central part of it goes towards a phenomenon of necrosis. In 1997 the author developed a technique that consisted in the transfer of rice grain-sized fat parcels for total facial rejuvenation. The technique focuses on

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_9, © Springer-Verlag Berlin Heidelberg 2010

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G. Fischer

a

c

d

b

e1

e2

Fig. 9.1  (a) Willi’s cover book. His book has never been cited in any plastic surgeon’s work. (b) Willi’s portrait. (c) Dr. Willi correcting facial lines and loss of tissue. (d) Dr. Willi transferring

fat to face. (e) Dr. Willi’s results with peeling and restoration of fat implantation around the mouth (e1) before; (e2) after

multiple transfers to the subdermal, intradermal, muscular, and fat layers using a microcannula to deposit tiny parcels of adipose tissue. The size of the graft is fundamental to ensure early and reliable neovascularization. This is why any implant whose size

is bigger than that of a rice grain, has less possibility of survival. Different authors describe different techniques of procedure in regard to instrumentation, harvesting processes, processing, and transfer techniques. Data of

9  Face Rejuvenation with Rice Grain-Size Fat Implants

a

b

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survival rates are inconsistent. The author has observed an 80–90% chance of survival with rice grain-size implant if the face is not overfilled. The procedure has to be repeated at least two times. The procedure is ideal for relatively young patients or older patients associated with other procedures. The implants stimulate new-vessel formation and give the skin an improved color, consistency, and texture. The next step in the evolution of this grafting technique focuses on the lines of gravity and other factors that determine the vector of placement of fat parcels. Fat is placed in an oblique manner, perpendicular to the nasolabial, marionette, orbicularis, and crow-feet folds; previously we used to work parallel to these folds. The great innovation of this technique is the fact that we are now working perpendicular to them. Insert­ing  the grafts in this way strength lines are created that contrast these same folds. Fat is deposited from the chin to the forehead in a herringbone manner; the head of the herringbone at the chin and the tail towards the forehead (Fig. 9.2). Much still has to be learned and proved in this technique but I believe this will be our future.

9.3  Preoperative Evaluation

c

As in any other cosmetic procedure, preoperative evaluation is very important both for the surgeon and for the patient. It is only by observing the patient in his/her normal attitudes that we are able to note the harmonies or disharmonies of a face. We must also try to understand what type of objective the patient wants to achieve. The patient must be informed that she will need at least another procedure, in 3 months’ time. The patient must also be informed that smoking is forbidden in the month prior and following the procedure. Initial consultation is important also because filling might represent only an adjunct procedure. Donor sites must be recognized and marked. Pictures are taken.

9.4  Harvesting Fig. 9.2.  Entry site at the angle of the mouth allows transfer of fat. (a) Cheek. (b) Posterior zygomatic area. (c) Anterior zygomatic area

All harvesting procedures are performed using intravenous sedation and modified tumescent anesthesia for harvest. The donor site is selected based on the

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availability of fat. Preferred areas are the flanks, the lower abdomen, the medial part of the thighs and knees, with the middle plane of fat being harvested from these anatomical sites. The donor site is prepared and draped in the usual sterile fashion as for liposuction. Modified tumescent technique is used for infiltration: lactated Ringer’s solution, xylocaine 10% and adrenaline. Approximately 25% of the normal amount usually administered for liposculpture is used. This quantity allows a more concentrated aspirate. An 18G needle attached to a 1 ml Luer Lock syringe is used. The 1 ml syringe is optimal since a larger one would end up in having too much strength in aspirating fat; what we want instead is lobulated rice grain-sized fat. The cannula used to transfer the fat is attached to the same syringe. The cannula is 1.6 mm wide. This avoids manipulation of fat and contamination of it with air, decreasing the rate of graft death. The harvest needle is directed in a spoke wheel fashion in order to prevent depressions of the skin overlying the donor site. Harvesting should be carried out in a slow and constant manner. It should be a constant and delicate movement. Excessive pressure on the donor site will end up in too much oil in the graft as a result of the rupture of the adipose cells. The syringe is then placed on the server in an upright position.

9.5  Fat Processing Fat can be processed in three ways. It can be centrifuged. Centrifuging will allow the graft to be isolated and separated quickly. The author believes it has a high risk of damaging the fat cells. The fat can also be washed with saline solution. The less we manipulate the fat, the less we risk damaging it. This is why the aspirate is allowed to settle for 5–6 min into two distinct layers. The bottom and more dense layer contains xylocaine and lacated Ringer’s solution, and the top layer will contain only viable fat cells. If the fat is harvested in the correct way, the two layers will not be present and only fat will be present in the syringe. The graft is not manipulated or touched in any way.

G. Fischer

9.6  Fat Transfer Face rejuvenation with my technique should be a sculpture, a contouring of the anatomical variations that can be present in every patient. The face should be studied in each aesthetic unit; not even an inch should remain unstudied. As already mentioned, transfer cannula is attached to the Luer Lock syringe. The entry site for the cannula is anesthetized and a small stab incision is made with a number 11 blade. The entrance incisions are placed on the margin of the hairline in the temple, at the angle of the mouth and under the chin (Fig. 9.2). From these entry sites we are able to transfer fat throughout the entire face. The fat parcels are transferred in a herringbone manner and the microcannula moves in a fanwise direction following the lines of the herringbone. The fat is deposited slowly and the fat lobules are transferred on insertion and withdrawal of the cannula. The cannulas are 1.6 mm wide and 10–13 cm long. The tip of the cannula is blunt, flattened and resembles a duck’s beak. They can be straightened or curved based on the different necessities of the anatomical region. Total face rejuvenation with rice grainsized fat parcels placed in a herringbone manner is able to give thickness to those areas of the face that have defatted with time. I do not use more than seven or eight syringes of fat for each side of the face, and this means that no more than 14 or 16 ml of fat are used for the entire face. Anything more than this will not survive. Only in this way will lobules of fat have the maximum capacity of receiving blood and rapid neovascularization occur. The face can be divided into a third superior, a third medial and a third inferior part. Each of these parts contains critical key points in which fat has to be placed. For what concerns the superior part of the face, the frontal and temporal areas are very important. The slight ptosis of the eyebrows that occurs with time is due to increased skin laxity and loss of fatty layer overlying the galea. Deposits of fat over the forehead will give a lifting effect of the eyebrows. The fat deposits on the forehead act against the force of gravity lifting the forehead and brow in an upward direction. Fat should not de deposited at more than 2 cm distance

9  Face Rejuvenation with Rice Grain-Size Fat Implants

from the superior margin of the eyebrow; otherwise a ptosis of the brow might occur. The eyebrow lift should be finished with filling of the eyeshadows under the eyes. These are a frequent sign of aging but it is often seen in young patients as well. Eye shadows are caused by the orbicularis oculi muscle that shines through the delicate transluscent infraorbital skin. This can be corrected by infiltrating a couple of cc of fat. Fat inserted in this area must be massaged by the patient. The implants must be carried out in a very delicate way. Single deposits are needed otherwise lumps might be visible after the operation. The temporal area is another important key point that should not be forgotten. Frequently with age, this area loses the normal quantity of fat present. The absence of fat here gives the patient a “skeleton look.” The roundness of this area is one of the criteria for a young looking face. Fat transfer in this area is however only for expert surgeons. This is a very delicate area where superficial vessels are very well represented. For what concerns the third inferior of the face, an important area is certainly the nasolabial fold. Today I do not place the grafts in the same way I did in the past. Fat is always deposited perpendicular to the fold. Attention should be paid to the triangle placed under the ala of the nose. This triangle has its apex facing the chin. If this triangle is filled the immediate effect will be that of the disappearing of the nasolabial fold. The perioral area can be thickened with this technique.

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Insertion of grafts in the chin and along the whole mandibular region enhances and rejuvenates the whole face.

9.7  Postoperative Care No sutures are needed on the temporal and perioral areas. Reston foam is applied on the donor site. Patients remove Reston foam after 2 days. After a further 7 days they come for a first check, and then after 3 months. Pictures are taken on both occasions. After 3 months, the restored area is evaluated further and additional augmentation is performed.

9.8  Discussion Face rejuvenation with rice grain-size fat implants is a versatile procedure. If carried out in the correct manner it has an effective and long-lasting result. The technique avoids excessive and unnecessary manipulation of the graft. Processing of fat is eliminated. Recon­ touring using autologous rice grain-size fat parcels involves precise layering of the graft in order to ensure a natural result. Overfilling of the face should be avoided.

Fat Transfer in the Asian

10

Samuel M. Lam

10.1  Introduction Rejuvenation of the aging Asian face mandates a unique set of strategies that differs from that of the Occidental face. However, certain commonalities stretch across racial divides. Fat transfer has become the cornerstone for facial rejuvenation in all races and genders for almost all age groups, as volume loss is a principal sign of aging in all categories. Although the principles of fat transfer are universal, the use of fat grafting specifically to modify and enhance an Asian face will be highlighted in this chapter.

10.2  Cultural Issues Although facial enhancement in its broadest sense may be the main objective for the Asian patient seeking facial plastic surgery, at times there may be a layered agenda that combines elements of cultural biases and folkloric beliefs. For instance, some Asians seek dimple fabrication solely for the inspired belief that a dimple will impart greater fertility or prospect for marriage. Similarly, augmentation rhinoplasty may be undertaken for cosmetic improvement or alternatively may be thought to increase the likelihood of one’s future wealth or add to one’s perceived wisdom. Reductive otoplasty may be less common in the Far East as well since large ears can also be favorable signs of wealth and wisdom. While freckles

S. M. Lam Willow Bend Wellness Center, Lam Facial Plastic Surgery Center & Hair Restoration Institute, 6101 Chapel Hill Boulevard, Suite 101, Plano, TX 75093, USA e-mail: [email protected]

can be thought of as an adorable attribute in some whites, any blemish on untrammeled porcelain skin can be considered both unaesthetic and a marker of moral transgressions. Fortunately, because of this fact and the fear of looking tanned (which is considered unaesthetic), many Asians loathe the sun and protect themselves from the effects of photoaging. In addition, the Asian skin quality is already relatively impervious to photodamage compared with the Caucasian counterpart. Interestingly, these cultural biases that dominate behavior and attitudes in individuals who reside in the Far East can be transmitted even a few generations down to immigrated Asians who have lived in the West for all of their lives. Asians also tend to be much more secretive about cosmetic surgery, as compared with current climate in the West of a gradually relaxing attitude toward plastic surgery. Although HIPAA (Health Insurance Portability and Accountability Act) rules apply universally, the surgeon should be even more circumspect when speaking with family members regarding an Asian patient’s care. Because culturally plastic surgery is not as universally accepted in Asian communities, negative remarks by family members or friends who suspect or know that someone underwent cosmetic enhancement can have devastating psychological ramifications that can then in turn be transferred to the surgeon. Another consideration is the convergence today of standards of beauty. The high arched crease and sculpted eyelid that looks particularly artificial in the Asian patient and was the hallmark of “Westernization” procedures in the 1980s has slowly been replaced with watchful words like “ethnic preservation” and “cultural identity.” Interestingly, the high arched crease and sculpted eyelid that follows browlift and upper blepharoplasty in the aging Caucasian face have also become increasingly suspect in its capacity to rejuvenate and not make an individual’s identity appear unfavorably

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altered. The lower crease height and fuller eyelid contour can be thought of as more universal aspects of beauty that transcend race. The details of the strategy to achieve this aesthetic will be outlined in the following section on Asian eyelid rejuvenation. Despite this trend toward ethnic preservation, many Asians who wed Caucasians tend to desire softening their ethnic features with more aggressive changes to resemble their spouse more closely. Interestingly, many Caucasians are specifically attracted to these Asian or ethnic features in the first place and offer some resistance to that change. Delving into these cultural and psychological issues is paramount when consulting a prospective Asian patient. Certain ethnic differences also prevail between the major Asian races. For instance, Koreans and Vietnamese are in general more predisposed toward cosmetic en­­ hancement and will spend disposable income toward that end. Until recently, Chinese were not very inclined toward spending money on plastic surgery with the exception of the rising demand in modern day China, where it was outlawed until 1979. Asians who have always resided in the West or have lived there since they were very young tend to either adopt Western perceptions or carry the cultural attitudes of their parents, or be somewhere in between these two polar positions. Whatever the case, the surgeon should explore (or at least be aware of) these cultural and psychological beliefs that can inform Asians’ motivation to undergo facial cosmetic enhancement.

10.3 Strategies for the Aging Asian Eyelid The aging Asian eyelid poses unique technical and aesthetic challenges for the Occidental surgeon unfamiliar with anatomy, surgical techniques, and prevailing psychological attitudes. The three major surgical techniques that are important for ideal eyelid rejuvenation in the Asian patient include fat transfer to the brow/ upper ­eyelid, standard upper blepharoplasty, and supratarsal crease formation or “double eyelid” surgery. When to use which procedure will be the focus of this section. Technical details regarding each operative method lie beyond the scope of this chapter. The key objective besides eyelid rejuvenation in the Asian patient is preservation of supratarsal crease height so

S. M. Lam

a

b

Fig. 10.1  (a) Preoperative Korean patient born with an upper eyelid crease that would have looked worse if raised through traditional blepharoplasty and browlift procedure. (b) Postoperative following periorbital fat transfer to the brow, upper eyelid, and lower eyelid that has maintained if not slightly decreased her eyelid crease height

that results appear natural. In order to understand how to approach the aging Asian eyelid safely, we need to categorize the types of Asian eyelids into the three subgroups: aging Asian eyelids with a natural supratarsal crease, aging Asian eyelids without a supratarsal crease, and aging Asian eyelids with a previously surgically fabricated crease (Fig 10.1–10.3).

10.4 Aging Asian Eyelids with a Natural Supratarsal Crease Perhaps this situation appears rather straightforward. All the surgeon need undertake is a standard upper blepharoplasty and/or browlift and the patient is properly rejuvenated. Unfortunately, a standard blepharoplasty and browlift both serve to elevate the natural crease height oftentimes to an unnatural level. The author believes in the same way that this high-arched crease looks fundamentally unyouthful in a Caucasian and can unfavorably alter a Western individual’s eyelid. However, in the Asian this high crease can in addition look simply unnatural. Accordingly, if the crease height is slightly above the ciliary margin, fat transfer alone is

10  Fat Transfer in the Asian Fig. 10.2  (a) Preoperative Chinese patient with multiple incomplete partial creases that the present text states should be treated as if she has no crease at all. In addition, she has a relatively negative vector eye shape. (b) Postoperative after full facial fat transfer

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a

a

Fig. 10.3  (a) Preoperative Chinese patient with a more prominent steatoblepharon and a relatively high crease height due to fat involution. She also has a wide, heavy lower face. She would have had a terrible result with any kind of browlift and/or skin removal from the upper eyelid. (b) Postoperative following ­concurrent transconjunctival blepharoplasty and full facial fat

b

b

t­ransfer including to the inferior orbital rim, brow, and upper eyelid region. By filling fat into the periorbital region, anterior cheek, and anterior chin, the face can ultimately look more dimensional (less flat) and less wide. She also underwent a corset platysmaplasty to improve her neck contour

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used to perform upper eyelid and brow rejuvenation by restoring the lost convexity of youth and also thereby preserving crease height. In the individual with eyelid crease that rests at or below the ciliary margin, conservative removal of skin alone plus fat transfer can yield the optimal results without altering crease height.

10.5 Aging Asian Eyelids Without a Supratarsal Crease Asian eyelids that have a weak, impartial, or absent supratarsal crease can pose a difficult challenge to the Western surgeon unfamiliar with how to create a supratarsal crease, i.e., perform a “double eyelid” surgery. However, it is not entirely necessary to learn this technique but what is important is performing safe surgery in these kinds of patients. For example, the temptation in an aging Asian eyelid without a discernible crease is to arbitrarily remove skin at a predetermined height. The problem with this maneuver is twofold: a scar can occur that remains visible in the area of skin removal (since there will be no crease to hide it in) and/or the patient who has a naturally narrow palpebral fissure already (that is associated with a monolid appearance) will see little to no improvement in how tired his or her eyes look after simple skin removal. What is worse is if the surgeon interprets the fullness of the eyelid as requiring reduction and decides to remove postseptal fat, an unpredictable scar can develop between the preand postseptal tissues to create an eyelid crease when one was not intended. This eyelid crease can also be variable in its extent making the appearance even worse since it is only a partial crease. It is fundamentally important in an Asian patient without a crease not to simply cut away skin or fat. Accordingly, there are three options for eyelid rejuvenation in individuals without a crease: fat transfer alone to the upper eyelid/brow complex, “double eyelid” crease surgery, or a combination of both. With the absence of a crease, fat transfer can transform what appears to be hanging skin into a more youthful convexity without risking any change in identity that can follow “double eyelid” surgery or arbitrary skin/fat removal with a standard blepharoplasty. In the individual who truly believes that he or she always looked sleepy even in youth, then a “double eyelid” surgery

S. M. Lam

may be required for optimal result. However, creating a supratarsal crease requires special skill on the part of the surgeon, and also eyelid crease creation will fundamentally change the nature of the eyelid in that individual. As one ages, one’s self-image becomes more static in nature, especially in men. Therefore, creating a supratarsal crease at this later age must be carefully weighed with the patient. Furthermore, although the objective for a patient should be to have a very low crease following Asian “double eyelid” surgery that appears natural, the eyelid edema particularly below the crease itself can make the eyelid crease appear unnaturally high and full for an unacceptably long time for the aging Asian patient. It can at times take a full year before a crease height achieves an entirely natural height. For these reasons, it is very important that the surgeon counsel the aging Asian patient considering “double eyelid” surgery later in life who wants to undergo that procedure primarily for purposes of eyelid rejuvenation. The third option mentioned is performing both supratarsal crease formation blepharoplasty and fat transfer for optimal eyelid rejuvenation in those who would benefit from such combined intervention and who would desire to proceed accordingly. In this circumstance, it is important for the patient to undergo the “double eyelid” procedure first since edema from fat transfer can make the ability to read symmetry virtually impossible, which is critical during “double eyelid” surgery. The patient should also be awake enough toward the end of the procedure to open and close his or her eyes to gauge the accuracy of symmetry. Fat transfer can safely proceed after symmetry has been confirmed and the “double eyelid” surgery is completed. One further nuance should be elaborated upon. At times, some Asians appear either to have a very slight crease or a slight crease only on one side. In these circumstances, they should be treated as individuals who have no crease at all.

10.6 Aging Asian Eyelids with a ­Man-Made Crease The final category of the aging Asian eyelid that merits separate attention is the aging Asian eyelid that has had a previous surgical crease created. If the crease was made

10  Fat Transfer in the Asian

in the past decade or so and undertaken in a conservative fashion, then the patient can be treated like an individual who naturally has a supratarsal crease. However, if the crease is originally “Westernized,” that is, overly sculpted and excised with the objective of a high crease, a different strategy must be enlisted. There are two ways to discern whether this is the case. First, simply looking at the individual will present to the surgeon the appearance of something unmistakably artificial looking to the upper eyelid despite the fact that the crease height is low. The reason for this fact is that the patient most likely underwent an aggressive “Westernization” procedure many years ago and with ongoing brow deflation, the crease height has fallen to a “natural” level but the thick brow skin now overhangs the eyelid skin and creates an unnatural look. Second, the way to confirm this fact is to lift the eyelid skin upward and see how high the original crease was. Generally, the crease was most likely made excessively high like 20 mm or beyond above the ciliary margin. Looking at an individual’s old photographs or asking him or her whether the previous eyelid height was very high can also be helpful. A standard upper blepharoplasty and/or browlift can unmask the unnaturally high crease height of the previous surgery unwittingly. Accordingly, about the only safe and reasonable approach in this individual is fat transfer to create convexity to the deflated eyelid contour without risking unmasking the unnatural crease height from before and thereby exacerbating the situation.

10.7 Strategies for the Aging Asian Face As far as rejuvenation of the aging Asian face, fat transfer can be the cornerstone to a successful outcome for several reasons. First, Asians have a predilection for hypertrophic scarring and hyperpigmentation, so a procedure that in essence removes these risks can be very attractive. Further, many Asians do not suffer from neck problems until an advanced age so a rhytidectomy may not be necessary comparative to the fairer-skinned races. Also, the weaker bone structure and thicker soft-tissue envelope predispose toward a poorer result when it comes to a lower rhytidectomy. The major drawback that can be foreseen in the Asian patient is why fat

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transfer looks good in the Asian patient who naturally may have more fat and soft-tissue already vis-à-vis their less angular bone structure. This question will be answered by understanding how to shape an Asian face with fat transfer to offset these problems. Most Asian faces appear to be wider and flatter than most Caucasian faces. Accordingly, fat transfer into the buccal region and lower lateral face like lateral mandible may serve to exacerbate the heavy quality of an Asian face rather than improve it. Instead, placement of fat along the prejowl sulcus, anterior chin, and anterior cheek can offset the heavy, wide, and flat qualities of the face in order to create a more artistically balanced face without radically altering identity. In addition, the relative premaxillary and lower chin deficiency that creates a simian appearance can also be balanced by focusing fat transfer to these specific deficient regions. The surgeon should be cautious when deciding to augment the outer malar region, i.e., the area that corresponds with the malar bony eminence, for two reasons. Many Koreans in particular have a very flared outer cheek region that they perceive as unattractive (for which many undergo malar bony reductions). Further, a wider flatter appearance to the face can be worsened by placing fat in the lateral face. For these reasons, in most cases the anterior cheek should be emphasized. In some Asians, the entire cheek complex appears excessively prominent. In this situation, some placement of fat into the buccal region can soften the appearance of the prominent cheek and there­ by improve overall facial proportion and balance. With all fat grafting endeavors, a level of artistry should be exercised to create a beautiful and balanced result.

10.8  Conclusions Fat transfer is an important method for facial reju­ venation in almost all races, gender, and age groups. However, specific application of this technique to the Asian face requires a combination of cultural sensitivity and expressed artistry. Understanding the Asian face and its problems may provide some thoughtful guidelines for the Western surgeon unaccustomed to dealing with the Asian patient except on rare or infrequent occasions.

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References 1. Lam SM, Glasgold MJ, Glasgold RA. Complementary fat grafting. Lippincott Williams & Wilkins, Philadelphia, PA, 2006. 2. McCurdy JA, Jr, Lam SM. Cosmetic surgery of the Asian face (2nd edition). Thieme Medical Publishers, New York, NY, 2005.

S. M. Lam 3. Lam SM. Aesthetic facial surgery for the Asian male. Facial Plastic Surgery 2005;21:317–323. 4. Lam SM. Aesthetic strategies for the aging Asian face. Facial Plastic Clinics of North America 2007;15(3):283–291. 5. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthetic Plastic Surgery 2003;27:397–402. 6. Shu T, Lam SM. Liposuction and lipotransfer for facial rejuvenation in the Asian patient. International Journal of Cosmetic Surgery and Aesthetic Dermatology 2003;5:165–173.

11

Subcison with Fat Transfer Melvin A. Shiffman

11.1  Introduction

Fig. 11.1  Toledo “pickle fork”

Scars are often tethered because of scarring to the tissues beneath the skin, usually fascia. This may cause a depression that is unsightly. Simply filling the depression with autologous fat or other permanent filler may not raise the skin permanently off the deep scar attachment. At the same time, only subcising will result in reattachment of the skin to the underlying scar. There is a need to subcise and add a filler underneath the region of detachment in order to prevent reattachment. Autologous fat is simple to obtain, inexpensive, and can be permanent.

11.2  Subcision The Toledo “pickle fork” (Fig. 11.1) comes in a variety of sizes and can be used to cut through subcutaneous scar, freeing up the overlying skin. To use the instrument, however, a small skin incision must be made depending on the width of the fork. Coleman devised a small pickle fork at the end of a hollow cannula with an opening just before the fork. This allows the injection of fat immediately after the subcision. The cannula can be used for subcision of the nasolabial fold, marionette lines, and glabellar lines at the time of fat injection. After subcising, the area should be compressed for at least 6 min to prevent bleeding. Blood is the enemy of fat grafting as fat cells can be reabsorbed by blood cells. Sulamanidze et al. (1) devised an instrument for subcision that is comprised of a wire attached to a

Fig. 11.2  Sula­manidze wire

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

straight needle (Fig. 11.2). Originally the technique was to start on one side of the lesion inserting a needle and then sequentially bringing the needle out of the skin and reinserting in the same hole to proceed to the

Wire

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_11, © Springer-Verlag Berlin Heidelberg 2010

Needle

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that could not be straightened out. This required cutting the wire at the point of the bend if there was enough intact wire left to complete the procedure or using a new needle and wire. A much simpler method was suggested by Fulton (2) that consisted of using 3-0 or 4-0 Vicryl either attached to the curved needle for small areas of depression or threaded into a Keith needle (Fig. 11.5). The needle is inserted through the skin a centimeter or more away from the depression and pushed through the subcutaneous tissue around one side of the depression. The needle is brought out through the skin on the opposite side of the depression and then turned around and inserted into the exit hole passing through the subcutaneous tissues on the opposite side of the depression from the original insertion. The needle is brought out through the initial skin puncture (Fig. 11.6). Vicryl

a Defect (wrinkles)

Needle Wire

b

Fig. 11.3  Initial technique with use of the wire. (a) Incomplete rectangle. (b) Danger of cutting through the skin when using a sawing motion to cut the scar Wire

Needle

Wrinkle

Fig. 11.5  Vicryl on curved or Keith needle

Fig. 11.4  Final technique with wire is to complete the oval and come out the original puncture site

next point forming an incomplete rectangle (Fig. 11.3). The needle was brought out at a point that was away from the original insertion site. This required care not to cut the skin when pulling the wire back and forth to cut the subcutaneous scar (Fig. 11.3). Ultimately the technique was changed to bring the wire out at the original point of entry and this would prevent cutting of the skin (Fig. 11.4). The major problem was keeping the wire from twisting and forming a bend in the wire

Fig. 11.6  Oval fashion of placing the Vicryl thread ending at the original insertion point

11  Subcison with Fat Transfer

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has a roughened surface that will cut through scar by using a back and forth motion.

11.3  Autologous Fat Injection The autologous fat can be obtained from the lower abdomen, lateral hips and thighs, or medial knees. The instrument used to harvest the fat is a blunt tipped ­2.5-mm cannula for fat to be inserted in the body or ­2.0-mm cannula for insertion of fat into the face or neck. The harvested fat is washed with normal saline and excess fluid decanted. Pure fat appears yellow and should not contain any blood products. About twice as much fat as determined for use should be removed and left-over fat frozen for future correction of any residual deficit.

Fat is injected with a 2.5 or 2.0-mm cannula through the original needle openings in each side of the depression. This is not only injected in tunnels into the level of the subcision area but can also be injected into tunnels at other levels of the tissues. Usually it is necessary to overinject about 10% since some fat is lost by absorption.

11.4  Conclusions Depressed scarred areas can be relieved with subcision and insertion of fat as a permanent filler. The total combined subcision and fat transfer technique is easy to learn and the results are satisfying to the patient and the surgeon (Fig. 11.7).

a

b

c

d

e

f

Fig. 11.7  Subcision and fat transfer to depressed scar of neck. (a) Indented scar in the right neck following infection as a child. (b) Marking area for subcision and fat transfer (c) Local anesthesia being injected. (d) Subcision can be performed with an 18-gauge needle. (e) The needle is swept side to side in the subcutaneous tissues under the depressed skin. (f) A Keith needle with 3–0 Vicryl. (g) The needle is inserted subcutaneously and passed along one side of the depression. (h) The needle is brought

out at the opposite end of the area of depression. (i) The suture has been passed around both sides of the depression and brought out of the original entry site. (j) The suture ends are held with slight tension and then with a sawing motion they will cut through the scar and come out at the entry site. (k) Washed fat for transfer. (l) Fat injected into depressed area with a small cannula. (m) Final result with the scar subcised and the depression filled

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M. A. Shiffman

i

k

l

h j m

Fig. 11.7  (continued)

References   1. Sulamanidze, M.A., Shiffman, M.A., Sulamanidze, G.M. Management of Facial Rhytids by Subcutaneous Soft Tissue Dissection. Int J Cosmet Surg Aesthetic Dermatol 2000; 2(4):255.   2. Fulton, J. Personal communication 2005.

Autologous Fat Transplantation for Acne Scars

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Bernard I. Raskin

12.1  Introduction There exist a bewildering array of injectable fillers which include short and longer duration products, as well as the recent introduction of permanent implantable agents. Lipofilling of acne scars is less frequently considered than other agents such as hyaluronic acids, and in particular subsets of acne scars autologous fat may be the optimal choice (1). Typically acne scars require more than one treatment modality, such as lasers and lipofilling injections (2). Frequently several autologous fat injection sessions are needed. As with many scar revision procedures, results are commonly imperfect and may conflict with patient expectations. Acne scars are complicated problems because the surgeon is dealing with scar tissue, three-dimensional contours affected by light and shadow and the often associated problem of dispigmented skin.

12.2  Volumizers and Fillers Injected contouring agents can be characterized primarily as volumizers, fillers, or both. Volumizers, such as Sculptra®, are introduced to enhance substantial defects of cheek hollows in fat-depleted HIV patients. Hyaluronic acids (Restylane®, Juvederm®, and others) are primarily considered fillers, and are effective for nasolabial folds; other similar deep rhytids are also often beneficial for superficial creases. Radiesse® is an example of a combination volumizer-filler but with its own limitation in

superficial product placement. Autologous fat performs well as both volumizer and filler with relatively few problems. Thus surgeons have excellent choices for injectable agents for correction of gravity-related aging, volume loss, rhytides, and superficial creases. Both volumizers and fillers are important in acne scar rejuvenation. Autologous fat transfer has enjoyed a renaissance in the last several years. As with other surgical approaches, renewed interest has evolved from refined techniques, enhanced instruments, and knowledge gleaned by new research (3, 4). Understanding fat physiology, stem cells and metabolism has benefited an appreciation of the longevity that is possible with fat transfer (5). Micro droplet injection methods and the concept of multiple injection sessions allow more effective contouring of both deeper and superficial defects (6). In particular, the micro droplet approach offers the surgeon an opportunity to address superficial skin problems such as acne scars and relatively shallow rhytids. The use of frozen fat facilitates small repeat injection sessions as may be necessary in acne scar treatment (7). Significant and substantial improvement in many aspects of the aging face is achieved with injectable agents for volumizing and filling. Various products result in satisfied patients and the choices depend on the surgeon’s preference, the patient’s desires, and the cost. A high degree of predictability exists. The various filling and volumizing agents such as fat may help avoid more extensive surgical procedures previously necessary for aging skin.

12.3  Treating Scar Tissue B. I. Raskin Department of Medicine, Division of Dermatology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA e-mail: [email protected]

Acne scars represent an entirely different, highly challenging frustrating clinical problem. In essence, the issue involves surface and subsurface scar tissue rather

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_12, © Springer-Verlag Berlin Heidelberg 2010

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than normal anatomy. This is further complicated by the three-dimensional face on which light and shadow interact such that shallow and relatively minimal scars may at times appear harsh and objectionable. The scar surface often has overlying dispigmented skin so that the improvement in the scar after treatment may appear clinically suboptimal because of residual color anomalies. However, the same concepts of volumizing and filling apply as with other cosmetic defects. The difference with acne scars is that multiple therapeutic modalities are generally necessary to effect overall improvement, such as laser resurfacing and/or surgical excision. Filling injections into acne scars is but one of several types of treatments that might be required, and filling is not necessarily the most appropriate choice for all depressed scars. Scars may need filling, but underlying volumization may need to be addressed to achieve maximum improvement. Independent of the area of scars, other treatments may be necessary for the remainder of the face as part of the comprehensive improvement needed. Even with multiple modalities available, substantial predictability of results may be ambiguous at best and the number of treatments required is highly variable. Many acne scar patients are among the most highly motivated cosmetic patients seeking assistance with an understanding and appreciation of treatment imperfections. Others require substantial counseling and education. The author advises patients to expect overall a 50% improvement in acne scars - certainly expected results may be better but may also be less. Patient satisfaction is variable and may be less than the actual improvement since patients often anticipate more than realistically possible.

12.4  Physiology of Acne Scars Acne is a disease of the perifollicular sebaceous glands (8). In many individuals this results in the well known whiteheads and blackheads that are essentially dried sebum within the glandular orifice. This type of acne is non inflammatory and does not result in scars. However a bacterial infection within the obstructed orifice results in an inflammatory reaction. This reaction may be minimal causing small elevated acne lesions called papules. A substantial inflammation may develop causing large cysts and deeper nodules. All inflammatory lesions may scar, but whether a scar occurs is highly

B. I. Raskin

variable and appears to depend on ethnicity, sebaceous skin quality, genetic tendency to scar, and unknown factors. The scars that develop may be superficial or deeper in the skin. The scars may be depressed, or hypertrophic and keloidal. The face usually develops depressed scars but the torso regions not uncommonly have elevated scarring, especially in individuals with darker complexion. Depressed scars are of variable morphology and thus treatments depend on the nature of the scar. Determining the approach to any given acne scar, or area of acne scarring depends on multiple variables including patient age, health status, scar location, skin color, and tendency for discoloration. Additionally the characteristics of the individual scar or area of scarring is important, such as whether the scars are ice pick type with significant adjacent cicatrix, or softer superficial scars. Individuals often have several types of depressed scars.

12.5  Evaluating Acne Scars The surgeon needs to first analyze the background skin type. Fitzpatrick color should be established (Type 1 lightest to Type 6 darkest) as part of the initial examination. The nature of the skin quality is important to determine if the skin has a smooth surface or sebaceous oily skin. Thickness should be noted. Sebaceous skin is usually thicker. Smooth skin may be thin and atrophic from previous therapeutic interventions or advancing age. The specific areas of scarring are important to document. Scar discolorations should be identified and pointed out to the patient since scar improvement may be less noticeable when post inflammatory scar pigmentation exists. Other general considerations must address the patient’s age and extent of other cosmetic issues of significance. For instance, a relatively young patient with currently active cystic acne may need acne treatment first rather than cosmetic intervention. Patients with photo aging may require procedures additional to any acne scar treatment. The patient’s verbalization of a complaint about acne scars may not in fact be the true issues requiring treatment. The surgeon must be particularly aware of any gravity-induced issues or age-related tissue loss that may explain why the patient is currently presenting. In the author’s experience patients may initially present

12  Autologous Fat Transplantation for Acne Scars

in their forties or fifties complaining about acne scars. They often state that over time the scars have become more difficult to camouflage with makeup. The scars are visible as a result of facial volume loss, or decreased skin turgor and loss of elasticity. As facial skin begins to droop from aging, the skin becomes irregularly suspended from fibrotic areas of scar, creating an uneven rolling appearance with step like drop offs. Treating just the acne scars in these patients provides only minimal or partial improvement. In fact this group of acne scar patients decidedly benefits from volumizing the underlying tissue loss, and/or tightening the skin. In terms of the volumizing needed, autologous fat transfer can be particularly useful.

12.6  Acne Scar Morphology There is not a well established descriptive or nomenclature system for acne scars, with the exception of the term “ice pick scarring.” Various approaches have been utilized to try and classify acne scars (1, 9), but the author has found that descriptive methods work best. Are the scars discrete (e.g., few scattered scars over an entire cheek) or numerous? What is the depth of the scar? Is the scar size small (a few millimeters) or wider? Is the individual scar well demarcated, or poorly marginated? Does the scar appear almost punched out (also known as crater form or ice pick)? Is the surrounding skin flat, or has there been so much acne activity that the skin has the characteristic of rolling hills and valleys? Is the adjacent tissue hard and scar like or relatively soft and elastic? Since there are typically multiple types of acne scars on any one person, the author has found it beneficial to utilize photos for marking and describing lesions. Checking to see if the scar is distensible is a crucial point. If the surgeon stretches the adjacent skin on opposite sides of the scar and the scar flattens, then the scar is much more amenable to various treatment options. If the scar is bound down and doesn’t flatten or smooth out with stretching, then the scar is substantially more resistant to any therapeutic modality. The term “ice pick scar” is a generally accepted description of a type of acne scar. The description comes from the concept of a sharply demarcated ice pick hole in ice. The dystrophic scar appears like a punched our crater and is usually deeper than it is wide. It is not

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distensible. This type of scar may be quite small and occur in a cluster of similar small scars on the malar prominence, or may be individual and large. Typically the surrounding tissue is firm and cicatricial. This type of scar is typically resistant to most forms of therapy, including surgical excision because of the extent of surrounding cicatrix. These descriptions are primarily useful on facial scars. The same considerations apply to scars on the torso but treatment for those scars overall is more challenging and results are generally less substantial. Elevated hypertrophic scars are common on the torso but rare on the face.

12.7  Acne Scar Treatment Options As many methods of treatment exist, the overlapping benefit is common. There is no single approach that stands out as most effective. Choices are dictated by the type of scars, age issues, skin color, financial considerations, procedural risk, and upon the patient’s acceptance of any available option. The intent of this chapter is to review autologous fat transfer as one option; however lipofilling may be utilized as part of a comprehensive approach treating both the acne scars and other related cosmetic issues (10). As a dermatologist, the author has considerable experience in various methods including full dermabrasions, CO2 and erbium resurfacing lasers, non ablative laser modalities, fractionated lasers, variable depth peels, multiple filling agents, excisions, grafting, and skin tightening modalities. A consistently beneficial approach in the author’s opinion is surgical subcision (11). In fact subcision is necessary to place any filler under a tight scar. Dermabrasion with a motorized diamond wheel or wire brush was the standard of care prior to lasers and fillers, and is now used more as localized dermasanding (12, 13). The concept became more refined with the accuracy allowed by high energy CO2 and Erbium (14, 15) laser resurfacing, where the surface of the skin was entirely removed to the level of the papillary dermis. This allowed tissue remodeling with the formation of new collagen and generally resulted in a smoother skin surface with reduction of acne scars. While highly effective and still utilized in the proper circumstance, the process was invasive and hypo pigmentation was common. In the author’s opinion, many of the somewhat older

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patients who benefited did so because the skin tightened substantially primarily with the CO2 laser. The technique had preclusions in the color of the skin. Non ablative (16) lasers were designed to keep the skin surface cool and unaffected while at the same time heating the underlying collagen enough to initiate collagen remodeling. Multiple treatments are required (often about 12 treatments with the 1,450 nanometer Smooth Beam), and significant improvement can occur however more often results are modest but noticeable (17). These lasers may be used in most Fitzpatrick skin types with some limitations (18). Fractionated Lasers are the newest modality, and can be beneficial, with minimal downtime and substantially reduced risk compared to the older high energy CO2 and Erbium systems (19). Depending on the type of system, one or several treatments may be needed. Skin tightening modalities (Thermage® and others) also benefit acne scars, probably from the skin contraction making the scars appear smaller and more superficial. Resurfacing Lasers including CO2 may also be utilized after fat injections (20). Monopolar radiofrequency has no adverse effect on commercial soft tissue fillers, although fat has yet to be specifically studied (21). Peels (22), even very mild no downtime glycolic peels, when repeated multiple times can be useful for mild acne scars. The reason appears to be that even superficial peels stimulate some amount of collagen remodeling, and over time skin smoothing occurs. Microdermabrasion has been suggested to be useful (23). Higher strength trichloroacetic acid (24) can be applied to individual scars and is helpful in combination with injectable fillers. Surgical scar excision, with or without skin or dermal grafting is considered a mainstay of treatment for ice pick or deep atrophic scars, with or without resurfacing techniques (9, 25–27). Surgical Subcision is simple, minimally invasive, performed under local anesthesia and is integral to successful filler treatment of acne scars by establishing a space for injection of the filler or fat (20, 28, 29). Since many acne scars are bound down, injecting fat or other filling substance directly under or into the scar without prior subcision can result in extrusion of the filling substance into the non scar surrounding tissue, and the clinical result is an elevated donut of filler substance around the scar. The author’s preferred subcision technique utilizes  variable gauge needles (18–26 gauge) inserted

B. I. Raskin

horizontally or at a slight angle adjacent to the scar. For larger scars or wider area treatment, a filter needle (Nokor, Becton Dickinson, Franklin Lakes, NJ) is excellent when sharp dissection is needed or a blunt cannula can also be effective if the subcision is within the fat (1). The needle is moved back and forth horizontally under the scar in a fanning configuration such that the entire cicatrix binding the scar is released. The subcision is usually performed from at least two insertion points so the tunneling is at 90° from the previous direction and large areas of scars can be treated easily at one session. The depth of the subcision is based on the cicatrix underlying the scar. On superficial scars, the subcision level is within the dermis while on deeper scars, the subcision is sub dermal or within the fat. Subcision at multiple depth levels can be accomplished at the same session on the same scar. Blood should not be removed from the pocket because the blood stimulates new collagen formation thus elevating the depression over time. Subcision repeated monthly may be effective as a monotherapy for some acne scars. Subcision is always performed immediately prior to filler or fat injection. Scar or dispigmentation developing at the needle insertion sites is rare.

12.8 Lipofilling Acne Scars (Figs. 12.1–12.4) Fat is not considered generally effective for individual bound down ice pick scars (30). However once the scar is freed, fat may be satisfactorily injected. For widespread grossly atrophic disease in combination with deeper tissue destruction, fat should be considered as the optimal filling and volumizing agent (1). Fat is an excellent deeper augmenting injectable in acne scars (1). Issues of permanence are gradually being resolved. Fat no longer appears to be as temporary as initially considered (31,  32). Accurate long lasting autologous corrections can result (1, 33, 34). When higher volumes are required, fat injections can considerably save costs for the patient (35). Fat can be combined with other resurfacing techniques (20). Numerous methods exist for harvesting, preparing and injecting which speak of the empirical nature of fat injections. Various factors may contribute to fat cell survival: harvesting method, manipulation of fat, exposure to blood or lidocaine, recipient site, donor site, centrifugation, injection method including syringe and

12  Autologous Fat Transplantation for Acne Scars

Fig. 12.1  The skin is pinched, creating a tunnel, and fat is injected in multiple tissue planes using a micro droplet technique

Fig. 12.2  Acne scars are treated by both volumizing the deeper underlying tissue and injecting superficially directly beneath the scar

needle size and overcorrection. These factors have been reviewed (33, 36, 37) without definitive result although differing opinions exist (3). However, a review of survival rates has demonstrated that good results are obtained independent of the technique employed when small

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Fig. 12.3  Marking of focal areas injected at a touch-up session utilizing the patient’s frozen fat

volumes are used (37). In histologic studies, the diameter of fat should be less than or equal to 3 mm for effective neovascularization (38). The donor area is selected in consultation with the patient. Hips, outer thighs, and medial knees provide a bloodless dense fat, although the abdomen is also convenient. An optimal donor site has not been documented (39) although it is felt that the take is similar among regions aspirated (40). Fat is harvested under the tumescent technique with blunt-tipped cannula, and manual aspiration with 10-mL syringes is effective (41). The fat is allowed to settle in the upright syringe, and the fluid is decanted. The syringe is then centrifuged for a few minutes, and transferred through a sterile syringe coupling device to 1-mL syringes since small syringes provide more control and less pressure is needed to deliver aliquots. Extra fat may be frozen for later use (3). As with lipofilling of cosmetic defects, the procedure should be considered as a multi treatment program. Small volumes are required even if multiple scars are infused, and as such the use of frozen fat aliquots from a single harvesting will save considerable time with future injection sessions. Any volumization should be performed first. While patients in the teens and early 20s may infrequently require volumizing, most patients that are older do need the enhanced volume. Volumizing smoothes and

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a

rounds the overall facial contour which reduces shadowing. Thus even when microinjecting fat intralesionally within the scar after subcision, the author still recommends instilling at least a small amount underneath to volumize the area. This helps to stretch or distend some scars making them more superficial in appearance. But the importance of overall facial volumizing is that a rounded facial contour has relatively the same shadowing in most head positions. The next step involves micro lipo injection of the individual scars. Fat will not normalize the contour unless the residual scar attachments are destroyed first. Subcision as described above should be completed initially and the blood from subcision should be left under the skin and not intentionally extruded. Because of the small fat volumes utilized, centrifuged fat will be more concentrated. The fat need not be blood free since blood stimulates new collagen formation in the injection pocket. When a larger infiltration needle or cannula is utilized, a nick is often made in the skin first - this can be accomplished with a Nokor® needle or #11 blade. The incision can be at a distance from the scar, allowing access to a wider area of treatment. When injecting under small scars, the injections should be performed with the surgeon’s choice of the smallest effective needle to allow accurate micro droplet infusion. Injections can be in any tissue plane as determined by the subcision, or within all three (intra dermal, sub dermal and subcutaneous) tissue planes (42). Only micro droplets are usually needed for intra dermal or immediate sub dermal placement. Often infusion is best accomplished as the needle is withdrawn. The endpoint is a slight over correction. Fat should be injected deeply as a three dimensional lattice with 0.1–0.2-mL aliquots. The site is gradually built up to enhance the superficial layers in a lipo layering technique (43). Approximately 50% of transplanted fat should be expected to survive (1). Thus touch up procedures at 3 months may be needed. Overcorrection of about 10% is usually needed. Post operative care usually only requires antibiotic application to the injection sites. Post operative pain is minimal, and oral antibiotics are not required in the author’s experience. Significant edema can be treated with a short course of oral steroids. Residual frozen fat can be utilized up to 12 months later (1).

b

Fig. 12.4  (a) Pretreatment photo of a 50-year-old female with acne scars. There are hollows in the cheek and loss of volume in the malar, periorbital, and perioral regions. (b) Significant overall improvement after a multi modality treatment program with Sculptra, Thermage, and fat. The face has a full rounded quality. Acne scars are considerably reduced. Fullness is present in the periorbital and perioral regions. The skin appears brighter due to increased light reflectance which is common in the author’s opinion after volumizing

12  Autologous Fat Transplantation for Acne Scars

12.9  Longevity Longevity of fat transplants has been extensively studied although consistent results in the literature varies (44–46). Theories include replacement fibrosis, neovascularization of transplanted fat, and differentiation of lipocyte stem cells into mature adipocytes (4, 37, 47– 49). Duration has not been specifically studied in acne scars. However one study of depressed post surgical scars in 30 patients utilizing a subcision technique followed by autologous fat grafting through 4-mm cannula, revealed 27 with very good results at 3 years (50). Two patients required an additional treatment at 6 months due to partial recurrence. A case of greater than 2-year persistence of autologous fat transplantation into a large post radiation thigh defect has been reported, although several sessions were required over 3 years to obtain satisfactory benefit (51). Recent research focuses on lipocyte stem cells rather than mature adipocytes as the driving force in long term clinical benefit for post radiation depressed scars (47). It has been established that adipose tissue contains a clonogenic pool of stromal cells having the same functional and immunophenotypic properties of bone marrow mesenchymal stem cells. Mesenchymal changes have been seen in the early stages after adipose stem cell transplant, and after maturation the tissue showed normal mature lipocytes. Based on recent studies (52, 53), administering the stromal vascular component of the adipose tissue which is rich in stem cell elicits an angiogenic factor response resulting in the formation of new vessels and an environment facilitating the development of mature adipocytes from stem cells.

12.10  Complications Complications after autologous fat transplantation are usually temporary and are the same as with fat injections for aging and volumizing. These include edema, ecchymosis, and variable contour irregularity and these may last a few weeks or longer (49).45 Occasional fat protrusions and persistent edema can be seen in the periorbital area. Localized fat hypertrophy has been described (54). Sterile fat cysts presenting as firm nodules can be

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reduced with triamcinalone or similar injected steroid locally into the site. Persistent inflammation can result in post inflammatory pigmentation or hemosiderin deposition. Other side effects documented from fat transplantation include herpes infection, localized lymph node enlargement and pain, localized infection, and rare cases of prolonged pain. Very rare adverse events have included blindness and cerebral artery infarction (55–57). Thus it is recommended particularly around the eyes that fat transfer occur while withdrawing the cannula under minimal syringe pressure (47). Additional complications may result from concomitant cosmetic procedures performed on the same anatomical area.

12.11  Conclusions Fat is a successful method for acne scar improvement, both in volumizing and filling for enhanced results. The concepts and understanding of the microbiology and physiology is evolving, with a trend towards considering the adipose stem cell as the main component providing long term results.

References   1. Goodman GJ, Baron JA. The management of postacne scarring. Dermatol Surg 2007;33(10):1175–1188.   2. Rivera AE. Acne scarring: A review and current treatment modalities. J Am Acad Derm 2008;59(4):659–676.   3. Markey AC, Glogau RG. Autologous fat grafting: Comparison of techniques. Dermatol Surg 2000;26(12):1135–1139.   4. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118(3S):108S–120S.   5. Rigotti G, Marchi A, Galie M, Baroni G, Krampera M, Pasini A, Sbarbati A. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007;119(5):1409–1422.   6. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: Indications, technique, and complications. Dermatol Surg 2007;33(5):572–578.   7. Shoshani O, Ullman Y, Shupak A, Ramon Y, Gilhar A, Kehat I, Peled IJ. The role of frozen storage in preserving adipose tissue obtained by suction-assisted lipectomy for repeated fat injection procedures. Dermatol Surg 2001;27(7):645–647.   8. Goodman GJ. Post acne scarring: A short review of its pathophysiology. Australas J Dermatol 2001;42(2):84–90.

76   9. Kadunc BV, Trindade de Almeida AR. Surgical treatment of facial acne scars based on morphologic classification: A Brazilian experience. Dermatol Surg 2003;29(12):1200–1209. 10. Grevelink JM, White VR. Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring. J Dermatol Surg 1998;24(5):527–530. 11. Burres SA. Recollagtenation of acne scars. Dermatol Surg 1996;22(4):364–367. 12. Zisser M, Kaplan B, Moy RI. Surgical pearl: Manual dermabrasion. J Am Acad Dermatol 1995;33(1):105–106. 13. Harris DR, Noodleman FR. Combining manual dermasanding with low strength trichloroacetic to improve actinically injured skin. J Dermatol Surg Oncol 1994;20(7):436–442. 14. Alster TS, West TB. Resurfacing of atrophic facial acne scars with a high energy, pulsed carbon dioxide laser. Dermatol Surg 1996;22(2):151–154. 15. Kye YC. Resurfacing of pitted facial scars with a pulsed Er:YAG laser. Dermatol Surg 1997;23(10):880–883. 16. Friedman PM, Jih MH, Skover GR, Payonk GS, KimyaiAsadi A, Geronemus RG. Treatment of atrophic facial acne scars with the 1064 nm Q-switched Nd:YAG laser. Arch Dermatol 2004;140(11):1337–1341. 17. Chan HH, Lam LK, Wong DS, Kono T, Trendell-Smith N. Use of 1,320 nm Nd:YAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians. Lasers Surg Med 2004;34(2):98–103. 18. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450 nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin: A prospective clinical study. Dermatol Surg 2004;30(10):1287–1291. 19. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004;34(5):426–438. 20. Goodman GJ. Autologous fat and dermal grafting for the correction of facial scars. In: Harahap M (Ed), Surgical Techniques for Cutaneous Scar Revision. New York: Marcel Dekker, 2000; pp. 311–347. 21. England LJ, Tan MH, Shumacker PR, Egbert BM, Pittelko K, Orentreich D, Pope K. Effects of monopolar radiofrequency treatment over soft tissue fillers in an animal model. Lasers Surg Med 2005;37(5):356–365. 22. Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical peels in the treatment of acne scars in dark skinned individuals. Dermatol Surg 2002;28(5):383–387. 23. Tsai RY, Wang CN, Chan HL. Aluminum oxide crystal microdermabrasion: A new technique for treating facial scarring. Dermatol Surg 1995;21(6):539–542. 24. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: Chemical reconstruction of skin scars method. Dermatol Surg 2002;28(11):1017–1021. 25. Johnson W. Treatment of pitted scars: Punch transplant technique. J Dermatol Surg Oncol 1986;12(3):260–265. 26. Orentreich N, Durr NP. Rehabilitation of acne scarring. Dermatol Clin 1983;1:405–413. 27. Griffin EI. Punch transplant technique for pitted scars. In: Harahap M (Ed), Surgical Techniques for Cutaneous Scar Revision. New York: Marcel Dekker, 2000; pp. 259–273. 28. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995; 21(6):543–549.

B. I. Raskin 29. Branson DF. Dermal undermining (scarification) of active rhytids and scars. Enhancing the results of CO2 laser skin resurfacing. Aesthetic Surg 1998;18:36–37. 30. Guidelines of care for soft tissue augmentation. Fat transplantation. J Am Acad Dermatol 1996;34(4):690–694. 31. Ellenbogen R. Invited comment on autologous fat injection. Ann Plast Surg 1990;24:297. 32. Fulton J, Suarez M, Silverton K, Barnes T. Small volume fat transfer. J Dermatol Surg Oncol 1998;24(8):857–865. 33. Coleman SR. Long term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19(5):421–425. 34. Pinski KS, Roenigk HH, Jr. Autologous fat transplantation: Long term follow up. J Dermatol Surg Oncol 1992;18(3): 179–184. 35. Author’s personal observation based on standard acquisition cost of commercial hyaluronic acid (Juvederm®.8cc or Restylane® 1.0 cc) of over $200 per syringe, and higher costs for Sculptra®. 36. Butterwick KJ. Autologous fat transfer: Evolving concepts and techniques. In: Robinson JK, Hanke CW, Sengelman RD, Siegel DM (Eds), Surgery of the Skin: Procedural Dermatology, St. Louis: C.V. Mosby, 2005; pp. 535–548. 37. Sommer B, Sattler G. Current concepts of fat graft survival: Histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166. 38. Carpeneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 39. Butterwick KJ. Rejuvenation of the aging hand. Dermatol Clin 2005;23(3):515–527. 40. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: A quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004;113 (1):391–395. 41. Coleman S. Autogenous fat harvesting. In: Tyers AG, Collin JRO (Eds), Colour Atlas of Ophthalmic Plastic Surgery, 3rd edition, Philadelphia: Butterworth Heinemann Elsevier, 2008; pp. 544–559. 42. Narins RS, Tope WD, Pope K, Ross EV. Overtreatment effects associated with a radiofrequency tissue tightening device: Rare, preventable, and correctable with subcision and autologous fat transfer. Dermatol Surg 2006;32(1):115–124. 43. Ersek RA, Chang P, Salisbury MA. Lipo layering of autologous fat: An improved technique with promising results. Plast Reconstr Surg 1998;101(3):820–826. 44. Guerrerosantos J. Long term outcome of autologous fat transplantation in aesthetic facial recontouring: Sixteen years of experience with 1936 cases. Clin Plast Surg 2000;27 (4):515–543. 45. Eremia S, Newman N. Long term follow up after autologous fat grafting: Analysis of results from 116 patients followed at least 12 months after receiving the last of a minimum of two treatments. Dermatol Surg 2000;26(12):1150–1158. 46. Butterwick KJ. Lipoaugmentation for aging hands: A comparison of the longevity and aesthetic results of centrifuged versus noncentrifuged fat. Dermatol Surg 2002;28(11): 987–991. 47. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005;31(11 Pt 2):1496–1505. 48. Rigotti G, Marchi A, Galie M, Baroni G, Benati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment of radiotherapy

12  Autologous Fat Transplantation for Acne Scars tissue damage by lipoaspirate transplant: A healing process mediated by adipose derived adult stem cells. Plast Reconstr Surg 2007;119(5):1409–1422. 49. Donofrio LM. Structural lipoaugmentation: A pan facial technique. Dermatol Surg 2000;26(12):1129–1134. 50. de Benito J, Fernandez I, Nanda V. Treatment of depressed scars with a dissecting cannula and an autologous fat graft. Aesthetic Plast Surg 1999;23(5):367–370. 51. Jackson IT, Simman R, Tholen R, DiNick VD. A successful long term method of fat grafting: Recontouring of a large subcutaneous postradiation thigh defect with autologour fat transplantation. Aesth Plast Surg 2001;25(3):165–169. 52. Rehman J, Traktuev D, Li J, Merfeld-Claus S, Temm-Gove CJ, Bovenkirk BE, Pell CL, Johnstone BH, Considine RV, March KL. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation 2004;109(10): 1292–1298.

77 53. Cao Y, Sun Z, Liao L, Meng Y, Han Q, Shao RC. Human adipose tissue derived stem cells differentiate into endothelial cells in vitro and improve postnatal neovascularization in vivo. Biochem Biophys Res Commun 2005;332(2): 370–379. 54. Miller JJ, Popp JC. Fat hypertrophy after autologous fat transfer. Ophthal Plast Reconstr Surg 2002;18(3):228–231. 55. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Opthalmol 1989;107(1):85–87. 56. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face. J Neurol 1998;245(1):53–54. 57. Lee DH, Yang HN, Kim JC, Shyn KH. Sudden unilateral visual loss and brain infarction after autologous fat injection into the nasolabial groove. Br J Ophthalmol 1996;80(11):1026–1027.

The Art of Facial Lipoaugmentation

13

Edward B. Lack

13.1  Introduction Lipoaugmentation refers to the art and science of restoring volume and contour to cosmetic units of the body. While this application can be used in any part of the human body, it is most fascinating when applied to the human face. A historical perspective of the evolution of fat transfer is appropriate in understanding what we have learned and where we are today. Glogau (1) was perhaps the first cosmetic surgeon to describe the aging process of the face as a compilation of the sum of various layers of facial anatomy. Specifically, he subdivided the facial contours to a bony layer, a muscular layer, a subcutaneous fatty layer and a cutaneous layer, and he concluded that these layers must be dealt with individually to evaluate and remedy signs of facial aging. Most readers will consider this too obvious, yet when he proposed the concept some 20 years ago it was novel. Subsequently numerous authors postulated an appreciation of the aging process as a shrinkage of the layers of the face, causing a collapse of facial contours and ultimately producing alternating hollows and redundancies of soft tissue. Previous concepts of the loss of skin elasticity paled when the differences between natural aging and solar elastosis became clear. The concept of using fat as a natural and perhaps permanent filler was initiated by Fournier (2) and was expanded upon by Asken (3). Among the reasons for their advocacy was the ready availability of fat, the absence of antigenicity when redistributing fat within the same individual, and the ease of the techniques of

E. B. Lack 2350 Ravine Way, Ste 400, Glenview, IL 60025, USA e-mail: [email protected]

application. Indeed, sterile technique was hardly a concern in the inception of fat transfer and yet the incidence of infection was surprisingly low. Little did anyone suspect that fat tissue would contain a myriad of stem cells and would be capable not only of surviving as a graft, but also of inducing regenerative changes in all tissues of the body. The initial attempts at fat transfer involved erasing facial lines but soon progressed to restoring volume-depleted cosmetic units: most often the malar fat pads. One of the early controversies in lipoaugmentation concerned fat longevity and what was perceived as resorption of the infiltrated tissue. From earlier studies of grafting living tissue it was known that survival of grafted tissue initially resulted from diffusion of oxygen and nutrients prior to establishment of vascularization. That is, the injected fat was devoid of capillary nourishment. Wound healing studies demonstrated that capillary ingrowth required about 72 h and during the latency period nourishment was provided by inoscultation. Since nourishment and oxygen could only reach as far as about 1 mm, it was obvious that only rivulets of fatty tissue could survive the trauma of transplantation while waiting for capillary angiogenesis to occur. Initial techniques of lipoaugmentation involved repeatedly piercing a cosmetic unit in the subcutaneous layer until sufficient fatty tissue had been deposited to inflate the tissue. Because of expected resorption of the tissue, overfilling was required and the amount of overfilling necessary was variously ascribed to the unique healing characteristics of the recipient and to the art of delivery demonstrated by the surgeon. Predictably considerable edema and contusions were induced and resolution of facial distortion not infrequently lasted up to 3 weeks. In spite of these inconveniences, the work of Berman (4, 5), Coleman (6), Obagi (7), and Donofrio (8) created more predictable

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_13, © Springer-Verlag Berlin Heidelberg 2010

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and esthetically pleasing results. Patients with redundancy and ptosis of facial contours increasingly benefited from lipoaugmentation as opposed to face-lifts. Gradually the camps advocating facial fillers and those advocating rhytidectomy came together to appreciate that there were indications where facial fillers were optimal and situations in which rhytidectomy was optimal; and increasingly many situations were identified in which the two procedures could be combined to produce the best results. Unfortunately, too many surgeons continued to misapply the concept of solar elastosis and poor elasticity in skin to defend their advocacy of one procedure over the other when in fact loss of elasticity must be dealt with by the rejuvenating skin. Increasingly apparent is the fact that skin and soft tissue redundancy is a result of atrophy of the underlying tissue, and cutting away skin and soft tissue only establishes a shrinking face as permanent – not dissimilar to Michael Keaton as the lead role in the movie, Beetlejuice. In approximately 1997 Amar arrived in the United States with a concept of intramuscular injections of fat into the muscles of facial expression that was reported in 1999 (9). Amar was the first to conclude that facial suspension and contours are determined by the vectors of contraction of the muscles of facial expression and that active and static contraction of these muscles within a cosmetic unit ultimately determined the contour of the cosmetic unit. As a corollary, atrophy of these muscles leads to reduced volume and loss of support of the soft tissues of the face which results in ptosis and redundancy of cosmetic units. He postulated that distributing implanted fat along the vectors of the muscles would have several beneficial effects: it would thicken the muscles of facial expression to increase muscular support; muscle volume would increase due to the action of stem cells; the deposition of fat in the vectors of facial muscles would preserve natural contours of cosmetic units and not lead to bulbous distortions which do not reflect normal physiognomy. In fact the whole concept of muscles of facial expression determining the specific contour of cosmetic units by supporting underlying and overlying soft tissue is unique and still not well accepted. Ultimately as more surgeons began performing lipoaugmentation of the face two seemingly competing schools of technique again seemed to merge into one. The first school originated by Fournier and best evolved by Obagi consists of inflating a cosmetic unit with rivulets of fat until the unit is slightly distorted

E. B. Lack

with overfilling. The second school, originated by Amar, consists of depositing rivulets of fat along and within the vectors of the muscles of facial expression with minimal overfilling. The author’s experience combines the two techniques, though his tendency is to follow the vectors of muscles of facial expression and minimize volume filling, so that patients can return to work in 3 days.

13.2  Goals of Lipoaugmentation Conceptually most cosmetic surgeons agree that lipoaugmentation replaces lost tissue. The question is where to put the fat in such a way that normal facial contours are re-established. Looking at the human face there are several projections which we appreciate in youth that establish both “normal” proportions and frames by which to delineate cosmetic units. The hairline, the brows, the cheek bones, and the jawline are the principal frames of the face (Fig. 13.1). The brow and the cheek are defined by soft tissue prominence, and the hairline and jawline by hair and bone respectively. Atrophy of the periocular and malar fat pads leads to collapse of the overlying skin envelope and subsequent ptosis of the eyebrow, redundancy and scleral show of the lower lids, hollowing of the

Fig. 13.1  The framework of the face establishes harmony and balance to contiguous cosmetic units

13  The Art of Facial Lipoaugmentation Fig. 13.2  (a, b) Aging does not diminish beauty. It does alter cosmetic units by deflating tissue and inducing ptotic change

a

orbital rim with exaggeration of a nasojugal fold and groove, cheek jowling, and either ballooning or hollowing of the mid cheek depending on the evolution of the buccal fat pad (Fig. 13.2). Not infrequently, descent of the malar fat pad pulls on the lower lid causing a hollowed and/or darkened appearance and accentuation or pseudoherniation of the orbital fat pad (Fig. 13.3). It therefore stands to reason that because cosmetic units are contiguous and their anatomic continuity affects adjacent contours, that observing both the shape of the atrophic fat pad and the shape of the cosmetic unit caused by both static and contracted muscles of facial expression would define the best recipient sites for the transplanted fat. The single most defining contour of facial health and youth is the malar fat pad which is further defined by the levator labii superioris and levator anguli oris and less so by the zygomaticus major and zygomaticus minor muscles (Fig. 13.4). The second most important contour of the face is the brow line. Twenty years ago stereotypic definitions of female brows as curvaceous and elevated and the male brow as straight and low lying were accepted as the norm. More recently a low lying brow has defined female facial models and we have come to appreciate that what was defined as elevation of the brow in youth is really an anterior projection of the brow by the sub-brow fat pads made up of a supraorbicularis and a suborbicularis fat pads. The effects of re-establishing the periocular contour is to visually make the eyes look bigger; reduce redundant

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b

Fig. 13.3  The atrophy of soft tissue produces collapse of the facial envelope

skin of the upper and lower eyelids; reduce protuberant lower lid bags; and re-establish the frames of the browline, the orbital rim inferiorly, and the projection of the cheeks. Secondarily the fullness of the central face

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Fig. 13.5  Cannulas fashioned with angles and curves make deep implantation easier when contouring over bony structures Fig. 13.4  Muscles of facial expression. The vectors of the muscles of facial expression are vertical

helps to reduce jowling and to reproduce a more normal perioral contour. Once the major landmarks of the face have been reestablished, secondary projections may be addressed. The mandibular line and in particular the prejowl sulcus can be filled to enhance the inferior frame of the face and reduce or eliminate the appearance of a narrow, and prominent (or “witches”) chin. The central cheek hollow, or buccinator region, can be enhanced to soften the submalar contour, and the canine fossa hollow can be filled both to support the medial cheek and to reduce and soften the proximal and distal nasolabial groove

13.3  Instrumentation The technique of lipoaugmentation may be divided into several stages including preparation of the donor site, fat extraction, fat preparation for injection, preparation of the recipient site, fat injection., and post operative care. This section will concentrate on instrumentation for fat extraction and fat injection. Preparation of donor and recipient sites will be dealt with in the section on technique. Fat appears to survive best when extraction is carried out with the least amount of trauma to the extracted fat.

Syringe liposuction is best suited for this objective when compared with machine suction due to lower negative pressures used to extract fat and to cause less trauma or bruising of the fat when it is deposited in the barrel of the syringe. For facial lipoaugmentation 10-mL LeurLock syringes can be easily manipulated in one hand, are small enough to allow thumb pressure to retract the plunger, and receive a Leur-Lock fitted cannula. Cannulas with an internal diameter of approximately 1–2 mm are ideal. The snub nose cannula with a divider extending from the tip of the cannula seems to be the most popular cannula with which fat can be extracted. There are numerous cannulas for injecting fat. These generally have a 1-mm internal diameter and vary from the straight to the curved, to the angulated. Amar fashioned a series of curved and angled cannulas which glide easily along the bony skeleton of the face. The difficulty in making these cannulas is in keeping the internal diameter fixed while avoiding an apparent constriction at the angle or bend of the cannula. Several manufacturers now fashion cannulas in a similar manner (Fig. 13.5).

13.4  Technique 13.4.1  Donor Site The donor site may be constructed from any viable source on the body. Various articles have purported to show differing longevity between comparative sites;

13  The Art of Facial Lipoaugmentation

however, none of these reports are reproducible and it is the author’s opinion that while some differences in longevity and adaptability may exist, they are too small to be considered when planning a procedure. Therefore the best plan is to adapt the donor site to the physiognomy of the patient. Common donor sites include the medial knees, medial thighs, trochanteric fat pads, the hips, and the abdomen. Common to all sites care must be taken not to distort the donor cosmetic unit so that one cosmetic deficiency is traded for another. Lipo-extraction should be carried out using principles of sterile technique. After preparation of the donor site, the subcutaneous fat can be tumesced by either the syringe technique or the peristaltic pump technique. I prefer a garden spray type 14- or 16-gauge infiltrator with a Leur-Lock adaptor. The tumescent solution may best contain 0.07 or 0.05% lidocaine. When tissue is tumesced at these concentrations of lidocaine, anesthesia is relatively complete if attention is paid to the sub dermal neurovascular plexus and the deep fascial plexus. Much literature has been devoted to considering whether lidocaine concentration affects fat graft survival and it seems prudent to minimize the effect of this variable. It is wise to wait at least 15 min for the tumescent fluid to be absorbed by the fatty tissue. Fenno’s dictum that “if you don’t leave the operatory, you will begin the surgery too soon” applies. Syringe extraction is gentler than machine extraction because it exerts less negative pressure and there is less trauma to the extracted tissue as it is suctioned into a cushioned wet environment. It also affords the ability to extract the fat into a sterile environment and transfer it back into the recipient site without compromising its sterility. The fat is extracted with a snub nosed divided cannula (Fig. 13.5) made for this purpose and the syringe is capped with a sterile Luer-Lock cap made by Byron, though other distributors not known by the author may exist. The syringe is then inverted and the infranatant liquid allowed to decant after which it is poured off by removing the end cap and pushing gently on the syringe plunger. The syringes may then be centrifuged at 2,000 rpm for 60 s, be allowed to further decant, or they may have albumin added to the solution for further extraction of absorbed saline. In all cases the syringes are placed in a holding basket for further use (Fig. 13.6).

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Fig. 13.6  Decanted and spun fat placed in holding basket

13.4.2  Recipient Site Attention is then directed to the recipient site. Nerve blocks appear to work best for creating comfortable anesthesia and they avoid the variable of injecting large quantities of lidocaine diffusely into the recipient site. Supraorbital, infraorbital, buccinator, and mental nerve blocks can be used. After sterile preparation of the skin, the injection of the fat may be performed in a clean/sterile manner. In addition to nerve blocks, local anesthesia using 1% lidocaine with epinephrine is used as a local infiltrate at the wet mucosa of the oral commissure of the upper lip and just lateral to the bony orbit at the level of the lateral canthus. A small wheal is raised at these sites after which a stab incision with a #11 blade is made. Virtually all of the injections will be made through these four insertion points minimizing the chance of unsightly scarring (Fig. 13.7). Using the insertion sites at the oral commissure all of the muscles of facial expression of the middle 1/3 of the face can be accessed in a deep muscular or submuscular plane. The advantage of deep injections is to minimize bruising in the subdermal plane and to minimize immediate contour deformities. Filling the area of the cosmetic unit will then be performed with minimal overfilling.

13.4.3  Final Fat Preparation The decanted fat is transferred from the 10-mL syringe to a 1-mL syringe using a sterile Luer-Lock coupling

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Fig. 13.7  X – Nerve block sites. O – Insertion points for procedure

device. Inclusion of air in the coupling device is carefully avoided and the 1-mL syringe is filled to approximately 0.7 mL. Most injections are made in a vertical inferior to superior plane although some horizontal injections may be necessary for periorbital enhancement.

13.4.4  The Malar Fat Pad In order to fill and elevate the malar fat pad, the vector of the levator labii superioris is first approached (Fig. 13.4). The cannula is carefully inserted through the puncture site at the oral commissure and advanced superiorly past

a

Fig. 13.8  (a, b) Fat transfer to cheeks, lips, and brows produces youthful contours of the face

the inferior orbital rim and anterior to the orbital septum to a level inferior to the tarsal plate. Minute aliquots of fat are injected as the cannula is withdrawn. The fat is injected with repeated pulses of pressure on the plunger creating a non continuous linear deposition of fat pearls. A syringe containing 0.7 mL is generally deposited with one pass of the cannula. This may be repeated several times both medially and laterally. Next the vector of the levator anguli oris is used to guide the second and third passes of the cannula. Ultimately the vectors of the muscles are repeatedly visualized and filled as the medial, mid, and lateral aspects of the muscles are appreciated. When appropriate, the vectors of the zygomaticus major and minor are traced as well. In using the oral commissure as the origin of the injections the canine fossa is easily filled which will support the medial malar fat pad and will help efface the nasolabial crease. This pattern will effectively elevate and define the malar fat pads, efface the inferior orbital rim, and reduce the bulge of the lower eyelid if present. It will create a framework to view the cosmetic units of the face as being proportional and will partially efface the nasolabial creases. Lastly it will give a slight elevation of the cheek jowls (Figs. 13.8 and 13.9). In some patients reversing the ptosis of the malar fat pad accentuates the atrophy of the buccal fat pad and its overlying subcutaneous tissue. The effect is an undesirable hollow beneath the projection of the cheek which is typical of aging or poor health. In order to avoid this, a straight cannula can be inserted through

b

13  The Art of Facial Lipoaugmentation Fig. 13.9  (a) Preoperative. (b) After periorbital filling as well as filling of the submalar fat pad that harmonizes contiguous cosmetic units

a

the oral commissure along a vector of the buccinator muscle and similar to the technique with the levator muscles of facial expression the sub malar cheek can be elevated in its inferior, middle, and superior aspects.

13.4.5  Other Facial Enhancements For many patients the procedure is completed with the restoration of the malar fat pad and its borders. However, if the patient desires, other enhancements can be made. The lips are particularly enhanced with fat, though the process may need to be repeated several times to get a long lasting result. Fat deposition appears to survive best when it is deposited within or about the orbicularis oris muscle. For both the upper and the lower lips fat may be deposited through the insertion sites at the oral commissure. Small rivulets of fat are deposited at the junction of the wet/dry mucosa and again at the vermillion border. Quantities should be kept small as this is not a site of normal fat deposition and the ability of the lip to hold transplanted fat is limited. The supra-orbit is a very important landmark and atrophy of the sub-brow fat causes a tired aged appearance because of brow ptosis and flattening of the brow/bony complex. In addition such wasting usually extends to the upper lid where hollowing of the eye is common. A stab incision lateral to the lateral canthus and outside the body orbital rim is used as the insertion  point. Fat may be injected above and below the

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b

orbicularis oculi muscle and often in both planes. It is usually necessary to inject superior, below, and inferior to the eyebrow. When injecting the superior aspect of the palpebral eyelid it is essential to keep the cannula in a plane above the orbital septum. In this way the hollow of the upper eyelid as well as the ptosis of the brow can be remedied and the anterior projection of both units improves the appearance of dermatochalasis and sad/tired eyes. The pillars of the lower lip and the chin may be enhanced with fat. Again it is the author’s preference to keep injections vertical and for this reason a submental insertion point may be created just medial to the midpupillary line. Rivulets of fat may then be deposited following the vectors of the depressor anguli oris, the depressor labii inferioris, and the mentalis muscles.

13.5  Repeat Procedures Controversy still exists regarding the longevity of fat transfer (10). This is most complicated by the fact that the patient continues to age and the deflationary changes that occurred due to aging continue to occur. On the other hand, like any graft, once tissue is integrated into a recipient site and nourished with adequate vascular integrity, it will behave like other cells in the recipient site. Reports of grafted fat surviving 6–12 months are no doubt due to poor technique resulting in tissue edema and unsuccessful grafting.

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Patient perceptions regarding their own appearance have also led to misconceptions of the longevity of grafted fat. Mirrors lie and patient preconceptions of their appearance influence how satisfied they are with the procedure and the longevity of its results. Therefore pictures taken in a reproducible manner provide the only reliable means of assessment of results. Given all of these variables it is best to educate patients that while fat grafts survive, they are subjected to the same aging processes as other tissue and it will be appropriate some time in the future to augment their results with another procedure. While most lecturers of techniques of lipoaugmentation use frozen fat (11) for secondary procedures (personal impression) there is confusion as to how this tissue enhances the procedure. Guidelines for tissue banks must be followed in order to avoid government imposed penalties for storing and injecting human tissue. Containers must be labeled and stored in double bags with each bag identically labeled. Freezers must be protected with monitoring devices and logs maintained as to the adequacy and continuity of the freezer. Generally speaking, most surgeons keep the temperature at −0.4°C (personal communication). There is no compelling evidence that fat tissue stored in this manner and then thawed is still alive. There are many reports, however, of the adequacy and durability of injected frozen fat and it is a convenient method of augmenting results without performing an additional surgical procedure. This technique is ideal for injecting lips which seem to require 4–5 sessions at monthly intervals to achieve pleasing and long lasting results (in the author’s experience).

13.6  Conclusions Lipoaugmentation is perhaps the most successful and most pleasing of any cosmetic procedure in this author’s experience. Postoperative morbidity can be minimized

E. B. Lack

by using microinstrumentation, delivering small aliquots of tissue, and depositing the fat grafts at the level of or deep to the muscles of facial expression. Following the vectors of these muscles may enhance overall results and provide better support for elevating cosmetic units. Repeat procedures may initially be performed at prescribed intervals and later on an as needed basis. Not surprisingly, with accumulated experience using hyaluronic acid and calcium hydroxylappatite successful results of lipoaugmentation may be enhanced with the use of allopathic filler substances.

References   1. Glogau RG. Physiologic and structural changes associated with aging skin. Dermatol Clin 1997;15(4):555–559.   2. Fournier PF. Liposculpture: The Syringe Technique. ArnetteBlackwell, Paris, 1991.   3. Asken S. Microliposuction and autologous fat transplantation for aesthetic enhancement of the aging face. J Dermatol Surg Oncol 1990;(10):965–972, Review.   4. Berman M. The aging face: A different perspective on pathology and treatment. Am J Cosm Surg 1998;15(2):167–172.   5. Berman M. Rejuvenation of the upper eyelid complex with autologous fat transplantation. Am J Dermatol Surg 2000; 26(12):1113–1116.   6. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S.   7. Obagi S. Autologous fat augmentation for addressing facial volume loss. Oral Maxillofac Surg Clin North Am 2005; 17(1):99–109.   8. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005;31(11 Pt 2):1496–1505.   9. Amar RE. Adipocyte microinfiltration in the face or tissue reconsturation with fat tissue graft. Ann Chir Plast Esthet 1999;44(6):593–608. 10. Kaufman MR, Bradley JP, Dickinson B, Heller JB, Wasson K, O’Hara C, Huang C, Gabbay J, Gahadjar K, Miller TA. Autologous fat transfer national consensus survey: Trends in techniques for harvest, preparation, and application, and perception of short- and long-term results. Plast Reconstr Surg 2007;119(1):323–331. 11. Donofrio LM. Structural autologous lipoaugmentation: A panfacial technique. Dermatol Surg 2000;26(12):1129–1134.

Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting1

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14.1  Introduction Autologous fat grafting meets all of the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, and avoids non-autograft disease transmission or incompatibility. Considering these facts, autologous fat transfer provides a very appealing resource for soft tissue volume augmentation in both small and large volumes. It is well established that autologous tissue grafts survive the harvest and trans­ fer procedures to a healthy recipient site by the princi­ ples of induction and conduction (1–7). Autologous fat graft­ing has rapidly become a very important treatment modality over the last 15 years. Fat tissue survival, although well documented, has often been reported as somewhat unpredictable in its effectiveness or longevity. In the early 1990s, bioengineers helped surgeons to become aware of the actual mechanism of liposuction surgery and harvest. That is, during liposuction or lipoharvest, cellular components and support matrix are loosened, become suspended in tumescent fluids, and “float” out during harvest. With the ability to use low vacuum pressures, closed syringe system harvest with super smooth harvest and transfer cannulas, fat grafting (large and small volumes) has become more understood

1  The author has no financial interest in Harvest Tech­nology, Tulip Medical, T&N Industries, or Shippert Medical companies.

R. W. Alexander Department of Surgery, University of Washington, Seattle, WA, USA, 3500 188th St. S.W. Suite 670, Lynnwood, WA 98037, USA e-mail: [email protected]

and effective. It has become one of the most frequently utilized therapy in face and body contouring procedures (8–13). Standardization of consistent harvesting, graft mani­ pulations, and transfer protocols is improving the ability to accurately predict volume enhancements and realize long-term survival of the grafted tissues (14). Controversy regarding efficacy of autologous fat grafting, seems to conflict our experiences relative to the amount of graft retained and for long-term retention of volume increase (1, 4, 5, 8, 15, 16). Many claiming relatively high resorption rates (30–60%) do not account for the fluid volumes needed to transport the graft cell from select donor to the recipient sites. For example, if the harvested and transferred graft materials are comprised of 30% tumescent fluid and 60% cellular elements, the observed reduction in mass volume seen in the first few weeks most likely represents the gradual resorption of the carrier fluids, and is not representative of the failure of graft cellular element survival. In vitro studies demonstrate very high survival rates in tissue culture. It appears that survival following lowpressure suction harvest is in the high 90 percentile of intact cells observed (4, 5, 11, 13, 17, 18). There are many factors recognized to exert substantial influence on the success of autologous fat transplan­ tation. Some of these include the patient’s systemic health, genetic predisposition for cellular fat storage from the preferred donor sites (so-called “primary” fat deposit locations), pre- and postgrafting patient nutrition, basal metabolic rate, use of minimally traumatic harvest and handling techniques, proper preparation of the recipient bed, and relative early graft ­immobilization in the recipient sites during the initial graft acceptance and initiation of the healing cascade (9). The value of additives to autologous fat grafts is becoming much better documented and understood.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_14, © Springer-Verlag Berlin Heidelberg 2010

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With the ability to favorably influence the body’s wound healing efforts through use of such additives, recognition of the value, safety, and predictability in autologous fat grafts has greatly increased (1, 10). In our experience, one of the most important influences of grafting adult lipocytes (plus stimulation of the very rich mesenchymal stem cells found within adipose tissues) is the addition of platelet-derived factors added to the harvested graft materials prior to graft placement (1) (Fig. 14.1). Platelets are living but terminal cytoplasmic portions of marrow megakaryocytes. They have no nucleus for replication and typically last for 5–9 days in vivo. For many years, their role was considered only to contribute to the hemostatic process, where they become tacky and adhere together to form a plug. Platelets are ­understood to extrude important initiators of the entire

Fig. 14.1  Activated platelets from the addition of plateletderived factors added to the harvested graft materials prior to graft placement

a

Fig. 14.2  (a) Before activation. (b) In response to platelet-to-platelet or platelet-to-connective tissue contact, the platelet cell membrane is “activated” to release growth factors from the alpha granules via active extrusion

inflammatory cascade. It is now well known that they also actively extrude multiple growth factors critical to early wound healing processes. In response to plateletto-platelet or platelet-to-connective tissue contact, the platelet cell membrane is “activated” to release these products from the alpha granules via active extrusion (Fig. 14.2). When these extruded growth factors are released, histones and carbohydrate chains are added to receptor sites, thereby creating their unique chemistries and making the “active” growth factors. It is important to have this basic appreciation of the contribution that platelet-derived products make in wound healing and extrapolate into autologous fat graft acceptance. Since the advent of a very convenient harvest and preparation system for the isolation of platelet rich plasma (Harvest Technology), the ability to use platelet rich plasma (PRP), also known as autologous platelet concentrates (APC) has become a reality in the outpatient ­clinics, ambulatory surgical and hospital sessions (10). Wound healing is initiated in a very complex environ­ ment, which is typically started and maintained from ele­ ments specifically derived from platelets. Besides the initiation of coagulation processes, the platelets undergo a degranulation process which releases a complex group of growth factors and cytokines (peptides) essential for wound-healing mechanisms. The platelet-derived growth factors (PDGF) are characterized as regulatory peptides which have specific tissue site receptors (19–22). These serve to regulate and deregulate cellular activity, enzymes, angiogenic factors, antiangiogenic factors, induction agents for gene expression, and much more (21, 23–25). Initial studies demonstrating the powerful expression of PDGF were reported in the bone healing (also from a mesenchymal-derived stem cell set) (3). It is now considered that the use of the platelet-derived factors in autologous fat transplantation and wound healing are of equal importance. b

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

It is important to express the potential enhancement of known pathways to improve and enhance the survivability of grafted cells for long-term volume success and to understand the basic concepts of the scien­tific relevance of utilization of PRP in autologous fat grafting techniques (26–29). The potential of enhanced viability and clinical success of using transplanted fat in both small and large volume applications explains the importance of such combination to promote natural wound healing mechanisms. Introduction of such concentrated growth factors during the preparation and transfer phase seem to potentiate wound healing via normal physiologic mechanisms that control cellular recruitment, migration, and differentiation within the recipient sites. In addition, such additives contribute to the induction and conduction aspects of both the donor and recipient mesenchymal stem cell (undifferentiated) population found in all fat deposits, and, in that way, significantly contribute to overall graft success. The author’s experience suggests that the use of PRP and calcium chloride with or without thrombin increases the long-term retention of the transplanted adipocytes and pre-adipocytes and increases the rate of revascularization and survival of the transplanted cells (10). This enhancement of the healing rate and graft acceptance is thought to decrease the potential for lipo­ necrosis, lipid cyst formation, and incidence of spherical microcalcifications, particularly within larger volume augmentation (breast and buttock) areas (1).

14.2 General Biology of Wound and Graft Healing with PRP The clinical value of PRP as a promoter of wound healing is very well documented (22, 25–30). PRP is rich in both PDGF and transforming growth factorbeta 1 (TGF-b1), both of which are derived directly from degranulating platelets and contain the highest concentrations of those elements. These growth factors are recognized as key elements in initiation and subsequent progression of the wound healing cascade. The addition of PDGF has been shown to stimulate the actual damaged cytoplasmic membrane repair and permit return to metabolic activity in the in vitro cultured lipocytes, and to synergistically promote the healing of wounds by its ability to restore the plasma’s function (22, 25, 31). It is also well established that the key

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Table 14.1  Some of the most common platelet-derived cytokines implicated in wound healing Platelet-derived growth factor aa, bb, ab PDGF Transforming growth factor b1, b2 TGF-b1, TGF-b2 Platelet-derived epidermal growth factor PDEGF Platelet-derived angiogenesis factor PDAF Platelet factor 4 PF-4 P-selectin GMP-140 Interleukin 1 IL-1 Fibroblast growth factor FGF Interferons: alpha, gamma IFN-a, IFN-g Insulin-like growth factor IGF Sustained and long-term effects of PDGF are maintained with recruitment and migration of essential inflammatory cells, which release additional PDGF within the graft site. Note that platelet elements are essential to initiate and maintain the inflammatory processes, as well as stimulating the tissues needed to provide the structural matrix for the grafted elements

cytokines derived from the platelet degranulation processes are intrinsically involved in the maintaining of the actual healing process. Cytokines most implicated in this wound healing process are listed in Table 14.1. Both PDGF and TGF-b1 are concentrated in the alpha granule of the platelet, and are released with plate­let cellular activation and degranulation. Each has shown a marked beneficial effect on wound healing (10, 32). As discussed, initial extrusion of such factors will become complete growth factors via the process of growth factors joining with histones and carbohydrate side chains in a wound site to result in fully “activated” growth factors. As an example of activation, PDGF has a direct mitogenic influence on the target cells by finding specific cell surface receptors and, indirectly en­­ hanc­ing the proliferative response even in cells lacking detectable PDGF receptors (22, 27). Platelets are the richest known source of PDGF, although it has also been identified within macrophages, fibroblasts, and some endothelial cells (30). Likewise, TGF-b1 concen­ trates are primarily released from the alpha granule, but has also been isolated in macrophages. Since TGFB1 is also chemotactic for recruitment of macrophages and fibroblasts, it is a potent stimulator of granulation tissue formation. Working synergistically, PDGF initially acts as an attractant for monocytes, macrophages, or both, and then becomes an activator to begin produ­ ction and secretion of additional PDGF into the wound area (Table 14.2). This is known as an autocrine amplification system, and is important in sustaining the wound healing processes (1, 22).

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Table 14.2  Simplification of the three stages of wound healing Injury Stage 1

Stage 2

Stage 3

Platelet activation Adhesion and degranulation PDGF actions begin – chemotaxis Monocytes – differentiation monocytes – inflammation Macrophage – PDGF, TGF-b1 + recruit and activate fibroblasts PDGF – activation collagenase Initiation of collagen matrix remodeling

In autologous fat grafting placement of harve­sted cells into created potential space (pretunneling) permits and encourages maximal recipient site cellular contact with graft cells. This tunneling and placement also produces some degree of platelet-containing blood to be released in the field from native sources. The addition of highly concentrated PRP then further enhances the activity of these processes and offers important acceleration of the early inflammatory activities. This complements and amplifies the native (recipient) site processes started with mild injury. In graft situations, initial wound oxygen concentration is decreased, resulting in relative hypoxic conditions (partial pressure of oxygen of 5–10 mmHg) and acidotic (pH 4–6) within the graft itself. This area is surrounded by recipient tissues that are normoxic (partial pressure of oxygen 45–55 mmHg) and physiologic (pH 7) (42). With placement of PRP with the graft materials, activity of the lipocytes, mesenchymal stem cell element (in both donor and recipient tissues), interstitial collagen, and fibroblasts are more rapidly activated to respond. The recipient site provides the needed circulation and cellular element access for structural cells, healing capable cells, and intact capillaries. It is in this junctional area that small capillaries develop terminal clots and offer exposed endothelial cells for revascularization. It has been suggested that this may explain why small aliquots of graft placed in prepared tunnels to provide surrounding native fat cells and stroma contribute to enhanced graft survival and success. The establishment of oxygen tension potential bet­ ween the graft and the surrounding recipient bed tissues is capable of inducing macrophage recruitment and pro­ moting angiogenesis by secreting macrophage-derived angiogenesis factor and macrophage-derived growth factor (33–35). The angiogenic effect of macrophages

is selectively induced by mild hypoxia and may be potentiated by hyperbaric oxygen therapy. In the presence of normal oxygen tensions, the number of fibroblasts and amount of collagen deposit, as well as the number of capillaries, can be increased by increasing the number of macrophages present. Therefore, it can be concluded that the healing potential of a wound is not only influenced by the presence or absence of chemotactic agents, but also by the number of competent cells. Working synergistically, the recipient site conditions plus the concentrated factors derived from PRP serve to enhance the healing environment. This very complex environment, simplified for the sake of this discussion, represents the basic model of wound healing in any tissue injury. The endogenous system of repair starts, maintains, and promotes repair related to the needs of the injury and offers an opportunity for surgeons to encourage enhanced tissue regen­ eration and graft tissue acceptance. Use of concentrated platelet gels, “activated” in PRP by the addition of calcium chloride and thrombin, appear to offer a unique biologic sealant and graft carrier (gel) to the recipient sites. This combination has been used extensively in a variety of disciplines with remarkable clinical success (1, 5–7, 16, 21, 26, 27, 36). In the activated PRP (PRP+) graft, the gel matrix may provide some helpful early graft immobilization, known to be contributory to a variety of autologous grafts situations. An additional use for autologous fat grafts with PRP has recently been recognized as forming a cellular carrier tissue and biologically active matrix for the orthopedic and podiatric inflammation sites, as well as for transfer into articular sites being treated for chronic inflammatory states. As an example, use of PRP gel in fat graft elements has been suggested to be placed in areas such as rotator cuff problems in order to “restart” a depleted inflammatory capability associated with chronic ligament and joint problems. Regenerative therapists are rapidly recognizing the value of this gel matrix (scaffolding) and the available precursor cells (derived from pre-adipocytes) contained in such grafts when placing this bioactive matrix into a variety of sites where exact placement and retention of the needed inflammatory healing boost in a musculo-skeletal or joint area is very important. Further advanced regenerative therapy is beginning to utilize autologous fat grafts (AFG) with activated PRP+ to serve as a stable scaffolding, healing stimulus, and cell source for needed regenerative wound

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

efforts. Combinations of AFG and bone marrow-derived stem cells (BMAC) are now being used in treatment of many complex musculo-skeletal and vascular disorders. In those applications, it is likely that the fat cells will be inducted to become their mesenchymal stem origin and be incorporated within the healing process dictated by the sites, as well as provide a necessary bioactive scaffold to hold the collection of stem cells within the desired sites of placement. As more clinical information is gathered, use of bone marrow-derived and fat cell-derived mesenchymal stem cells in a very wide group of applications are becoming very important.

14.3 Autologous Fat Graft Healing Model Some early investigators suggested the possibility that some or all transplanted mature adipocytes might dedifferentiate into a precursor phenotype or might maintain characteristics of donor site adipose tissue. Work by Jones and Lyles (32) clearly demonstrated in vitro that low pressure, syringe-harvested fat did not regress, but actually became metabolically active and began to store lipid within the cells grown in three-dimensional media. In addition, considering the fact that autologous fat grafts do best where existing adipose tissues exist, it is considered very likely that additional induction stimuli within the recipient and/or donor cell populations do exist. This promotes differentiation of precursor ­elements into new adipocytes, making additional quantities of lipocytes from transferred and host-tissue stem cell ele­ ments from within the recipient bed (37–40). Later studies, which involved the placement of PRP into the cell culture, have further demonstrated actual repair of damaged cytoplasmic membranes to an intact state, metabolically active. In addition, it appeared that some induction of pluripotential cells into metabolically active adipocytes was stimulated and liponeogenesis initiated in three-dimensional tissue culture matrix (31). In the autologous fat graft, it is convenient to characterize three stages of graft acceptance (Table 14.2). During the first stage, cellular differentiation and activation of preadipocytes begins with release of PDGF and TGF-B1 during degranulation of platelets. PDGF is believed to both stimulate mitogenesis and differentiation of the preadipocyte. Simultaneously, angiogenesis is stimulated, resulting in capillary budding and

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in-growth via induction of endothelial cell mitosis. This initial stage of graft healing is measured in hours and days, with high activity persisting for up to 1 week. The second stage, typified by fibroblast activation, usually lasts for up to 2 weeks. It is suggested that the TGF-B1 is responsible for initial fibroblastic activation, resulting in increased numbers of fibroblasts, and stimulates additional differentiation of precursor adipocyte cells. The prolonged presence of TGF-B1 further acts to stimulate adipocyte lipogenesis, while fibroblasts begin to synthesize pro-collagen type 1 in preparation for deposit of the collagen matrix to support the capillary ingrowth activities. The activated fibroblasts begin synthesis of fibronectin and hyaluronic acid - known essential elements of the new extracellular matrix. The third stage represents the beginning of wound maturation and typically remains active for up to 1 year. During this time, the TGF-B1 continues to be active, encouraging additional fibroblast activity. PDGF activates the secretion of certain enzymes (i.e., collagenase) to assist in collagen remodeling and wound maturation processes. The action of these growth factors is clearly synergistic in the promotion of acceptance of autologous fat grafts (22). As discussed previously, PDGF participates in the development of the autocrine amplification system. This feedback system both initiates and maintains the healing and integration of the newly transplanted and differentiated cells by capillary in-growth and collagen remodeling within the recipient bed.

14.4  PRP Technique 14.4.1 Isolation of Platelet-Rich Plasma Early experiences with isolation techniques for PRP were difficult because of the equipment size, cost, and need for a perfusionist. This resulted in making its use inconvenient, expensive, and requiring substantially larger blood volume draw than the current system (1). Since the development of simple, precise equipment in a complete kit format, the costs of isolation and ease of use have been greatly reduced (10). It is now practical to have the isolation capability within a practice surgical suite, ambulatory surgery center, or hospital set­ting without the need of additional personnel, requiring only 18–48 mL volume of patient blood draw, and at a dra­ma­ti­cally less cost basis. The author currently uses an

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automated, dual spin process (SmartPrep IITM, Harvest Technologies Inc., Plymouth, MA) (Fig. 14.3). The patient is phlebotomized to obtain a whole blood sample, the volume of which is dependent on the amount of APC needed for a given protocol. For large volume grafting, as in the breast or buttock augmentation, 10–20 mL of PRP is used following the simple protocol and kits containing everything needed to properly isolate the platelet concentrate. The drawn specimen is placed in the provided sterile container containing citrate phosphate dextrose as an anticoagulant. This container is then placed in the SmartPrep dual spin centrifuge (2,400 rpm) for an automated cycle, resulting in the separation into its three primary components: red blood cells, PRP, and platelet poor plasma (PPP). Owing to the differing a

densities of the above components, each isolates in its own respective layer following timed centrifugation. The cell separator allows removal of the least dense top layer of PPP (which is saved in many cases, as it offers the ability to form a fibrin glue when mixed with thrombin, useful in many open surgical and graft procedures). Following removal of the PPP layer, the remaining specimen allows accurate separation of the PRP layer from the denser blood cell layer. The isolated PRP is then introduced into the sterile field for use directly in surgical wound sites, or physically mixed with graft materials, in preparation for tissue transfer. In large volume transfers, addition of PRP in a ratio ranging from 10 mL per 500 mL harvested graft materials to 20 mL per 500 mL of graft (0.5–1% concen­tration) is favored. c

d

b

Fig. 14.3  Isolation of PRP harvest with an automated, dual spin process (SmartPrep IITM, Harvest Technologies Inc., Plymouth, MA)

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

In small volume transfers, the PRP to graft ratio of 1 mL PRP added to 9 mL of rinsed, harvested grafts (10% concentration) is most commonly utilized. Advances in understanding the potential for storage of small volume graft now permit surgeons to harvest additional graft materials, do the rinsing, introduce the PRP additive, allow frozen storage of patient’s graft materials for future augmentations. To date, tissue culture of prepared frozen grafts, gradually thawed to room temperature, show a 90+ percentile viability in vitro. Rapid freezing techniques are not acceptable for graft storage because of intracellular crystallization and cellular death of the grafts. Today, grafts placed in controlled and monitored frozen state are in common use. The isolated grafts are brought to a frozen state (–4 degrees C) slowly, by placement in a secure, dedicated freezer system. Storage within sterile, labeled containers (within injection syringes) is kept for a maximum of 18 months. It is possible that longer storage protocols may be developed, but current in vitro documentation has not been demonstrated. The value of having small volumes set aside, ready for secondary grafting, is obvious. To date, the author is not aware of storage of greater than 10-mL syringes with prepared grafts. Storage at −4°C standard freezer temperatures with monitored temperature stability is readily available in dedicated medical tissue freezers. Additional studies are underway trying to identify the minimal PRP concentration to graft volume to maximize effects (10). Grafts may be transplanted in both a fibrin gel form (i.e., “activated,” after addition of the proper proportions of thrombin and calcium chloride) or in the isolated graft plus PRP form with no additional additives (41–44). On the basis of current clinical observations in fat grafting, there seems to be no distinct difference between the two techniques, unlike in bone and cartilage graft applications which are improved by placement of grafts in a gel matrix. Immobilization of grafted tissues via this activation is intuitively felt to encourage successful maintenance of carefully placed autologous fat grafts. The remaining blood cells are discarded rather than returned to the patient. As the volumes now extracted are typically less than 50 mL (some 10 times less than previous isolation cell separator devices which required 500–600 mL draw), there is no significant concern about volume loss to the patient.

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14.5 Harvest of Autologous Fat by Closed Syringe Most experienced fat transfer surgeons have adopted use of low pressure, syringe harvesting of autologous fat graft materials. Selection of donor site for harvest is considered an equally important issue. It appears that autologous fat grafts display “donor site memory” (i.e., it may retain the metabolic and storage characteristics of adipocytes common to the sites selected for harvest). This suggests that genetic influence varying with the hereditary distribution commonly reported with related individuals may be of great significance (1, 9, 10, 45). This has significant clinical importance in determination of the ideal donor site areas, making such selection not on the basis of surgeon convenience or preference, but on the basis of demonstrated fat storage preference and fat metabolic activity levels in each individual patient. These so-called “problem” areas are recognized as metabolically resistant locations (i.e., to exercise and diet programs), and are commonly referred to as “primary deposit sites.” Other areas that are influenced with diet and exercise are known as “secondary deposit sites.” Harvest is carried out utilizing tumescent fluid infiltration of the selected donor sites, composed of sterile saline containing 0.05% xylocaine with 1:1,000,000 epinephrine. It is common to infiltrate in a ratio of 1:1 up to 2:1 (infiltrate:extraction volumes) via a multiport infiltrator to evenly distribute the fluids throughout the donor site tissues which provides the liquid vehicle to gently remove the graft tissues. Currently, use of superpolished sleeve (internally via extrusion techniques, and externally by coating techniques, Tulip Cell FriendlyTM system) is favored (Fig. 14.4).

Fig. 14.4  Tulip syringe system

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In small volume transfers, we utilize superpolished, disposable harvesters and transfer cannulas (Tulip BioMed DisposablesTM) (Fig. 14.5). Since the smaller diameter cannulas cannot be effectively cleaned, disposing after each use protects the integrity of the sterile harvest and transplantation process, and thus pro­vides improved patient safety. For large volume transfer, the author attempts to minimize graft harvest trauma by utilization of 2.1–3.7 mm external diameter cannulas, and displace air from the

Fig. 14.5  Disposable supercoated and polished Luer-Loc Tulip BioMed System for both harvest and transfer. Diameters range from 0.9 to 2.1 mm with choices of openings depending on application and harvest sites (courtesy of Tulip BioMed Co., San Diego, CA)

a

b

Fig. 14.6  Tissue transfer equipment using a sleeve (Tissue-TransTM system)

system by filling the cannula with saline or ringers lactate solution prior to application of negative pressure. During the actual graft harvest, low pressure is applied by limiting the plunger movement to one-half or less of the syringe being used. The Tulip Cell Friendly System was patented for use with 60 mL Toomey syringes and the superpolished, coated titanium cannula and the bibeveled cobra tip (9, 10). Recent advances in harvesting large volume grafting is seen in the use of Tissue-TransTM system to harvest, rinse, and permit addition of PRP directly into the harvesting syringes. Toomey (60 cc) syringes can be used to load directly into smaller transfer syringes without needing additional transfer steps to provide rinsing, PRP additive placement, and preparation for actual grafting procedures (14) (Fig. 14.6). The actual ideal diameter of cannulas for harvest is not certain. The evolving belief is that transfer of mature adipocytes and their stromal matrix both of which contain significant undifferentiated precursor cells (adiposederived mesenchymal stem cells) may, in fact, be contributory to improved long-term graft success by reducing cellular trauma associated with low aspiration pressures. This makes use of larger harvesting cannulas potentially more effective by subjecting cellular element to minimal pressure during extraction and placement. Use of larger harvesting cannulas is considered to be more efficient in harvest speed, substantially reducing the time for harvesting viable cellular and stromal (containing adult stem cell) materials. For small volume transfers, use of disposable cannulas ranging in size from 1.25 to 2.1 mm O.D. seems to provide the most consistent graft harvesting for size and ease of placement. After rinsing the harvested graft material to effectively reduce the intracellular lidocaine concentration (46) and permit the removal of extracellular lipid

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materials and debris, the PRP is added to the autologous graft materials in an approximate ratio of 10% in small volume cases and 0.5–1% of the total graft prepared for large volume transplantation. Very low-speed centrifugation may be used to further concentrate the graft materials from infranatant fluids. It is important to note that centrifugation speeds should be minimized as excessive forces (rpm relative) have been shown to increase cellular trauma and actually rupture otherwise intact cellular membranes. When the thrombin-calcium chloride additive is introduced into the graft materials treated with PRP, the physical condensation of the graft is found to be equally effective to concentrate it without the use of any additional centrifugation. Following gentle agitation to thoroughly mix the graft and PRP, it is left for a 5–10-min period to permit release of platelet concentrate component elements. Following this interval, to biologically “activate” the graft, it is ready for placement in the recipient sites (1). Fig. 14.7  Marking the breast

14.6 Autologous Fat Grafting with PRP In preparation for transfer augmentation of the face or body areas, the patient is marked in an upright position in a fashion similar to that for alloplastic augmentation, but with the breasts also marked in quadrants centered on the nipple-areolar complex (Fig. 14.7). The line intersecting the inframammary crease and the vertical quadrant line represents the primary 3-mm access point for pretunneling and graft placement in layers. With the larger or small volume grafts, pre-tunneling is carried out using small (1.47–3.0 mm) bibeveled cobra-style cannula along the deeper aspects of native fat of the recipient site(s), thence layering more superficially (Fig. 14.8). As an example, in the breast area tunnels are placed below the breast glandular elements in preparation for subsequent grafting in layers (Fig. 14.9). Note that, in the breast areas, glandular elements are lifted from the Pectoral Muscle surface to permit tunneling for grafts in the retroglandular deposits. There has been some suggestion that intramuscular or submu­scular grafting that may be advantageous has not been well documented (41). In the case of small volume grafts, disposable cannulas ranging from 1 to 2.1 mm external diameters are typically recommended, with utilization of the layered tunneling of equal importance to volume success. These are mounted to

standard luer-lock syringes of various sizes (typically 1 cc, 10 cc, or 20 cc syringes). Preferred sizes are sometimes dictated by the relative thickness of the donor-recipient site deposits. It is important that the surgeon select the diameters of the harvesting instrumentation based on the locations to be grafted and the desired size of transfer cannula. It is clear that in order to be able to extract graft tissues that can gently be transferred through the placement cannulas, one must use harvest instrumentation of similar size. As an example, when harvesting for small volume transfers, it is common to extract with disposable, superpolished cannulas of similar diameters. This effectively insures that the amount of matrix and graft sizes will pass smoothly through the transfer cannulas, and permit accurate placement in the prepared tunnels while minimizing cellular membrane trauma. Avoiding sudden “clumps” of graft insertions helps avoid unwanted pooling of grafted lipocytes and precursor elements. Utilization of a mechanical syringe offers some advantages in placing activated grafts, as it delivers exact aliquots of graft-PRP+ materials with each compression of the trigger (typically provides 0.5 cc increments). Pretunneling, in both small and large volume grafting, is considered very important to provide loosened tunnels of “native” fat tissues, initiate recipient site

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Fig. 14.8  Buttock augmentation. (a) Preoperative buttock lipodystrophy in a 33-year-old female. (b) Twelve months after fat (FFT-PRP) transfer with a total of 340 mL into buttocks bilaterally

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Fig. 14.9  In the breast area, tunnels are placed below the breast glandular elements in preparation for subsequent grafting in layers

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting Fig. 14.10  Cheek fat augmentation. (a) Preoperative malar-submalar lipodystrophy in a 56-yearold female. (b). Eighteen months after fat transfer of 8 mL to each malar-submalar complex

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Fig. 14.11  Lip augmentation. (a) Preoperative. (b) After fat transfer

healing efforts, and provide a resident cellular and precursor cell matrix to receive the graft materials. Stack­ ing of layers of graft is recommended to provide the desired increase in volume in an evenly distributed and effective manner. As in small volume experiences with

autologous fat, it is clear that the grafted fat does best in  areas where existing fat is found and where graft can  be  surrounded by these native elements (10, 47) (Fig. 14.10). An exception appears to be in the placement of fat grafts to augment the anterior-posterior lip

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Fig. 14.12  (a) TenderCups garment. (b) TenderFoam

volume (in submucosal plane). The submucosal lip tissues provide circulation for the graft elements believed to be derived from the minor salivary glandular vasculature (Fig. 14.11). In lip augmentation procedures, it is common to repeat the grafting in two to three separate grafting procedures. The initial grafting appears to “seed” the site, making secondary grafting more successful than the initial procedure. As in most autologous tissue graft situations, early mild compression and immobilization (where possible) is typically recommended. In order for the grafted materials to have maximal recipient site contact, use of compressive foam (TenderFoam™) or specifically formed foam (TenderCups™, T&N Industries) has proven safe, comfortable, and effective for providing gentle compression of the grafted fields. In addition, use of such closed cell foam dressing have proven very efficient at eliminating postoperative ecchymosis in the vast majority of cases (Fig. 14.12). TenderFoam avoids the irritation associated with some tacky foam options, and is commonly used in all types of liposuction and lipoharvest situations. Compression for the first 2–3 days is typically sufficient to insure the graft immobilization during the critical hours where transplanted tissues are receiving the responses needed to insure cellular survival.

In the area of large volume cases involving breast augmentations, the clinical trial period of 1992–1996, limited volumes of grafts were selected to be limited to 150 mL (±10%), with efforts to evenly distribute graft within all the four quadrants of breast (exceptions made in presurgical volume discrepancies). Since that time, volumes up to 300 mL per breast are transferred effectively, with placement of more volume within the upper hemispheres where significant volume losses are commonly found (48). It is considered very important to understand that the amount of graft volume that can be placed is in direct correlation with the existing native fat volumes. That is, in patients with greater amounts of native breast fat, larger volumes may be transplanted and well vascularized during the healing process (10). Very thin, or patients with essentially no palpable retroglandular fat deposits may not be ideal candidates for the fat graft augmentation of the breasts or buttocks. In those with very limited recipient site fat tissues, it is common to transfer lower volumes (such as 150 mL or less to each side), and plan on a secondary transfer in 4–6 months (Fig. 14.13). With the initial stage increasing the volume of adipose tissues, the breasts may effectively accommodate larger graft volume placement in the subsequent treatment (Fig. 14.14). In our experience,

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting Fig. 14.13  In patients with very limited recipient site fat tissues, it is common to transfer lower volumes such as 150 mL or less to each side. (a1, a2) Preoperative. (b1, b2) Postoperative

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out of approximately 240 fat graft augmentations since the clinical trial experience, 28% opted to have a second transfer for this reason, or simply to further augment the breasts. The average clinical volume increase at 1 year is estimated at one cup size, with some achieving larger enhancements. Placement options to accurately deal with small asymmetries, depressions, alloplastic implant rippling, and help restore the upper hemisphere fullness needed in many augmentation patients is available via this technique (48, 49). As discussed, retention of

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grafted tissues taken from the hereditary (genetic) sites is considered very high. There observations, coupled with in vitro studies, confirm that cell viability may be well within the 90th percentile. Research on the ability to provide a quantitative analysis based on biochemical characteristic differential is underway at this time. Further, longevity of such volume increases followed over past 15 years confirms that volume retention is a long-term effect considering the anticipated loss of subdermal fat deposits in the face and breast areas

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Fig. 14.14  (a) Preoperative. (b) First fat transfer. (c) Second fat transfer

associated with normal aging processes (1, 10). It is very important to understand many reports regarding the “take” rate is often misinterpreted. Owing to the fact that authors do not account for the fact that at least 30–40% of the transferred volumes do not represent cellular tissues, but rather the carrier fluids introduced with the graft cell placement at the time of transfer. It should not be surprising to see initial volume reductions following graft surgery resulting from the gradual removal of these carrier fluids during the healing and graft acceptance process. Experience with auto­logous fat grafting suggests that volumes achieved at 4–6 weeks represent the graft placed with most of the edema and transfer fluids moving away from the graft sites within that period (1, 48–50). Occasionally, surgical interventions within dependent drainage areas may produce a slower resolution of perioperative interstitial edema.

14.7 Results and Complications Using PRP More than 20 years of experience confirms that small and large volume (face, trunk, and extremities) augmentations utilizing autologous fat grafting can be

safely, predictably, and effectively accomplished. Use of additives, such as PRP, appears to further enhance the success and rate of graft acceptance in both small and large volume applications. PRP has proven to provide such improvements, and can be inexpensively isolated and applied to multiple surgical applications, including face, body, and extremity augmentation by fat grafting (Fig. 14.12). There appears to be minimal morbidity associated with transplantation of autologous fat in the facial and body areas, and those described appear to be similar or less severe than those associated with alloplastic choices. With the limited size of the access points (<3 mm), the gentle blunt tunneling in the recipient bed, and the autologous nature of grafts appear favorable in volume enhancement by this modality. Similarly, in the case of facial small volume graft efforts, use of superpolished, disposable microcannulas are most effective in preparation and actual grafting. As it is recognized that use of very small cannulas (i.e., 2.1 mm or less) for harvest and transplantation cases poses an almost impossible task of effectively cleaning instrumentation of all organic and cellular debris, disposables should be given major consideration. Most encountered limitations and complications with this group of procedures relate to the harvesting,

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

preparation, and delivery of the autologous grafts to the prepared recipient bed rather than the graft itself. One of the ongoing difficulties in interpretation of many reports relates directly to limited or no standardization of techniques for each step in the process. This being the case, accurate comparisons or the ability to duplicate results of the studies, is essentially impossible to draw valid scientific opinions. Recently, the American Society of Lipo­suction Surgery has prepared a preliminary standardization of protocols which will hopefully improve the ability of surgeons to interpret and compare the reports in scientific sessions and publications. There is no single “correct” way to perform the harvest, preparation, or transfer, but the ability to observe consistency of results and long-term efficacy may be improved by better understanding the nuances that enhance the patient results (14). The basic risks associated with conventional liposuction harvest techniques, albeit relatively infrequent, is even less encountered based on the limited volumes typically extracted for fat transfer. The morbidity of this procedure seems to be directly proportional to the instrumentation, technique, and aggressiveness of the harvesting procedure. As a secondary benefit, donor areas often achieve a desired benefit associated with unwanted, exercise-diet resistant deposit reduction and improved contouring (10, 51). Autologous fat grafting in large volume cases has advantages and limitations when compared with alloplastic augmentation. In the breast example, no implant related difficulties such as neurological nipple-areola injury, deflation, leakage, rippling or visible margins of implants, limited capsule expected longevity, or capsular contraction is encountered (10, 49–51). The ability to selectively augment specific areas allows surgeons to deal with mild asymmetries or shape requirements not available via preformed implants (such as chin, cheek, buttocks, or breast). Limitations observed in fat graft augmentation of the breast and buttocks areas, makes patient selection extremely impor­tant. Since there is no limiting capsule filled with volume material, the resultant volume increases realized may be somewhat limited. In other words, patient’s whose primary concern is size increase; it is often better to recommend implants to achieve their goals. With structural augmentation via fat grafting in the face and body areas, the tissues should be diffusely infiltrated in stacked tunnels which are feathered along the margins. This permits the

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opportunity to provide specific area support and volumes in the areas desired, without leaving evidence of the graft location. (Fig. 14.13). In breast cases, candidates selecting the fat graft alternative tend to be moderately older, in the 26–55 years age group. In this mature population, often restoration of fullness and support exceeds the desire for large volume increases. There may be a modest difference in the realized graft enlargement based on vascular patterns changed with pregnancy and hormonal cycle changes. This variable is the subject of additional study, including retrospective analysis of volume increases and patient satisfaction analysis (50). Reports of additional unanticipated disproportional enlargement has been reported up to 10 years after grafting in patients having substantial weight gains in that period. This is interpreted as consistent with the genetic predisposition of grafted cells to store lipid and to the induced differentiation of adipose-derived stem cells placed with the adipocyte grafts (Fig. 14.14). Simultaneous augmentation of malar and submalar areas permits a more natural, three-dimensional restoration of support identified as very important in facial and body aging appearances. This permits surgeons to effectively restore the tissue changes inevitable with the progressive loss of native subdermal fat deposits and their important support mechanisms (so called three-dimensional restoration of central facial fullness). It is believed that recipient site characteristics (such as thickness, density and vascularization of recipient bed, etc.) may contribute to limitations of graft volumes that are readily accepted in the site. As mentioned, it has been well documented that autologous fat grafts do better in sites rich in existing “native” fat cellular and stromal elements. Whether this is involved in cellular survival or a function of induction effects on undifferentiated stem cells (preadipocytes and mesenchymal types), or simply the presence of favorable infrastructure and environment, remains unclear at this time. Early tissue culture evidence suggests a stimulation of harvested cells experience a more rapid return to active metabolic state when directly enhanced with addition of APCs (APC-PRP) (Fig. 14.15). This has been demonstrated in examples of cytoplasmic closure and repair following suction harvest, with return to fat metabolic activity in vitro (31) (Fig. 14.16). Recipient site morbidities are similar to those cited with regards to small volume transfers. There is a possibility for development of palpable cystic or nodular

102 Fig. 14.15  Long-term fat transfer. (a) Preoperative. (b) One year after fat transfer

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Fig. 14.16  Microgram in vitro PRP fat stem response. Micrographs courtesy of Mark Lyles, D.D.S, PhD

accumulations in the recipient site following transplantation (34, 35). This is postulated to represent small areas of extracellular lipid accumulation or steatonecrosis with failure of cellular acceptance (45, 51–59). It is important to note that the clinical frequency of such changes have substantially decreased since the advent of utilization of platelet concentrates. It is believed that the presence of palpable nodules or cystic accumulations may be a direct function of

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delayed healing or poor circulation within the grafted recipient site (10). Cytosteatonecrosis, resulting in a low-grade inflammatory response may encourage formation of microcysts and spherical calcifications as has been documented as morbidities associated with traditional autologous fat grafting. Such findings, an early expressed concern of many breast surgeons, have become relatively easily differentiated via mammography and ultrasound studies. Current studies using magnetic resonance imaging (MRI) review to gain greater detail of any suspicious areas, much like the recommendations in current silicone implant evaluations, are ongoing. Patients are recommended to have preoperative mammography to serve as a baseline prior to breast augmentation by either alloplastic or autologous means. Following autologous fat graft augmentation, we recommend a follow-up study at 6 months to 1 year to reset the baseline. After several hundred experiences, it appears that the vast majority of changes typically are visible within 6–12 months. In our large volume transfer cases, on four occasions, the findings did not appear for more than 18–24 months. Specifically in the breast areas, imaging specialists report comfort in differentiation of the spherical-type cysts and/or microcalcifications from those potentially harmful to the patient (56). In the clinical trial, the radiologists were blinded as to any procedure, and in many instances

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

their only findings were reported as “greater retroglandular fat matrix of unknown origin” as the only changes noted (50). The occurrence of the above described morbidity can be related to graft trauma at time of placement, delayed revascularization, or increased inflammatory response within the recipient bed. It has been postulated that the addition of PRP may enhance the healing cascade rates and specifically stimulate greater revascularization processes (10, 48, 50). Recent approval from the FDA for utilization of PRP with bone marrow aspirate confirms the efficacy and safety associated with PRP and mesenchymal stem cell tissues (such as those derived from bone marrow aspiration or autologous fat harvesting). As a source of mesenchymal stem cells, fat tissue has been well documented to provide significantly greater concentrations of such cells than is present in bone tissues (37). The importance of stem cell induction-differentiation in both bone and fat grafting is the current subject of extensive investigations.

Discussion The scientific literature contains numerous studies to date which have sought to elucidate a biochemical or bioactive additive or agent which can improve or speed the acceptance and outcome of autologous fat grafts. Numerous additives such as heparin, calcium, thyroid hormone, bezafibrate, vitamin E, albumin, and insulin have been studied with relatively no evidence supporting greater graft acceptance (1, 10, 60–67). In that regard, suggestions that alteration of osmotic gradients (e.g., albumin) may stabilize adipocyte cellular membranes need to be further explored. It is possible that a portion of the effects of PRP additives may also relate to the osmotic characteristic in addition to the wound healing factors. Growth factors are the biologically active signal pep­tides released from local tissue or blood products (particularly the platelet fraction) that play a critical role in influencing the initiation and progression of the normal wound healing process. Such factors coordinate the processes of epithelialization, angiogenesis, collagen-matrix formation; the key steps in the wound healing sequence. Growth factors function in paracrine, endocrine and autocrine manners in order to guide the dynamic stages of wound healing. No single growth

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factor appears to maintain a total physiologic task, but instead these peptides work in a coordinated fashion to orchestrate the normal wound healing processes. A substantial volume of basic research has displayed the efficacy of these bioactive peptides with regard to healing in both soft and osseous tissues. Steed (68), in a randomized, prospective, double blind, placebo controlled study of 118 patients with chronic, full thickness lower extremity diabetic neurotrophic ulcers of at least 8-week duration, displayed a statistically significant difference in both numbers of patients healed and healing rates after daily application of topical recombinant growth factors. Forty-eight percent of patients randomized to the growth factor application group achieve complete wound healing, compared to only 25% wound closure in the control group. Knighton (69) displayed a 93% re-epithelialization in 41 patients displaying a total of 71 chronic wound after receiving daily treatments with APC (PRP). In a second study, Knighton et al. (70) confirmed the first study in complete resolution of wound in 17 of 21 chronic lower extremity ulcerations, treated over an 8-week course of twice daily PRP/APC application. Of those patients in the placebo group, only 2 of 13 displayed the same results. Upon crossover treatment of the control group with APC (PRP), all previously unresponsive wounds displayed re-epithelialization. Extensive reports in other mesenchymal-derived tissues have documented enhanced healing in bone and cartilage models in vivo. Powell et al. (71) reported trends suggesting enhancement of recovery with decreases in postoperative edema and ecchymoses in a pilot, randomized, prospective, controlled clinical trial involving patients undergoing standard deep place facelifting. The effect of growth factors on enhancement on neovascularization was reported by Khouri et al. (72). This study demonstrated that after the application of basic fibroblast growth factor (FGF) to ischemic flaps in a rat model displayed greater flap survival rates, as well as a greater increase in the number of new blood vessels upon histologic examination. PRP, as a clinical enhancement to native wound healing capabilities, contains supraphysiologic concentrations of growth factors. Reports extrapolating the basic wound healing model with respect to transplantation of autologous fat show significantly improved efficacy of such small and large volume grafts in the clinical setting. In those, it is postulated that the effects of PRP with regard to enhancement of the normal wound healing processes, can be safely and effectively be utilized

104 Fig. 14.17  (a1, a2) Preoperative and postoperative fat transfer without PRP. (b1, b2) Preoperative and postoperative fat transfer with PRP. Note the fuller breast than without PRP

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as an additive in autologous fat grafting. Addition of PRP to grafts appears to actively promote increased graft volume retention and return to metabolic activity, plus promotes pre-adipocyte elements to differentiate into mature, active adipocytes. On the basis of those clinical observations, it is reported that addition of PRP (and the attendant addition of high concentrations of

growth factors and cytokines) increased the retention of the transplanted fat cells, increased the rate of revascularization of the grafts, and aided the differentiation of preadipocyte precursor cells into mature adipocytes to further enhance the retained graft volumes (1, 10, 17, 40) (Fig. 14.17). Use of mesenchymal stem cells derived from fat tissue is the current subject of study, as

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting

they appear to be able to undergo induction-differentiation into a variety of tissues of similar origin, and are more prevalent and easier to obtain than those found in bone marrow aspiration (37–40). In the case of autologous fat transplantation, the recipient bed represents a basic model of soft tissue injury. There appears to be clinical enhancement of wound repair within that site following introduction of grafts with the PRP additive, favoring maintenance of graft volumes and acceptance. Autologous fat cells are injected into a created potential space which is subjected to mild tissue injury as a result of pretunneling in the recipient locations. Following grafting, these created spaces consist of transplanted cellular elements, clotted blood containing platelets, exposed endothelial cells, interstitial collagen, fibroblasts, and undifferentiated stem cell elements. Use of activated PRP gel or plain PRP-added grafts appear to actively initiate the hemostatic phase of wound healing, which is expected to last for the first few minutes following injury. With the initial tissue injury, the damaged recipient bed cells (native) release their own growth factors (notably PDGF and TGF). Concurrently, activation of the clotting cascade results in the transformation of fibrinogen to fibrin, a potent stimulus for the further release of growth factors from the alpha granules within the aggregated platelets. These factors then activate their target cells (PMNs, macrophages, lymphocytes, fibroblasts, endothelial cells, epithelial cells, etc.) to proliferate and migrate to the wound site and carry out important functions in acceptance of grafts and site healing (Table 14.3). Knowledge of the inflammatory stage of wound healing (3–5 days after initial injury) is important. It is during these times that success or failure of free grafting may be determined. In this stage, activation of Table 14.3  The three stages of graft acceptance Stage 1 Stage 2

Stage 3

Capillary budding; ingrowth endothelial cell mitosis Fibroblast activation Differentiation of precursor adipocyte cells (stem) Adipocyte lipogenesis initiated Collagen I synthesis for matrix begins (fibroblasts) Fibronectin, hyaluronic acid synthesis Wound maturation Collagen remodeling

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inflammatory cells such as macrophages secreting growth factors, induction of fibroblast proliferation, early collagen synthesis, endothelial cell replication and mobilization, and epidermal cell mobility and proliferation must be appreciated. Next, the proliferative phase (days 3–12 following injury) of the process continues the graft acceptance processes. During this phase, fibroblasts are activated to lay down a new extracellular matrix. Angiogenic growth factors are simultaneously released by injured cells, platelets, macrophages, and extracellular matrix aimed at inducing early vascularization. The remodeling phase (approximately 2 weeks after injury) is a gradual process, lasting for up to 1 year, and is considered to be less critical to the success of individual grafts. During this time, a balance is achieved between synthesis of new matrix and degradation by proteases and provides a permanent infrastructure for long-term graft volume maintenance. Type III collagen is gradually replaced by Type I collagen. The final result of the remodeling phase is formation of the supportive fibrous matrix. Thus, the conclusion drawn regarding addition of concentrated platelet-derived factors to a wound bed is that it will markedly augment and improve the healing process. This enhancement of healing rate and graft survival may result in more favorable and reliable results with regard to the success of transplantation of autologous fat in small and large volume applications. The importance of growth factors in initiating the differentiation of adipose precursor cells into mature adipocytes is current under extensive study. In vitro studies have shown that such factors do, in fact, stimulate the proliferation and differentiation of precursor adipose cell cultures (32, 37–40). This bioactivation phenomena has been studied in a number of clinical trials with success. Yuksel et al. (73) demonstrated quantitative increases in weight maintenance and adipocyte area percentage means in the rat model following addition of insulin-like growth factor 1 and basic FGF delivered by PLGA/PEG microspheres in conjunction with autologous fat grafts. Small volume fat graft survival after growth factor application in the facial region has been studied by Eppley et al. (30) Ninety days postgrafting, those treated with basic FGF soaked dextran beads exhibited greater graft weight maintenance. In addition, the experimental group grafts histologically displayed greater numbers of intact cells as compared to the control graft group. Eppley et al. (67) in another study

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observed near complete graft weight maintenance, larger adipocyte volume, increased number of intact cells, and the presence of numerous smaller adipocyte-like cells 1 year after grafting as compared to the controls. These small adipocytes may represent a group of newly differentiated cells, slowly beginning to return to the metabolic activity of a mature adipocyte. In some autologous fat grafting cases, delayed volume increases have been observed, particularly in cases of large volume transfer. This may suggest a differentiation of precursor cells to adipocyte form, and the delay in restoration of metabolic activities of cytoplasmic lipid storage. Suggestions that growth factors enhance graft volumes as well as increase the actual number of adipocytes with grafted tissues are very significant. With these observations, it is possible that those mature adipocytes lost in the harvest and transplantation process may be replaced by newly inducted-differentiated cells allowing the overall graft volume to be retained. Further importance of platelet-rich plasma concentrates with autologous fat grafting is evidence in the field of sports medicine. In that application, the autologous grafts are used as both a bioactive-scaffold matrix and to provide needed stem cell elements needed to repair musculo-skeletal injuries and joint degeneration. This regenerative therapy is rapidly gaining importance in orthopedics and sports medicine fields. It is believed that activated PRP+ works with the cellular graft tissues, and provides the fibrin active biomatrix to serve as the needed scaffold and precursor cell source to

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Fig. 14.18  (a) Patient with failed implants. (b) Postoperative following autologous fat transfer

contribute to the wound repair of complex soft and hard tissue injuries. The examples learned in autologous fat grafting for augmentation purposes have expanded the utilization of the available mesenchymal stem cell engineering to include a variety of mesenchymal derived tissues (bone, cartilage, skeletal muscle, cardiac muscle, nerve-related tissues besides the host fat cell).

Conclusions Autologous fat grafting offers a viable and safe alternative means of soft tissue augmentation in select patients (50, 74). Long lasting, natural contouring, and volume increases are attainable (Fig. 14.18). Since the advent of the closed syringe system for lipocontouring and harvesting for grafts, the predictability and safety is gaining recognition. Many of the early contributions to the literature have made use of autologous fat grafting feasible, and it is a useful modality in volume augmentations to the breasts (79) (Fig. 14.19), body, and facial areas. Use of additives to bioactivate the grafts (Figs. 14.20 and 14.21) and recipient bed appears to substantially improve the augmentation achieved (Figs. 14.22 and 14.23) and reduce the incidence of lipid cysts, cellular loss, and microcalcifications. The exact incidence of microcalcifications is not established, but on the author’s personal experience the incidence was found

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14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting Fig. 14.19  Fat augmentation in older patient. (a1, a2) Preoperative. (b1, b2) Postoperative

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Fig. 14.20  Differentiation of precursor cells. Micrographs courtesy of Mark Lyles, D.D.S, PhD

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Fig. 14.19  (continued)

to be 12% in the non-PRP treated grafts, vs. 8% in the PRP treated breast graft patients (50). This trend suggests improvement in the acceptance of low-pressure, syringe-harvested free fat grafts. The literature is now beginning to provide more reporting of such findings, and the actual incidence of lipid cysts and characteristic microcalcifications in a large sample should be forthcoming.

Fig. 14.21  PRP effects on adipocyte-stem cells. Micrographs courtesy of Mark Lyles, D.D.S, PhD

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting Fig. 14.22  (a) Preoperative mammogram. (b) Post operative mammogram following fat transfer

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Fig. 14.23  (a) Preoperative. (b) Postoperative following fat transfer with PRP

Fat graft augmentation may be of value as a simple aesthetic enlargement, or for correction of various asym­metries and contour deformities in a reconstructive application. Patient satisfaction is very high, especially in those in the older median

age group and those with major aver­sion to use of artificial implants of any kind (10). Improvement of iatrogenic, acquired, or natural depressions is often attained. As experience gained in improving major extremity asymmetries (such as in polio

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patients), extraction from the larger side and relocating to circumferential extremities has been very rewarding. Larger volume grafting spread over a large surface area seems to have the most successful outcomes. Patient selection and communication remains the most important determinants in successful augmentation with grafts. Establishing patient expectations remains the crucial point in the selection of grafting techniques. Attempts at augmentation of areas with inadequate recipient tissue elements continue to be problematic. In other words, asking autologous grafts to accomplish more than what can be expected should be avoided. Use of additives such as PRP appears to have improved the efficacy, speed of recovery, and safety of the graft alternative. As mainstream practitioners begin to report their findings of these techniques, much needed reproducibility of results and qualitative-quantitative analysis of the augmentation volume will be available. Standar­dization of techniques is needed to permit practitioners to more effectively appreciate the results and satisfaction with structural fat grafting in both small and large volume applications. The importance of grafting of autologous fat may be further enhanced with increased understanding of the stem cell implications associated with the tissue. Addi­tional research relative to the induction-differentiation of transplanted cellular elements is underway at this time. Such information may provide much greater understanding of our clinical experience and explanation of the success for long-term maintenance of results. With the rush to explore the possibilities of the use of precursor cells, there may be many more clinical applications for the use of mesenchymally derived, adult stem cell tissues in many areas of medicine and surgery. Current regenerative therapy regimens in orthopedics and sports medicine are beginning to utilize an autologous fat graft with activated PRP + to serve as a scaffolding and source of multipotential cells for ultrasonic-guided regenerative injection therapy into muscles, joints and periarticular tissues, and damaged cardiac tissues. This may greatly increase the interest and experience utilizing autologous fat for esthetic and restorative therapy applications, and further contribute to the understanding of its potential as a reliable, safe soft tissue augmentation modality plus easily accessible mesenchymal stem cell resource.

R. W. Alexander

References   1. Alexander RW, Abuzeni PZ. Enhancement of autologous fat transplantation with platelet rich plasma. Am J Cosmet Surg 2001;18:59–70.   2. Whitman DH, Berry RL, Green DM. Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg 1997;55(11): 1294–1299.   3. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Path Oral Radiol Endod 1998;85(6):638–646.   4. Fagrell D, Eneström S, Berggren A, Kniola B. Fat cylinder transplantation: an experimental comparative study of three different kinds of transplants. Plast Reconstr Surg 1996; 98(1):90–96.   5. Niechajev I, Sevc´uk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506.   6. Billings E, May JW, Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381.   7. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386.   8. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24(8):273–279.   9. Alexander RW. Liposculpture in the superficial plane: closed syringe system for improvement in fat removal and free fat transfer. Am J Cosmet Surg 1994;11:127–134. 10. Alexander RW, Sadati K, Corrado A. Platelet-rich plasma (PRP) utilized to promote greater graft volume retention in autologous fat grafting. Am J Cosmet Surg 2006;23(4): 203–221. 11. Obaji S. Selecting for fat transfer success. Cosmet Surg Times 2006;9(4):26. 12. Bircoll M. A nine-year experience with autologous fat transplantation. Am J Cosmet Surg 1992;9(1):55–61. 13. Coleman SR. Structural Fat Grafting, Quality Medical Publishing, St. Louis, MO., 2004, pp. 30–175. 14. Shippert R. Autologous fat transfer: eliminating the centrifuge, decreasing lipocyte trauma, and establishing standardization for scientific study. Am J Cosmet Surg 2006;23(1): 21–27. 15. Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg 1991; 87(2):219–227. 16. Pinski KS, Roenigk HH, Jr. Autologous fat transplantation. Long-term follow-up. J Dermatol Surg Oncol 1992;18(3): 179–184. 17. Lyles MB. Adipocytes hearty: certain storage conditions favor pre-adipocyte survival. Cosmet Surg Times 2003;6: 10–11. 18. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S. 19. Forgue-Lafitte ME, Van RL, De Gasquet P, Rosselin G. The presence of epidermal growth factor receptors in cultured human adipocyte precursors. Scand J Clin Lab Invest 1982; 42(8):627–631.

14  Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting 20. Lau D, Roncari D, Yip D, Kindler S, Nilsen SG. Purification of a pituitary polypeptide that stimulates the replication of adipocyte precursors in culture. FEBS Lett 1983;153(2): 395–398. 21. Zapf J, Schoenle E, Froesch R. Insulin-like growth factor I and II: some biological actions and receptor binding characteristics of two purified constituents of nonsuppressible insulin-like activity of human serum. Eur J Biochem 1978; 78(2):285–296. 22. Reeder GD, Hood A, Hill A. Perioperative autologous sequestration I: physiology, phenomena, and art. Proceedings of the American Academy of Cardiovascular Perfusion, San Antonio, TX, 1993. 23. Haystead TA, Hardie DG. Both insulin and epidermal growth factor stimulate lipogenesis and acetyl-CoA carboxylase activity in isolated adipocytes. Biochem J 1986;234(2): 279–284. 24. Ng TB, Wong CM. Epidermal and nerve growth factors manifest antilipolytic and lipogenic activities in isolated rat adipocytes. Comp Biochem Physiol 1985;81(3):687–689. 25. Chai Y, Salvkin HC. Biology of bone induction and its clinical applications. Oral Maxillofac Surg Clin 1994;7: 739–753. 26. Cromak DT. Current concepts in wound healing: growth factor and macrophage interaction. J Trauma 1990;30(12 Suppl):S 129–S133. 27. Pierce GF, Vande Berg J, Rudoph R, Tarpley J, Mustoe TA. Platelet derived growth factor-BB and transforming growth factor-beta1 selectively modulate glycosaminoglycans, collagen, and myofibroblasts in excisional wounds. Am J Pathol 1991;138(3):629–646. 28. Ross R, Raines EW, Bowen-Pope DF. The biology of platelet-derived growth factor. Cell 1986;46(2):155–169. 29. Pierce GF, Mustoe TA, Altrock BW, Deuel TF, Thomason A. Role of platelet derived growth factor in wound healing. J Cell Biochem 1991;45(4):319–326. 30. Eppley BL, Snyders RV, Winkelmann T, Delfino JJ. Auto­ logous facial fat transplantation: improved graft maintenance by microbead bioactivation. J Oral Maxillofac Surg 1992; 50(5):477–482. 31. Lyles M. Personal Communication 2006. 32. Jones JK, Lyles M. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997; 14: 275–279. 33. Eppley BL. Growth factor enhancement for bone grafts. J Oral Maxillofac Surg 1993;51:1181–1193. 34. Knighton DR, Hunt TK, Scheuenstuhl H, Halliday BJ, Werb Z, Banda MJ. Oxygen tension regulates the expression of angiogenesis factor by macrophages. Science 1983;221(4617): 1283–1285. 35. Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg 1990;160(5):519–524. 36. Carpaneda CA, Ribiero MT. Study of histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17(1):43–47. 37. Zuk PA, Zhu M, Mizuno H, Huang J, Futrell JW, Katz AJ, Benhaim P, Lorez HP, Hedrick MH. Multilineage cells from human adipose tissue: implications for cell-based therapies. Tissue Eng 2001;7(2):211–238. 38. Aust L, Devlin B, Foster SJ, Halvorsen YD, Kocok K, du Laney T, Sen A, Willingmyre GD, Gimble JM. Yield of

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human adipocyte-derived adult stem cells from liposuction aspirates. Cytotherapy 2004;6(1):7–14. 39. Strem BM, Hicok KC, Zhu M, Wulur I, Alfonso Z, Schreiber RE, Fraser JK, Hedrick MH. Multipotential differentiation of adipose tissue-derived stem cells. Keio J Med 2005;54(3): 132–141. 40. Gimble J, Guilak F. Adipose-derived adult stem cells: ­isolation, characterization, and differentiation potential. Cytotherapy 2003;5(5):362–369. 41. Fulton JE. Breast contouring with “gelled” autologous fat: 10 year update. Int J Cosmet Surg Aesthetic Dermatol 2003; 5:155–161. 42. Santrach PJ, Hoffman M. Laboratory validation of autologous platelet gel. Transfusion 2004;44(12 Suppl):68A–69A. 43. Sacchi MC, Maresca P, Tartuferi L, Bellanda M, Micheletti P, Riva S, Borzini P, Levis A, Rosti G. Platelet gel as a new routine method to improve wound healing and regeneration. Transfus Med 2000;10:325. 44. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 2001;107(1):229–237. 45. Fulton JE. Breast contouring by autologous fat transfer. Am J Cosmet Surg 1992;9:273–279. 46. Alexander RW, Maring T, Aghabo T. Autologous fat grafting: a study of residual intracellular adipocyte lidocaine concentrations after serial rinsing with normal saline. Am J Cosmet Surg 1999;16:123–126. 47. Ersek RA, Chang P, Salisbury MA. Lipo-layering of autologous fat: an improved technique with promising results. Plast Reconstr Surg 1998;101(3):820–826. 48. Alexander RW. Breast augmentation by injection of autologous fat. Proceedings of American Society of Cosmetic Breast Surgery, Newport Beach, CA, 1996. 49. Alexander RW. Use of fat transfer for facial and breast augmentation. Proceedings of World Congress On Liposuction Surgery, San Francisco, CA, 1996. 50. Alexander RW. Use of fat grafts for augmentation mammoplasty, summary of clinical information with radiographic documentation. Proceedings of American Society of Cosmetic Breast Surgery, Newport Beach, CA, 1998. 51. Coleman SR. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 2007;119(3):775–787. 52. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79(2):267–271. 53. Bircoll M. Autologous fat transplantation: an evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosmet Surg 1998;5(4): 283–288. 54. Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. The mammographic spectrum of fat necrosis of the breast. Radio­ graphics 1995;15(6):1347–1356. 55. Johnson GW. Benign breast calcifications. Am J Cosmet Surg 1988;5:177–180. 56. Pulagam SR, Poulton T, Mamounas EP. Long-term clinical and radiologic results with autologous fat transplantation for breast augmentation. Breast J 2006;12(1):63–65. 57. Fine RE, Staren ED. Updates in breast ultrasound. Surg Clin North Am 2004;84(4):1001–1034. 58. Chala LF, de Barros N, de Camargo Moraes P, Endo E, Kim SJ, Pincerato KM, Carvalho FM, Cerri GG. Fat necrosis of

112 the breast: mammographic, sonographic, computed tomography, and magnetic resonance imaging findings. Curr Prob Diagn Radiol 2004;33:106–126. 59. Kneeshaw PJ, Lowry M, Manton D, Hubbard A, Drew PJ, Turnbull LW. Differentiation of benign from malignant breast disease associated with screening detected microcalcifications using dynamic contract enhanced magnetic resonance imaging. Breast 2006;15(1):29–38. 60. Menschik Z. Vitamin E and adipose tissue. Edinburgh Med J 1944;51:486–489. 61. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anat Rec 1956;124(4):723–739. 62. Reynold AE, Marble A, Fawcett DW. Action of insulin on deposition of glycogen and storage of fat in adipose tissue. Endocrinology 1950;46:55–66. 63. Krawisz BR, Scott RE. Coupling of pre-adipocytes growth arrest and differentiation. I. Induction by heparinized medium containing human plasma. J Cell Biol 1982;94(2): 394–399. 64. Flores-Delgado G, Marsch-Moreno M, Kur-Harcuch W. Thyroid hormone stimulates adipocyte differentiation of 3T3 cells. Mol Cell Biochem 1987;76(1):35–43. 65. Brandes R, Hertz R, Arad R, Naishtar S, Weil S, Bar-Tana J. Adipocyte conversion of cultured 3T3-L1 pre-adipocytes by benzafibrate. Life Sci 1987;40(10):935–941. 66. Ullmann Y, Hyams M, Ramon Y, Beach D, Peled IJ, Lindenbaum ES. Enhancing survival of aspirated human fat injected into nude mice. Plast Reconstr Surg 1998;101(7): 1940–1944. 67. Eppley BL, Sidner RA, Platis JM, Sadove MA. Bioactivation of free-fat transfer: a potentially new approach to improving fat survival. Plast Reconstr Surg 1992;90(6):1022–1030. 68. Steed DL. The Diabetic Ulcer Study Group. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. J Vasc Surg 1995;21(1):71–78.

R. W. Alexander 69. Knighton DR. The use of topically applied platelet growth factors in chronic non-healing wounds. Wounds 1998;1: 71–78. 70. Knighton DR, Ciresi K, Fiegel VD, Schumerth S, Butler E, Cerra F. Stimulation of repair in chronic, non-healing cutaneous ulcers using platelet-derived wound healing formula. Surg Gynecol Obstet 1990;170(1):56–60. 71. Powell DM, Chang E, Farrior EH. Recovery from deepplane rhytidectomy following unilateral wound treatment with autologous platelet gel. Arch Plast Surg 2001;3(4): 245–250. 72. Khouri RK, Brown DM, Leal-Khouri SM, Tark KC, Shaw WW. The effect of basic fibroblast growth factor on the neovascularization process: skin flap survival and staged flap transfers. Br J Plast Surg 1991;44(8):585–588. 73. Yuksel E, Weinfeld AB, Cleek R, Wamsley S, Jensen J, Boutros S, Waugh JM, Shenaq SM, Spira M. Increased free fat-graft survival with the long-term local delivery of insulin, insulin-like growth factor-1, and basic fibroblast growth ­factor by PLGA/PEG microspheres. Plast Reconstr Surg 2000; 105(5):1712–1720. 74. Alexander RW. Results are satisfying using autologous fat: breast augmentation with autologous fat transfer. Cosmet Surg Times 1998;2(4):4. 75. Wabitsch M, Hauner H, Heinze E, Tellere WN. The role of growth hormone/insulin-like growth factors in adipocyte differentiation. Metabolism 1995;44(10 Suppl 4):45–49. 76. Boney CM, Moats-Staats BM, Stiles AD, D’Ercole AJ. Expression of insulin-like growth factor-1 (IGF-1) and IGFbinding proteins during adipogenesis. Endocrinology 1994; 135(5): 1863–1868. 77. Alexander RW. Platelet rich plasma offers vast fat graft benefits. Cosmet Surg Times 2004;7(3):18–20. 78. Fournier PF. The breast fill. In: Fournier PF (Ed), Liposculpture: The Syringe Technique. Arnette-Blackwell, Paris, 1991, pp. 357–367.

Fat Transfer to the Face

15

Melvin A. Shiffman and Mitchell V. Kaminski

15.1  Introduction The minimally invasive technique using autologous fat transplantation has become a standard procedure in facial rejuvenation. It is simple, inexpensive, permanent, and effective. Injectable fillers, such as collagen and hyaluronic acid, are only temporary and, therefore, have minimal indication. Goretex, which is a permanent material, may extrude or be palpable. Since 1994, when Adatasil (silicone) was approved by the Federal Drug Administration (FDA) for use in ophthalmic problems, the use of silicone injected into other areas of the body is called an “off-label use” and is considered legal if it is used for a specific patient with a specific product and there is no advertising. Autologous fat can be used to augment facial structures, rejuvenate rhytids, or fill depressed scars or defects of the face. Since the introduction of liposuction in 1975 (1) for body contouring, there has been an easy way to obtain fat for transplantation through very small incisions. The use of the tumescent technique for retrieving large amounts of fat for transfer has reduced the amount of blood loss and made the technique safer (2). Although some reports have shown that fat transfer had disappointing results in some cases, the success of fat transfer is operator-dependent and can be quite successful if attention is paid to the details of the techniques of the procedure. The transfer of fat to the face, where vascularity is excellent, has an excellent chance for fat survival.

M. A. Shiffman (*) Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

The only relative drawback has been the resorption of some of the fat graft. With proper technique, approximately 30–70% of the fat is retained. Low speed, short time centrifugation of the fat decreases the fluid in the transplant and reduces the apparent loss of graft by compacting the fat and separating out the excess liquid. Since some of the apparent graft loss is the resorption of fluid from the transplanted fat, there is less fluid in centrifuged fat and, therefore, more mass remains. A newer concept to facilitate graft retention is the use of albumin during the harvesting and transfer phases. Albumin reduces the colloid osmotic pressure (COP) disparity between the low COP of the fat graft with saline, epinephrine, lidocaine, and sodium bicarbonate and the interior of the fat cells. The higher the difference in COP between the cells and the surrounding fluids, the more will be the fluid thatenter the cells and the more the likelihood of cell destruction. If the COP between the fat cells and the surrounding fluid with albumin are almost equal, then it is more likely that there will be improved fat survival and retention.

15.2  History of Fat Transfer Since Neuber (3), in 1893, reported that transplanted fat can be used to fill in a depressed area of the face, there have been many reports (4–14) that have shown fat, in pieces, can be transplanted and survive in various areas of the body. Since liposuction was conceived by Fischer and Fischer in 1974 [cited in (15)] and put into practice in 1975 (1), the aspirate has been used to fill defects and for contouring (16–22). Aspirated fat should be atraumatically washed in physiologic solution to remove blood, which would allow better fat survival (23).

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_15, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 15.1  Hematoxylin eosin stain 200×. (a) Central core of fat with 95–100% intact fat cells that was harvested with a 3-mm cannula at 500 mm mercury vacuum. (b) Periphery of core with

>10% fat cell disruption (arrow) when harvested with a 3-mm cannula at −700 mm mercury vacuum

Certain principles of fat transfer have evolved (24–69) over the years, which include aspiration at lower vacuum rather than at atmospheric pressure (Fig. 15.1). It is essential to avoid desiccation of fat during transfer. Fat that is present for over 120 days after transfer will survive and grow, and fat grafts survive when there is vascular ingrowth. The survival of free fat used as an autograft is operator-dependent and requires delicate handling of the graft tissue, careful washing of the fat to minimize extraneous blood cells, and installation into a site with adequate vascularity. There is evidence that fat cells will survive and that filling of defects is not from the residual collagen following cell destruction. There is some loss of fat after transplant and most surgeons will overfill the recipient site.

15.4  Centrifugation

15.3  Insulin Some physicians have added insulin to the fat in preparation for transplantation (19, 70, 71). The theory is that insulin inhibits lipolysis. Sidman (72) found that insulin decreases lipolysis. Hiragun et al. (73) stated that theoretically insulin may induce fibroblasts to pick up the lipid lost and become adipocytes. Chajchir et al. (74) found that the use of insulin did not show any positive effect on adipocyte survival during transplantation compared to fat not prepared with insulin.

Some physicians centrifuge the adipose tissue to remove blood products and free lipids to improve the quality of the fat to be injected (70–72). Asken (42) stated that his “method of reducing the material to be injected to practically pure fat is to place the fat-filled syringe with a rubber cap (the plunger having been previously removed and kept in a sterile environment) into a centrifuge. The syringe is then spun for a few seconds at the desired rpm and the serum, blood, and liquefied fat collects in the dependent part of the syringe….” Toledo (75) reported that “for facial injection we spin the full syringes for 1 min… in a manual centrifuge (about 2,000 rpm), eject the unwanted solution, and transfer the fat….” Chajchir et al. (74) centrifuged 1 mL of bladder fat pad from mice (both at 1,000 rpm for 5 min and 5,000 rpm for 5 min) and injected this into the subdermis of the malar area. Microscopically, after 1–2 months there were macrophages filled with lipid droplets, giant cells, focal necrosis of adipocytes, and cyst-like cavities of irregular size and shapes. After 12 months following injection, no recognized adipocytes could be found. Total cellular damage was present in both groups. Brandow and Newman (76) found that centrifugation of harvested fat did not after the microscopic structured integrity of cells. Spun and unspun samples were examined and were similar. Fulton et al. (69) noted that centrifuged fat, 3 min at 3,400 rpm, works well for small

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Berdeguer (77) used a lipo transplant gun to inject fat into areas to be enhanced. Fulton et al. (69) stated that it is beneficial for a beginning surgeon to use a ratcheted pistol for injection as this gives a more uniform injection volume.

15.6 Albumin in Improving Fat Cell Survival 15.6.1  Oncotic Pressure

Fig. 15.2  Hematoxylin eosin stain 200×. Centrifugation at 3,600 rpm for 1 min showing cell compaction

volume transfers, but not for large volume transfers into breasts, biceps, or buttocks. Low-rpm centrifugation for a short period of time will compact the fat cells and not destroy them (Fig. 15.2).

When a molecule is greater than 10,000 Da (Dalton – arbitrary unit of mass equal to the mass of the nuclide of carbon-12 or 1.657 × 10–24 g), it is called a colloid and is capable of generating an oncotic pressure if it is restricted to one side of a semipermeable membrane. Colloid restricted to one side of a semipermeable membrane creates an osmotic gradient measured in millimeters of mercury. Very small molecules and ions such as sodium, potassium, glucose, and urea easily cross a capillary membrane and can increase osmolarity toward isotonicity to prevent red blood cells from taking up water and bursting. Osmolarity is measured by freezing point depression and the greater the number of particles in solution the colder the solution must be before it will freeze.

15.6.2  Colloid Osmotic Pressure 15.5  Ratchet Gun for Injection Newman and Levin (23) designed a lipo-injector with gear-driven plunger to inject fat tissue evenly into desired sites. Fat injected with excessive pressure in the barrel of a syringe can cause sudden injections of undesired quantities of fat, which will pour into recipient sites. Agris (45) stated that a ratchet-type gun allows controlled accurate deposition of autologous fat. Each time the trigger is pulled, 0.1 cc is deposited. Asaadi and Haramis (56) described the use of a gun with a disposable 10-cc syringe for fat injection. Niechajev and Sevcuk (61) utilized a special pistol and a blunt typed cannula, with 2.3 mm internal diameter, to inject the fat.

In determining the COP, the Landis – Papenheimer equation (78) takes into account that soluble proteins -– whether albumin, globulin, or fibrinogen – are highly negatively charged:

COP = 2.1(TP) + (0.16 TP2) + 0.009 TP3 COP = Colloid osmotic pressure TP = Total protein

Positively charged sodium ions surrounding the core protein attracts and holds water thus accumulating more fluid on one side of the semipermeable membrane. The combination of the oncotic pressure of the protein and the osmotic pressure of the sodium ions

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resulting in an increased pressure gradient is called the COP. Albumin is 69,000 Da, whereas globulin is 150,000 Da and fibrinogen 400,000 Da. Since it is the number of molecules that are held on one side of the semipermeable membrane that creates COP, albumin will create the most pressure because 1 g of albumin has twice as many molecules as globulin and five times the number of molecules as fibrinogen. Starch molecules, found in hetastarch and dextran, should not be used for fat transfer since such molecules are too large to be evacuated through the lymphatics and will cause localized edema in the interstitial space.

15.7  Starling’s Equation Starling’s equation (79–80) represents, in equation form, the hydrostatic pressure pushing fluid through the capillary pore (Pc through d) vs. COP forces holding fluid in circulation, and the rate of fluid flow across the gel-sol matrix (Kf is inversely proportional to Pif) and back into circulation via lymphatic channels (Qlymph). When all of  these factors are combined, the entire equation is written as:

Jv = Kf [(Pc − Pif) − d (Pc − Pif)] − Qlymph Jv = Interstitial fluid flow Kf = Filtration coefficient Pc = Central venous pressure Pif = Interstitial space pressure d = Reflection coefficient Pc = Total protein in circulation Pif = Interstitial protein Qlymph = Lymph flow

The pressure in the capillary minus the opposing pressure in the interstitial space is known as the hydrostatic pressure. Central venous pressure (Pc) is the pressure pushing fluid across the endothelial membrane through the body. The total protein in circulation creates COP (Pc). At any given time and at any given pore in the vascular endothelium, there is more protein concentrated in circulation than there is at that site in the interstitial space. The COP creates a constant negative force holding the fluid in circulation and keeping interstitial fluid flow to a minimum, packing cells together, and preventing edema.

15.8 Avoiding Hypo-Oncotic Trauma in Fat Transfer When Klein’s solution or any modification is used in harvesting fat, the infranatant of the harvested fat contains 1.1–1.2 wt% protein. The normal level is 2.0–4.0 wt%. When one ampule of concentrated human albumin (12.5 g in 50 mL) is added to 1 L of tumescent solution or 8.3 mL added to a 60-mL harvesting syringe, the harvested fat contains 2.6 wt% protein. Three washes of harvested fat also increase the difference in COP and, therefore, it is necessary to add 18.75 g of albumin to each liter of washing solution. Adequate time must be allowed between each wash to allow the fat cells to pack above the infranatant layer. The process can be accelerated by centrifugation. The supranatant oil must be removed before insertion of the fat into the recipient site.

15.9  Indications for Fat Transfer There are a variety of indications for fat transfer, which can be distilled down to the following: 1. Fill defects (a) Congenital (b) Traumatic (c) Disease (acne) (d) Iatrogenic 2. Cosmetic (a) Furrows (rhytids, wrinkles) (b) Refill of lost supportive tissue (aging) (c) Enhancement

15.10  Preoperative Consultation The patient is carefully examined in relation to the specific complaint for which the patient has come in for consultation. A description of the physical problem needs to be recorded with appropriate measurements. Pictures should be taken before any procedure is undertaken and postoperative photos taken at an appropriate interval of time when healing is completed. If there are other problems detected by the physician, other than that which the patient complains, this must be recorded and possible treatment explained to the patient so that steps may be taken to correct other

15  Fat Transfer to the Face

deficits not previously identified by the patient or so that the patient understands that adequate correction may require other procedures. At the same time, the patient must not be talked into procedures that are not really wanted by the patient. An interval of time may be needed for the patient to think about what surgery may be necessary and to seek other consultations. The patient must understand the need for using autologous fat as a filler substance in comparison to other fillers presently available. To conform to the standard of care for informed consent, the patient must have sufficient information to be knowledgeable about the procedure, the possible material risks and complications, and the alternatives and their possible material risks. Someone in the office must take time to explain this information and the physician must at least make sure the patient understands the procedure, risks, and alternatives and answer any questions about the procedure. It is suggested that the physician include in the record the statement that “the surgical procedure was discussed as well as viable alternatives and all material risks and complications.”

15.11  Technique Fat survival depends upon the careful handling of fat during harvesting, cleansing, and injecting. Harvesting is performed by liposuction in areas of fat with alpha 2 receptors where the fat responds poorly to diet such as the abdominal or lateral thigh areas (genetic fat) (42). The fat can be retrieved with liposuction using a 2.0–3.0-mm cannula or blunt needle (14–16-gauge) with syringe (10–60 mL) 10% prefilled with saline and albumin in equal amounts. The fat should be cleansed with a physiologic solution of normal saline or lactated Ringers by gently mixing and decanting the infranatant liquid consisting of tumescent fluid, serum, and blood (Fig. 15.3). Fat can be concentrated with the use of centrifugation at 3,600 rpm for 2 min. This allows less need for as much overfilling (30–50%) as is usually used. Kaminski (81) has proposed the addition of 12.5 g of concentrated human albumin for each 1,000 mL of Klein’s solution used for harvesting and 18.5 g for each 1,000 mL washing fluid in order to maintain the normal extracellular oncotic pressure necessary to prevent the influx of solution into the cells with possible rupture. Alternatively, 8.3 mL of human serum albumin can be added to a 60-mL harvesting syringe.

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a

b

Fig. 15.3  (a) Fat retrieval with supranatant fat and infranatant fluid of blood and local tumescent fluid. (b) Fat following washing with sterile saline

Injection of fat is with a blunt needle (18-gauge) or cannula (1.5–2.0 mm) uniformly distributed into tunnels in multiple layers to fill the defect (Figs. 15.4 and 15.5). With depressed scars, the attachments to the skin should be subcised before fat injection. The use of ratchet gun for injection does not damage fat cells (82). The areas of the face that can be enhanced include the cheeks (malar, submalar), lips, and chin (mentum) (Fig. 15.6). The brows may be lifted with fat transfer to the forehead and indentations can be improved in almost any area of the face. Rhytids in the glabella, nasolabial fold, and marionette lines can be improved. If the glabella is to be injected, the patient should be informed of the rare possibility of blindness. Any area of the face can have a depressed scar elevated by subcision and fat transfer.

15.12  Complications There are very few serious complications of autologous fat transfer. Since it is the patient’s own tissue, there is no rejection phenomenon or allergic reaction. The harvesting of large amounts of fat using liposuction is

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a

b

Fig. 15.4  (a) Fat transferred to 1-mL syringe with small cannula attached. (b) Injecting fat into face with palm of hand pressing on the plunger

a

b

Fig. 15.5  (a) Ratchet gun with 1-mL syringe and cannula. (b) Fat being injected with ratchet gun

prone to the complications of liposuction in the donor area but facial fat transfer is usually with small amounts of fat. If small amounts of fat (under 50 cc) are retrieved, then one may expect the possibility of bruising or infection in the donor site. The injection of autologous fat may be associated with the following risks: 1. Loss of fat volume (the most frequent problem) 2. Possible need for repeat injection(s) of fat 3. Bruising, hematoma 4. Swelling (especially with over injection)

5. Asymmetry 6. Prolonged erythema (usually temporary over a short period of time) 7. Scar that is depressed or thickened (rare except in the area of liposuction) 8. Tenderness, pain 9. Fibrous capsule around fat accumulation (from too much fat injected into one area) 10. Fat cyst (mass) 11. Infection (rare) 12. Microcalcifications (has not been reported in the face)

15  Fat Transfer to the Face

119

a1

a2

b1

b2

c1

c2

a3

c3

Fig. 15.6  Sixty-year-old female with atrophy of facial fat. (a1–a3) Preoperative. (b1, b2) Fat transfer markings in submalar area. (c1–c3) Four years postoperatively

120

13. Central nervous system damage and/or loss of sight from retinal artery occlusion (can occur with injection in the glabellar or nasal areas) 14. Plus all of the problems following liposuction if a large amount of fat is removed

15.13  Conclusions Autologous fat transfer has been a very successful filler in the facial area. If care is taken in the transfer process and postoperatively, there will be 40–60% fat survival on the first transfer. At times, a second or even third fat transfer (using the patient’s frozen fat) may be necessary to reach the volume best for the patient.

References   1. Fischer, G. Surgical treatment of cellulitis. Third Congress International Academy of Cosmetic Surgery, Rome, Italy, 31 May 1975.   2. Klein, J.A. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263–267.   3. Neuber, F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   4. Czerny, M. Plastischer ersatz der brusterlruse durch ein lipom. Verhandl d Deutscher Ges f Chirurg 1895;2:126   5. Verderame, P. Ueber fettransplantation bei adharenten knochennarben am orbitalrand. Klin Monatsbl fur Augenh 1909; 47:433–442.   6. Lexer, E. Freie fettransplantation. Deutsch Med Wochenschr 1910;36:640.   7. Bruning, P. Cited by Broeckaert, T.J., Steinhaus, J. Contribution e l’etude des greffes adipueses. Bull Acad Roy Med Belgique 1914;28:440.   8. Tuffier, T. Abces gangreneux du pouman ouvert dans les bronches: Hemoptysies repetee operation par decollement pleuro-parietal; guerison. Bull et Mem Soc de Chir de Paris 1911;37:134.   9. Willi, C.H. The Face and Its Improvement by Aesthetic Plastic Surgery. London, MacDonald & Evans, 1926, pp. 15–41. 10. Straatsma, C.R., Peer, L.A. Repair of postauricular fistula by means of a free fat graft. Arch Otolaryngol 1932;15:620–621. 11. Cotton, F.J. Contribution to technique of fat grafts. N Engl J Med 1934;211:1051–1053. 12. Peer, L.A. The neglected free fat graft. Plast Reconstr Surg 1956;18:233. 13. Peer, L.A. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217. 14. Peer, L.A. Transplantation of Tissues, Transplantation of Fat. Baltimore, Williams & Wilkins, 1959. 15. Fischer, G. The evolution of liposculpture. Am J Cosmet Surg 1997;14(3):231–239.

M. A. Shiffman and M. V. Kaminski 16. Fischer, G. First surgical treatment for modeling body’s ­cellulite with three 5 mm incisions. Bull Int Acad Cosmet Surg 1976;2:35–37. 17. Fischer, A., Fischer, G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977;2(4):40–43. 18. Bircoll, M. Autologous fat transplantation. The Asian Congress of Plastic Surgery, February, 1982. 19. Illouz, Y.G. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 20. Johnson, G.W. Body contouring by macroinjection of autologous fat. Am J Cosmet Surg 1987;4(2):103–109. 21. Bircoll, M.J. New frontiers in suction lipectomy. Second Asian Congress of Plastic Surgery, Pattiyua, Thailand, February, 1984. 22. Krulig, E. Lipo-injection. Am J Cosmet Surg 1987;4(2): 123–129. 23. Newman, J., Levin, J. Facial lipo-transplant surgery. Am J Cosmet Surg 1987;4(2):131–140. 24. Verderame, P. Ueber fettransplantation bei adharenten knochennarben am orbitalran. Klin Montsbl f Augenh 1909, 7:433. 25. Lexer, E. Ueber freie fettransplantation. Klin Therap Wehnschr 1911;18:53. 26. Kanavel, A.R. The transplantation of free flaps of fat. Surg Gynecol Obstet 1916;23:163–176. 27. Davis, C.B. Free transplantation of the omentum, subcutaneously and within the abdomen. J Am Med Assoc 1917;68: 705–706. 28. Lexer, E. Fatty tissue transplantation. In: Die Transplantation, Part I. Stuttgart, Ferdinand Enke, 1919, pp. 265–302 29. Mann, F.C. The transplantation of fat in the peritoneal cavity. Surg Clin N Am 1921;1:1465–1471. 30. Neuhof, H. The Transplantation of Tissues. New York, D. Appleton, 1923, p. 74. 31. Guerney, C.E. Experimental study of the behavior of free fat transplants. Surgery 1938;3:679–692. 32. Hilse, A. Histologische ergebuisse der experimentellen freien fettgewebstronsplantation. Beitr 2 Path Anal U Z Allg Path 1928;79:592–624. 33. Green, J.R. Repairing bone defects in cranium and tibia. South Med J 1947;40:289. 34. Wertheimer, E., Shapiro, B. The physiology of adipose tissue. Physiol Rev 1948;28:451. 35. Bames, H.O. Augmentation mammoplasty by lipotransplant. Plast Reconstr Surg 1953;11:404. 36. Hansberger, F.X. Quantitative studies on the development of autotransplants of immature adipose tissue of rats. Anat Rec 1995;122:507. 37. Schorcher, F. Fettgewebsver pflanzung bei zu kneiner. Brust Munchen Med Wochenschr 1957;99(14):489. 38. Van, R.L.R., Roncari, D.A.K. Complete differentiation of adipocyte precursors: A culture system for studying the cellular nature of adipose tissue. Cell Tiss Res 1978;195:317. 39. Van, R.L.R., Roncari, D.A.K. Complete differentiation in vivo of implanted cultured adipocyte precursors from adult rats. Cell Tiss Res 1982;225:557. 40. Saunders, M.C., Keller, J.T., Dunsker, S.B., Mayfield, F.H. Survival of autologous fat grafts in humans and mice. Connect Tiss Res 1981;8:85. 41. Illouz, Y-G. New applications of liposuction. In: Illouz, Y-G. (ed), Liposuction: The Franco-American Experience Beverly Hills. California, Medical Aesthetics, 1985, pp. 365–414.

15  Fat Transfer to the Face 42. Asken, S. Autologous fat transplantation: Micro and Macro techniques. Am J Cosmet Surg 1987;4:111–121. 43. Campbell, G.L.M., Laudenslager, N., Newman, J. The effect of mechanical stress on adipocyte morphology and metabolism. Am J Cosmet Surg 1987;4:89–94. 44. Johnson, G.W. Body contouring by macroinjection of autogenous fat. Am J Cosmet Surg 1987;4(2):103–109. 45. Agris, J. Autologous fat transplantation: A 3-year study. Am J Cosmet Surg 1987;4(2):95–102. 46. Bircoll, M. Autologous fat transplantation: An evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosmet Surg 1988;5(4): 283–288. 47. ASPRS Ad-Hoc Committee on new Procedures. Report on Autologous fat transplantation. 30 September 1987 48. Billings, E. Jr., May, J.W. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381. 49. Markman, B. Anatomy and physiology of adipose tissue. Clin Plast Surg 1989;16:235. 50. Illouz, Y-G. Fat injection: A four year clinical trial. In: Hetter, G.P. (ed), Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy, 2nd edition. Boston, Little Brown, 1990, pp. 239–246. 51. Hudson, D.A., Lambert, E.V., Block, C.E. Site selection for fat autotransplantation: Some observations. Aesth Plast Surg 1990;14:195–197. 52. Nguyen, A., Pasyk, K.A., Bouvier, T.N. et al. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85: 378–386. 53. Kononas, T.C., Bucky, L.P., Hurley, C., May, J.W. Jr. The fate of suctioned and surgically removed fat after reimplantation for soft-tissue augmentation. A volume and histologic study in the rabbit. Plast Reconstr Surg 1993;91:763–768. 54. Ersek, R.A. Transplantation of purified autologous fat: A 3-year follow-up is disappointing. Plast Reconstr Surg 1991; 87:219–227. 55. Courtiss, E.H., Choucair, R.J., Donelan, M.B. Large-volume suction lipectomy: An analysis of 108 patients. Plast Reconstr Surg 1992;89:1068–1079. 56. Asaadi, M., Haramis, H.T. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg 1993;91(4): 755–756. 57. Samdal, F., Skolleborg, K.C., Berthelsen, N. The effect of preoperative needle abrasion of the recipient on survival of autologous free fat grafts in rats. Scand J Reconstr Hand Surg 1992;26:33–36. 58. Eppley, B.L., Sidner, R.A., Plastis, J.M., Sadove, A.M. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90: 1022–1030. 59. Carpaneda, C.A., Ribeiro, M.T. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17:43–47. 60. Carpaneda, C.A., Ribeiro, M.T. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 61. Niechajev, I., Sevchuk, O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94:496–506.

121 62. Courtiss, E.H. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg 1994;94:137–138. 63. Fagrell, D., Enerstrom, S., Berggren, A., Kniola, B. Fat cylinder transplantation: An experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996;98(1):90–96. 64. Jones, J.K., Lyles, M.E. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997;14:275–279. 65. Coleman, S. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19:421–425. 66. Sattler, G., Sommer, B. Liporecycling: Immediate and delayed. Am J Cosmet Surg 1997;14:311–316. 67. Ullmann, Y., Hyams, M., Ramon, Y., Peled, I.J., Linderbaum, E.S. Enhancing the survival of aspirated human fat injected into mice. Plast Reconstr Surg 1998;101:1940–1944. 68. Fulton, J.E. Jr. Breast contouring by autologous fat transfer. Am J Cosmet Surg 1992;9(3):273–279. 69. Fulton, J.E., Suarez, M., Silverton, K., Barnes, T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865. 70. Ellenbogen, R. Free autogenous pearl fat grafts in the face a preliminary report of a rediscovered technique. Ann Plast Surg 1986;16:179–194. 71. Newman, J. Preliminary report on “fat recycling” - liposuction fat transfer for facial defects. Am J Cosmet Surg 1986;3:67–69. 72. Sidman, R.L. The direct effect of insulin on organ cultures of brown fat. Anat Rec 1956;124:723. 73. Hiragun, A., Sato, M., Mitsui, H. Establishment of a clonal line that differentiated into adipose cells in vitro. In Vitro 1980;16:685. 74. Chajchir, A., Benzaquen, I., Moretti, E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg 1993;17: 113–115. 75. Toledo, L. Syringe liposculpture: A two-year experience. Aesthetic Plast Surg 1991;15:321–326. 76. Brandow, K., Newman, J. Facial multilayered micro lipoaugmentation. Int J Aesthetic Restor Surg 1996;4(2): 95–110. 77. Berdeguer, P. Five years of experience using fat for leg contouring. Am J Cosmet Surg 1995;12(3):221–229. 78. Guyton, A.C. Capillary dynamics and exchange of fluid between the blood and interstitial fluid. In: Guyton, A.C. (ed), Textbook of Medical Physiology, 7th edition. Philadelphia, Saunders, 1986, p. 348. 79. Kaminski, M., Haase, T. Use of albumin in total parenteral nutrition solutions: Understanding Starling’s law and the resolution of hypo-oncotic edema. In: Van Way, C. (ed), Handbook of Surgical Nutrition. Philadelphia, Lippincott, 1992, pp. 272–282. 80. Civetta, J. A new look at the Starling equation. Crit Care Med 1979;7:84–91. 81. Kaminski, M.V. Jr., Fulton, J.E., Wolosewick, J.J. New consideration in fat transfer: A possible role for maintaining interstitial protein to reduce shrinkage of transferred volume. In: Shiffman, M.A. (ed), Autologous Fat Transplantation. New York, Marcel Dekker, 2001. 82. Shiffman, M.A. Effect of various methods of fat harvesting  and reinjection. J Aesth Derm Cosm Surg 2000;1(4): 231–235.

Fat Autograft Retention with Albumin

16

Mitchell V. Kaminski and Rose M. Lopez de Vaughan

16.1  Introduction A collection procedure for adipose tissue destined for autologous transplantation, using fatty acid-free albumin to improve adipocyte viability, has recently been reported (1). The authors recognized that adipose tissue collection procedures under tumescent anesthesia im­­ posed an oncotic shock or perturbation on the adipocytes as a result of the severe diminution of soluble protein. Further washing of adipose tissue in proteinfree solutions exacerbates adverse effects, which is, perhaps, the reason for poor or spotty retention of transplanted tissue. Thus, washing was abandoned and rapid restoration of soluble protein (albumin) was accomplished by adding 1 mL of human serum albumin to a 10-mL collection syringe; e.g., add 1 mL of albumin to a 10-mL syringe, 2 mL to a 20-mL syringe, and 6 mL to a 60-mL syringe before harvesting the fat. While the clinical approach is of recent vintage, basic scientists have long recognized the efficacy of using fatty acid-free albumin during adipocyte preparation and isolation procedures. More than three decades ago Cushman (2), and later Hazen et al. (3), noted that free fatty acids released from damaged cells are complexed by albumin. Subsequently, uncomplexed fatty acids subsequently can induce further lipolysis in undamaged cells. In fact, the literature is replete with reports on all facets of adipocyte biology, wherein authors routinely utilize albumin in adipocyte preparation and isolation procedures that, ostensibly, are modifications of the pioneering techniques of

Rodbell (4). The list of reports is extensive and may be found in published reviews of Ahima and Flier (5), Gregoire et al. (6), and Gregoire (7).

16.2  Background Without albumin, injection of autologous fat to enhance an anatomic feature or to fill a soft-tissue defect fails to produce consistent results (8, 9). However, because there are many advantages in using an autograft for these purposes, interest in improving the technique remains high (10, 11). Although using Klein’s solution to cause tumescence of the door site makes harvesting adipocytes safe (12, 13), it creates the equivalent of gross edema, which, though isotonic, causes a dilutional hypo-oncotic environment that contributes to the shrinkage problem. In aesthetic surgery, it is more common to add soft tissue than to take it away. Surgeons recognize that one aspect of aging is the gradual loss of subcutaneous fat. The soft, rounded curves of youth eventually become the flattened, thinned-out features of old age. Even after a facelift, in which redundant tissues are resected and repositioned, an improved but not a youthful countenance is seen because of a lack of volume under the skin. Autologous fat is the ideal soft tissue filler. It is nonallergic, inexpensive, safe, and easy to obtain. Fat-transfer techniques and liposuction continue to evolve (14–17).

16.3  History R. M. Lopez de Vaughan () Successful Longevity Clinic, 381 W. Northwest High way., Palatine, IL 60067, USA e-mail: [email protected]

Homograft transfer of adipocytes from one location to the other was almost abandoned during the 1960s as silicone injections gained popularity. Enthusiasm waned,

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_16, © Springer-Verlag Berlin Heidelberg 2010

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however, in the 1990s as real or imagined systemic side effects related to this material were the subject of a class action lawsuit (18). Fat potentially suited for homografting became available during the 1980s as early attempts at liposuction provided material. Liposuction at that time, however, was associated with pain, blood loss, and varied results. In the early 1990s, Klein (12, 13) published his tumescent technique for regional anesthesia, which made liposuction safer and more reliable when used with smaller-diameter cannulas. With the availability of this fat tissue, and the need for a volume filler growing, the idea of homografting lipocytes was rekindled. Cosmetic surgeons, including Coleman (19) and Fulton (20), have pioneered techniques for small- and large-volume fat transfer. There is a difference, however, in how the harvested tissue is processed before injection. For example, some surgeons wash the sample while others do not. Several authors advocate cleaning liposuction aspirate with saline or lactated Ringer’s solution; others suggest using sterile water as a means to obtain the highest proportion of viable cells (21), but none suggests normalized colloid pressure. Both groups overcorrected by anticipating shrinkage of the transplanted material. What is agreed on is that aseptic technique must be observed and the graft in the form of smallest pearls of adipocytes placed into the recipient tissue nutrient bed to ensure nourishment and survival. A closed technique for harvesting and layering has evolved (22). Without the restoration of soluble protein around the cells, fat grafting remains unpredictable. From Neuber’s (23) first attempts in 1893, discussed by Chajchir (24), the results of fat transplantation have been disappointing (9, 25). Some publications show a resorption rate of 20–90% (26–28). Various other techniques suggested for improving the long-term take of fat grafts, include centrifugation (29) and selection of the harvest site, both of which have been shown to make no difference (30). Attempts to normalize the microenvironment have been made, ranging from growth factors to growth medium (31–35). Without a nurturing microenvironment, implanted fat resorbs in a two-stage fashion (36). There is an acute drop in the cell population followed by resorption of oil cysts of nonviable adipocyte (37). It is obvious that the number of viable cells at the time of transplantation correlates with fat-graft survival volume (10, 38), but the cells need the oncotic pressure provided by albumin to be in contact with the host nutrient bed and minimal exposure to toxic free fatty acids.

M. V. Kaminski and R. M. Lopez de Vaughan

Anecdotally, some cosmetic surgeons reported that an unwashed, centrifuged sample is a more reliable filler. Others have observed that when plasma and platelets are added back to the fat tissue as a platelet gel, volume retention is improved from the expected 50% or less up to 80% (39). Plasma, like albumin, is composed of proteins in solution and will correct dilution by tumescence. Compared with plasma, albumin is inexpensive and easy to obtain.

16.4  Microenvironment Normally, adipocytes are packed tightly together and are adjacent to their blood supply (Fig. 16.1). Note that every cell is surrounded by or touches the microvasculature. This explains why, before tumescence with Klein’s solution, liposuction was a bloody affair. Including epinephrine in the tumescent formula and allowing time or mechanically assisting its perfusion into the tissues is the reason why blood transfusion during the procedure is no longer necessary. For the most part, the adipocytes are not rounded, bloated spheres. They have one or more flattened sides and are better described as polygonal and they appear packed between the vasculature. This is because they are compressed by colloid osmotic pressure, which is generated by soluble protein in the interstitial space. The cells are like peanuts sealed by vacuum in a bag. The interstitial proteins that surround cells create −7 mmHg pressure (40). Interstitial protein is reported as total

Fig. 16.1  A spread preparation using Fankels combined orcein connective tissue stain that reveals rich microvasculature and adipocytes packed against each other. Ad = adipocyte; C = collagen; E = elastin; V = vein; A = artery

16  Fat Autograft Retention with Albumin

protein (TP) when measured by a laboratory. Its three components are albumin, globulin, and fibrinogen. Albumin is the principle soluble protein and makes up at least 60% of TP (41). Because albumin is the smallest molecule that cannot pass easily through the semipermeable membrane of the capillary, it contributes most of the oncotic force, squeezing cells together. The number of particles in solution on one side of a semipermeable membrane, not their size, creates an oncotic force. To be specific, albumin is 69,000 Da, whereas globulin is 150,000 Da, and fibrinogen is 400,000 Da. Thus, 1 g of albumin has twice as many molecules as 1 g of globulin, and eight times that of 1 g of fibrinogen. To understand that this is oncotic pressure and not osmotic pressure, one should recall that if the particle in solution can pass back and forth across the semipermeable membrane, it cannot create an oncotic force. For example, if a glass funnel is covered with a semipermeable membrane whose pore size allows water, sodium, and chloride to pass but not sucrose, and if that funnel is then partially filled with a solution of sugar and salt water and placed upside down in a beaker of fresh water, after a period of time the sugar molecules on the funnel side of the membrane are responsible for drawing fluid into it. Because sodium and chloride easily traverse the membrane, they cannot create an oncotic force and will distribute equally on both sides of the membrane. Unlike this example, in vivo soluble proteins that surround adipocytes are dynamic. That is, albumin molecules make a circuit from the heart across the capillary membrane through the interstitial space and return to the heart by way of lymphatic flow within 24–48 h. The amount of protein in the interstitial space reflects protein in circulation. The TP creates colloid osmotic pressure, which holds fluid in the capillary. This force is opposed by hydrostatic pressure that pushes fluid from the capillary. These forces were described over 100 years ago by Starling (12).

16.5  Starling’s Equation The amount of protein in circulation, along with precapillary and postcapillary sphincters creates an alternating push and pull on the tissue fluids of the body. When the precapillary and postcapillary sphincters are neutralized, one can better understand the role of soluble protein (Fig. 16.2).

125 Pi

(Pc - Pi)

Pc

}σ

πc πi

V (πc-πi)

Kf

Kf

Q Lymph

Starling's Law Jv = Kf [(Pc-Pi) - σ (πc-πi )] - Q Lymph

Fig. 16.2  The capillary sphincters have been removed to better appreciate the role of colloid and hydrostatic pressure, which governs interstitial fluid flow

In Starling’s equation, pc represents colloid (TP) in circulation. This opposes the pressure pushing fluid out of the capillary (Pc). In the corpus, Pc is generated by the central venous pressure, whereas in the lung it is the pulmonary capillary wedge pressure. The rate of interstitial fluid flow across a membrane is also governed by its pore size. In addition, pi is the concentration of soluble protein in the interstitium, which creates series resistance to interstitial fluid flow and pi is the gel of the gel–sol matrix. If the gel–sol matrix is diluted below its lower limit of normal, it can create the appearance of a capillary membrane leak because interstitial flow is increased. In a clinical setting, patients suffering from profound interstitial hyperproteinemia are fragile and prone to fluid overload and congestive heart failure. The epinephrine in Klein’s solution is protective and decreases the rate of venous return in the face of a diluted pi. However, if very large volumes are administered widely, the epinephrine effect may wear off and fluid overload can occur. Starling’s Equation is:

where Jv = interstitial fluid flow. The equation (Pc– Pi) shows that the hydrostatic pressure in the capillary is much greater than the pressure in the tissues. Tissue hydrostatic pressure (Pi) can be increased by an elastic garment to literally squeeze edema out. The s in Starling’s equation represents the reflection coefficient. It is caused by the size of the pore in

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the membrane and is different for different tissues of the body. For example, the brain’s s is so tight that many antibiotics cannot cross it, whereas in the liver s is so large that it freely allows albumin to cross. The reason for such large pores in the the liver is obvious. Albumin is produced there and albumin carries noxious molecules to the liver for detoxification. Refering to the (pc–pi) portion of the Starling’s equation, total protein produces colloid osmotic pressure, which is rendered as p in the equation. In addition, pc is TP concentration in capillary circulation, and pi is TP in interstitial fluid. Normal TP in circulation is between 6 and 8.5 g/dl, whereas TP in interstitial fluid is 2 to 4 g/dl. Next, Qlymph is the rate of lymph flow that carries interstitial fluid back into circulation. Decreasing pi increases Qlymph. However, if a garment is too tight it can collapse lymph channels, resulting in a seroma. As the epinephrine effect on vasoconstriction abates, the diluted gel of the gel–sol matrix may not have time to recover. That decreases series resistance to interstitial fluid flow, which can mimic a leaky membrane. Finally, Kf is termed the filtration coefficient. It probably changes as pi is diluted by Klein’s solution, or it is diluted in the clinical setting because of hypoproteinemia or congestive heart failure. Both disorders cause dependent edema.

16.6  Effect of Tumescence Tumescing tissues generally drop pi from 2–4 to 0.5 g/dl. This rate was determined by allowing the harvested tissue to stand in the syringe for approximately 30 min

and then sampling the subnatent fluid using a spinal anesthesia needle to traverse the floating supranatent fat. It is assumed that the protein in the subnatent solution equals that surrounding the lipocytes. It was determined that washing the sample three times with an electrolyte solution can drop pi to 0 g/dl. A series of experiments were carried out to determine the effect of tumescent anesthesia dwell time vs. centrifuge time on the characteristics of the ratio of supranatent to subnatent fat and the TP of the subnatent fluid layer. The first experiment was conducted on tissue collected during contouring of the lower leg calf. Samples were obtained from the left calf at 1, 5, 15, and 25 min. These samples were put in the centrifuge for 1, 2, or 3 min at 3,000 rpm. The supranatent and subnatent layers were measured, and a ratio was determined. The larger the ratio, the more tissue there was for fat transfer. The subnatent fluid was sampled and sent to the laboratory for measurement of TP. Results showed that longer dwell times resulted in higher TP and a larger supranatent layer. In addition, the longer the centrifuge time, the better the supranatent/subnatent ratio (Table 16.1). The TP in the subnatent fluid was independent of centrifugation but increased as dwell time increased. This result probably reflects mobilization of the Klein’s solution administered subcutaneously and movement toward resolution of the artificial edema. The experiment was repeated using different anatomic sites with the same result. Again, the best-quality fat layer paralleled longer tumescence dwell time and longer centrifugation (3 min).

Table 16.1  Dwell time vs. centrifuge time Centrifuge timea 1 min, Supranatent/subnatent ratio TP (g/dl)b Ratio 2 min, Supranatent/subnatent ratio TP (g/dl)b Ratio 3 min,a Supranatent/subnatent ratio TP (g/dl)b Ratio 4 min,a Supranatent/subnatent ratio TP (g/dl)b Ratio

Dwell time 1 min

5 min

15 min

25 min

0.16/0.4 0.4 0.11/0. 0.55 0.09/0.2 0.45 0.19/0.4 0.475

0.18/0.3 0.6 0.15/0.3 0.50 0.19/0.4 0.475 0.18/0.3 0.6

0.23/.3 0.77 0.2/0.3 0.667 0.79/0.5 1.58 0.63/0.4 1.575

0.57/0.4 1.43 0.68/0.4 1.7 0.76/0.6 1.27 1/0.7 1.429

Centrifuge at 3,000 rpm TP indicates total protein. These rates indicate that the interstitial protein is washed down to low levels by tumescent regional anesthesia. Normal levels are 2–4 g/dl. Supranatent/subnatent ratio is the size in millimeters of the floating fat layer divided by the fluid layer beneath

a

b

16  Fat Autograft Retention with Albumin

Fig. 16.3  Liposuction syringes of 10 mL were progressively prefilled with human serum albumin at 0.5 mL increments (0–2 mL). Note the compacting effect on the adipocyte fraction as interstitial protein is restored to physiologic levels. At 1.0 mL, total protein in the infranatant fluid was normalized

16.7 Use of Albumin to Correct pi Deficit Physical Characteristics Adding 1 mL of human serum albumin (HSA) per 10-mL syringe volume also changes the physical characteristics of the fat during the procedure (Fig.16 3). It rarely produces troublesome air spaces when filling the 1-mL transfer syringe. The homograft may be injected more smoothly and much less fat needs to be used to achieve the desired effects. Colloid resuscitation with HSA adds to the benefit achieved by longer tumescent dwell and centrifugation times resulting in greater graft volume retention.

16.8  Importance of Not Washing 16.8.1  The Interstitium The connective tissue of the interstitium is host to ­myriad cell types, including fibroblasts, adipocytes, macrophages (histiocytes), neutrophils, eosinophils, lymphocytes, plasma cells, mast cells, monocytes, and undifferentiated mesenchymal cells. These cells, either fixed or transient, interact with each other and the extracellular matrix components (i.e., collagen, elastic fibers, adhesion glycoproteins) and substantial amounts of soluble protein comprising pi (42, 43). Within this

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integrated gel–sol assemblage are the vital components of the vasculature, initial lymphatics, and nervous system (lightly myelinated fibers to free nerve endings, myelinated fibers to encapsulated neural structures). The importance of the vasculature and lymphatics in maintaining homeostasis of protein and fluid concentration of the blood and interstitium is well documented and cannot be overstated. The neural components at a single anatomic site, although perhaps not vital, provide for the general sense of well-being. The presence of the above constituents within the interstitium, however, cannot be overlooked and may represent seed medium for the growth of normal adipose tissue. Klein’s pioneering work using a crystalloid solution, epinephrine and lidocaine has been a significant advance in lipoplasty (13). Considering the cell biology of the anatomic site, liposuction procedures and autologous transfers are traumatic, albeit transient, events. Even with the most careful technique, the architecture and physiology are altered dramatically, which sets in motion a cascade of systemic and cytokine-mediated cellular responses. The individual components of this integrated unit have been studied extensively and the literature is replete with thousands of reports. Providing a unified concept on the restructuring of this anatomic site after traumatic events is a challenge that needs to be met. The inventory of the components of the interstitium and how they interact is far from complete. At best, we can attempt to cull some of the more pertinent and interesting facts, and use these data as guides so as to make the procedures for autologous fat transfer more efficacious. As expected, current techniques yield a heterogeneous material composed of liberated fat, locules of adipose cells, collagen fibers and septa, vessels and nerves, clots, ruptured cells, hemoglobin, inflammatory proteins, proteases, lipogenic enzymes, and electrolytes including calcium (21, 44). The removal and subsequent transfer of tissue may seem to be dissimilar events, but the factors governing the restructuring of the microenvironment (of the interstitium) at both sites must be similar, if not the same. While the adipocyte is the main focus, the microenvironment of the interstitium would be altered dramatically by repeated washings in salt solutions. The goal of maintaining the in vitro microenvironment of the isolated cells or tissue fragments at physiologic levels is not only to prevent cell death, but also to promote and enhance the restructuring process at a new anatomic site.

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The complete removal of the interstitial components may not be necessary, and may be detrimental to the restructuring process. The rationale for providing a more appropriate microenvironment is gaining interest. For example, Fulton (39) reports the use of an autologous platelet gel, whereas Har-Shai et al. (35) have used an enriched tissue culture medium to increase the ­survival of adipocytes and promote the restructuring ­process. Both approaches add soluble protein to the harvested sample and report good success. Kaminski et al. (1) suggest the use of protein (albumin) to resuscitate or protect the adipose tissue from oncotic shock during the removal and transfer processes and restore the in vitro protein concentration to in vivo levels. These reports represent some of the initial attempts to solve a highly complex problem (i.e., how to protect the cells and promote restructuring of a functional microenvironment). It seems unlikely that the microenvironment can be duplicated precisely in vitro given that the contents of this environment are not known with complete certainty. Several reports can guide investigators to design a more optimal in vitro environment. The removal and transfer of soft tissue must immediately initiate the restructuring processes, likely mediated by cytokines. All of these factors are naturally present within the recipient site, and are sufficient if the pearl of transplanted fat is small enough and in contact with the nutrient bed. The essentials in this scenario could be: (1) the elaboration or remodeling of the extracellular matrix that holds in place the resident cells and structures (i.e., fibroblasts, adipocytes, undifferentiated mesenchymal cells, vasculature, and lymphatics), (2) maintenance of the viability of existing adipocytes, and possibly promotion of differentiation of adipocytes from resident mesenchymal cells, (3) reformation or remodeling of the microvasculature and initial lymphatics, and (4) reestablishment of the homeostasis of the interstitium to quell the induced edema. If points 1, 3, and 4 are performed as recommended here, edema will be dissipated approximately 1–2 week after the procedure. Establishing optimal conditions for adipocyte survival and differentiation has proven to be more elusive. Considering the induced trauma, it does not seem unreasonable to suggest that adipocytes must undergo some alterations (e.g., differentiation, dedifferentiation) so as to adopt normal structure and function. Gregoire et al. (6) and Pinski and Roenigk (11) have assembled an

M. V. Kaminski and R. M. Lopez de Vaughan

extensive review of adipocyte differentiation and the numerous factors involved in this process. That the extracellular matrix of the interstitium is a complex entity composed of numerous proteins involved in diverse cellular phenomena is an accepted fact. Even more intriguing, with regard to restructuring, is the regulation and assembly of this fibrous complex into a functional, nonrandomly organized unit. That this restructuring event occurs is obvious, given the rapid healing of this area after surgery. Weber et al. (45) developed a concept of extracellular homeostasis. This concept is one of self-regulation of cellular composition and structure based on fibroblast-derived angiotensin that regulates the elaboration of transforming growth factor-1. This is a fibrogenic cytokine responsible for connective tissue formation at normal and pathologic sites. Biologic responses are found in various connective tissues, including adipose tissue. Given that the 3-dimensional architecture is altered profoundly, it is astonishing that it can be reconstituted to normalcy in a relatively short period of time Lipocytes are not islands unto themselves. They are surrounded by a sea of supportive cells, proteins, growth factors and electrolytes. In light of this, it is probably wise not to wash the sample vigorously, if at all.

16.9  Procedure and Methods Draw 8 mL of human serum albumin from a 50-mL ampoule (Baxter Laboratories, Deerfield, IL, 12.5 g/50 mL) using a 19-gauge needle on a 10-mL disposable syringe. Then, transfer 1 mL of HSA into each of seven 10-mL disposable syringes. The collection syringe is fitted with a 16- or 17-gauge liposuction cannula. Liposuction commences in a field previously anesthetized using Klein’s tumescent formula, modified to include 2 mL epinephrine instead of 1 mL at 1:100,000. The samples are decanted and centrifuged for 6 min. The infranatant is again drained, and the supernatant free triglyceride is wicked off. The remaining fat samples are combined and drawn into individual 1-mL Luer Lock syringes (Becton Dickson Luer Lock Syringe, manufacturer’s product Code#58-309604). No special cannulas are used to inject the fat. Instead, to eliminate the extreme scalpel-like sharpness of the needle, a 19- or 23-gauge needle is blunted against the

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a

b

Fig. 16.4  (a) The scalpel-like sharpness of 19- or 23-gauge needle is blunted against the diamond of another instrument. (b) The blunted needle is then polished against the “x” configuration of a disposable syringe plunger. The modified needle efficiently pushes its way into the target without lacerating the anatomy

diamond of another instrument and polished against the crisscross plastic of the syringe plunger (Fig. 16.4). A solution of 1% lidocaine with epinephrine is injected sparingly into the recipient site so as not to distort the anatomy. Three layers of mini-pearls are injected. Each layer consists of rows of mini-pearls trailed parallel to the each other. The needle is placed in the mid-upper cheek over the zygomatic bone, and directed in the target area. The fat is then tracked out while the needle is slowly withdrawn. For example, to augment the tear trough the first string of mini-pearls is placed over the periosteum, the second is placed within the orbicularis oculi muscle, and the third is

Fig. 16.5  The transplant needle is inserted in the mid-cheek. From here, both the tear trough and the nasolabial fold (NL) can be rejuvenated. Three layers of fat are injected on either side and beneath the fold crease at a 90°angle. Injecting fat is different from using collagen or other nonviable fillers when rejuvenating the NL fold

injected from a position approximately one finger breadth lateral to the angle of the eye, on top of the muscle. Two or three such strings fan out from the lash line toward the inferior orbital rim. For the superficial fine work, a 16-gauge harvesting cannula and a blunted 22-gauge injection needle are preferred. The nasolabial (NL) fold is first freed from its attachment to the orbicularis oris muscle using a wire scalpel (KMI, Corona, CA). Once freed, compression is applied for 2 min to control oozing and bruising. Then, from the mid-cheek, strings of fat beads are laid at a 90° angle across the NL fold from the lip to the cheek. Once again, a three-layer technique is used (Fig. 16.5).

16.10  Case Results The authors’ usual practice is to combine an S-lift and fat transfer. The S-lift addresses gradational aging effects of the lower face and neck. Fat transfer corrects atrophy and gravitational changes common to the midface. A total of 9 mL of fat was autografted (Fig. 16.6). In the case of moderate to severe tear trough, deformity with lower lid fat can be significantly improved with fat transfer alone. A total of 8 mL of fat was autografted (Fig. 16.7).

130 Fig. 16.6  (a) Preoperative. (b) Postoperative after S-lift and fat transfer of 9 mL of fat

M. V. Kaminski and R. M. Lopez de Vaughan

a

b

a

b

Fig. 16.7  (a) Preoperative. (b) Postoperative following 8 mL fat transfer to the tear trough

16.11  Fat’s Future The traditional concept of the adipocyte as simply a calorie storage cell has been shattered over the past few years. Fat is an exocrine, endocrine and apocrine organ and plays a role in immunity. This complexity is shown in Table 16.2 by the list of representative factors secreted by adipocytes and their presumed functions. For almost two decades, leptin was pursued as the Holy Grail in the control of obesity. It was considered

the adipostat mediator. A specific adipostat may never be found because there are many factors that contribute to energy homeostasis. Since the introduction of fat-free and low-fat food, the average American’s weight for any given age has increased by 10 pounds. Adipocyte number is not as stagnant as previously thought. A process occurs on an ongoing basis which increases or decreases the fat cell population. Decrease occurs via a process called apoptosis of both preadipocytes and adipocytes. Adipocytes may also dedifferentiate into preadipocytes. Adipocyte differentiation is

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Table 16.2  Representative factors secreted by adipocytes and their presumed functions Secreted molecules and their targets Energy homeostasis   Agouti   Leptin   Lipoprotein lipase   Insulin-like growth factor   Immunoglobulin F-binding protein   Acylation-stimulating Protein   Tumor necrosis factor-a   Adipose most abundant gene transcript1 Cardiovascular   Angiotensinogen   Apolipoprotein E   Cholesterol ester transfer protein   Plasminogen activator inhibitor-1 (PEI-1)   Adiponectin Complement factors   Adipsin   Adipo Q/Adipocyte complement related protein 30   Complement factor B Other   Vascular endothelial growth factor angiogenesis   Interleukin-6   Preadipocyte factor1   Colony stimulating factor

Adipocyte specific

Reference

No Yes No No No No No Yes

46 47 48 49 50 51 52 53

No No No No Yes

54 55 56 57, 58 59

Yes Yes

60 61 62

No No No No

63 64 65 66

Source: Halvorsen et al. (67)

the in vitro process by which differentiated fat cells revert morphologically and functionally to less differentiated cells (68). The process has been observed in vitro. These adipocytes lost their cytoplasmic liquid and acquired fibroblast morphology (69). These dedifferentiated cells also display the gene expression patterns of preadipocytes (70, 71). This is intriguing behavior in that preadipocytes exhibit stem cell-like qualities. Zuk (71) reported isolation of a population of stem cells from human adipocyte tissue. The cells were obtained from liposuction aspirate, and were determined to be mesodermal and mesenchymal in origin. In vitro, these cells could differentiate into adipogenic, chondrogenic, osteogenic, and myogenic cells in the presence of proper induction factors. Researchers from Duke University Medical Center have enthusiastically reported that adipocytes can become true stem cells (72). Their research exposed cells taken from human liposuction procedures to different cocktails of nutrients and vitamins. They successfully reprogrammed 62% of them to grow into bone, cartilage, fat or nerve cells. Because nerve tissue is ectodermal, and not mesodermal in embryonic origin, these

experiments confirm true stem cell potential. This may be the reason why, if handled properly, there is justified optimism for the future of fat-transfer technology.

16.12  Conclusions The field and study of fat grafting continues to evolve. As it does, the science behind graft retention continues to grow and has led to a better understanding of the adipocyte as a member of a dynamic organ with endocrine, apocrine and paracrine functions. The fat mass is dynamic. The fact that adipocytes can differentiate and dedifferentiate is exciting in its application to redifferentiation into other cell types. Stem cells from lipoaspirate make more sense than bone marrow or embryonic sources. It is easy to obtain, and when used in the same patient its endogenous genetic code is identical, removing yet another obstacle to retention. In summary, the steps to ensure fat autograft retention are: (1) harvest using small cannulas (16- or 18-gauge); (2) restore colloid pressure using albumin in

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the collection syringe; (3) inject the graft with relatively atraumatic needles (modified 18- or 22-gauge needles); (4) inject the fat to produce a trail of small beads in multiple fine layers, with each (bead) pearl touching the nutrient bed.

References   1. Kaminski, MV Jr, Wolosewick JJ, Smith J. Preservation of interstitial colloid. A critical factor in fat transfer. Oral Maxillofac Surg Clin North Am 2000;12:631–639.   2. Cushman, SM. Structure - function relationships in the adipose cell. J Cell Biol 1970;46(2):326–341.   3. Hazen SA, Rowe WA, Lynch CJ. Monolayer cell culture of freshly isolated adipocytes using extracellular basement components. J Lipid Res 1995;36(4):868–875.   4. Rodbell M. Metabolism of isolated fat cells. Effects of hormones on glucose metabolism and lipolysis. J Biol Chem 1964;239:375–380.   5. Ahima RS, Flier JS. Adipose tissue as an endocrine organ. Trends Endocrinol Metab 2000;11(8):327–332.   6. Gregoire FM, Smas CM, Sul HS. Understanding adipocyte differentiation. Physiol Rev 1998;78(3):783–809.   7. Gregoire FM. Adipocyte differentiation: From fibroblast to endocrine cell. Exp Biol Med 2001;226(11):997–1002.   8. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865.   9. Ersek RA. Transplantation of purified autologous fat: A three-year follow up is disappointing. Plast Reconstr Surg 1991;87(2):219–227. 10. Niechajev I, Savcuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 11. Pinski KS, Roenigk HH Jr. Autologous fat transplantation. Long-term follow-up. J Dermatol Surg Oncol 1992;18(3): 179–184. 12. Klein JA. The tumescent technique for liposuction surgery. Am J Cosm Surg 1987;4:263–267. 13. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction: Peak plasma concentrations are diminished and delayed 12 hours. J Dermatol Surg Oncol 1990;16(3):248–263. 14. Agris J. Autologous fat transplantation: A three year study. Am J Cosm Surg 1987;4:95–103. 15. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosm Surg 1987;4:111–121. 16. Peer LA. Loss of weight and volume in human fat grafts: With postulation of a “cell survival theory.” Plast Reconstr Surg 1950;5:217–230. 17. Shiffman MA. Principles of liposculpture. Am J Cosm Surg 1997;14:331–334. 18. Connell EB. The exploitation of autoimmune disease: Breast implant litigation and its dire implications for women’s health [editorial]. J Womens Health 1998;7:329–338. 19. Coleman WP III. The history of liposuction surgery. Dermatol Clin 1990;8(3):381–383.

M. V. Kaminski and R. M. Lopez de Vaughan 20. Fulton JE Jr. Breast contouring by autologous fat transfer. Am J Cosm Surg 1992;9:273–279. 21. Kaminski M, Haase T. Use of albumin in total parenteral nutrition solutions: Understanding Starling’s law and the resolution of hypo-oncotic edema. In Van Way C (ed), Handbook of Surgical Nutrition. Philadelphia, JB Lippincott, 1992, pp. 272–282. 22. Jones JK, Lyles ME. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosm Surg 1997; 14:275–280. 23. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66. 24. Chajchir A. Fat injection: Long-term follow-up. Aesthetic Plast Surg 1996;20(4):291–296. 25. Goldwyn RM. Unproven treatment: Whose benefit, whose responsibility? [Editorial]. Plast Reconstr Surg 1988;81(6): 946–947. 26. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386. 27. Boyce RG, Daniel W, Nuss, Kluka EA. The use of autologous fat, fascia, and nonvascularized muscle grafts in the head and neck. Otolaryngol Clin North Am 1994;27(1):39–68. 28. Matsudo P, Toledo L. Experience of injected fat grafting. Aesthetic Plast Surg 1988;12(1):35–38. 29. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis of lipocyte viability after liposuction. Plast Reconstr Surg 2002;109(2):761–765. 30. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: A quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004;113 (1):391–396. 31. Sidman RL. The direct effect of insulin on organ culture of brown fat. Anat Rec 1956;124(4):723–739. 32. Hiragun A, Sato M, Mitsui H. Establishment of a clonal cell line that differentiates into adipose cells in vitro. In Vitro 1980;16(8):685–693. 33. Freshney RI. Culture of Animal Cells: A Manual of Basic Technique, 2nd edn. New York, Liss, 1998, pp. 160–167. 34. Smith J, Kaminski MV Jr, Wolosewick J. Use of human serum albumin to improve retention of autologous fat transplant. Plast Reconstr Surg 2002;109(2):814–816. 35. Har-Shai Y, Lindenbaum ES, Gamliel A, Beach D, Hirshowitz B. An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg 1999;104(4):945–954. 36. Smahel J. Experimental implantation of adipose tissue fragments. Br J Plast Surg 1989;42(2):207–211. 37. Billings E Jr, May JW Jr. Historical review and present status on free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381. 38. Moore JH, Kolaczynski KW, Morales LM, Considine RV, Pietrzkowski Z, Noto PF, Caro JF. Viability of fat obtained by syringe suction lipectomy: Effect of local anesthesia with lidocaine. Aesthetic Plast Surg 1995;19(4):335–339. 39. Fulton JE. Stabilization of fat transfer to the breast with autologous platelet gel. Int J Cosm Surg 1999;7:6–16. 40. Guyton AC. Capillary dynamics and exchange of fluid between the blood and the interstitial fluid. In Guyton AC

16  Fat Autograft Retention with Albumin (ed),Textbook of Medical Physiology, 7th edn. Philadelphia, WB Saunders, 1986, pp. 348–360. 41. Kaminski MV, Haase T. Albumin and colloid osmotic pressure implications for fluid resuscitation. Crit Care Clin 1992;8(2):311–321. 42. Fawcett OW. A Textbook of Histology. New York, Chapman and Hall, 1994. 43. Kessel RG. Basic Medical Histology. New York, Oxford University Press, 1998. 44. Lalikos JF, Li YQ, Roth TP, Doyle JW, Matory WE, Lawrence WT. Biochemical assessment of cellular damage after adipocyte harvest. J Surg Res 1997;70(1):95–100. 45. Weber KT, Swamynathan SK, Guntaka RV, Sun Y. Angiotensis II and extracellular matrix homeostasis. Int J Biochem Cell Biol 1999;31(3, 4):395–403. 46. Michaud EJ, Mynatt RL, Miltenberger RJ, Klebig ML, Wilkinson JE, Zemel MB, Wilkison WO, Woychik RP. Role of the agouti gene in obesity. J Endocrinol 1997;155(2): 207–209. 47. Zhang Y, Proenca R, Maffei M, Barone M, Leopold L, Friedman M. Positional cloning of the mouse obese gene and its human homologue. Nature 1994;372(6505):425–432. 48. Fried SK, Russell CD, Grauso NL, Brolin RE. Lipoprotein lipase regulation by insulin and glucocorticoid in subcutaneous and omental adipose tissue of obese women and men. J Clin Invest1993;92(5):2191–2198. 49. Kern PA, Svoboda ME, Eckel RH, Van Wyk JJ. Insulin-like growth factor action and production in adipocytes and endothelia1 cells from human adipose tissue. Diabetes 1989;38(6):710–717. 50. Boney CM, Moats-Staats BM, Stiles AD, D’Ercole AJ. Expression of insulin-like growth factor-I (IGF-1) and IGFbinding proteins during adipogenesis. Endocrinology 1994; 135(5):1863–1868. 51. Cianflone K. Acylation stimulating protein and the adipocyte. J Endocrinol 1997;155(2):203–206. 52. Hotamisligil GS, Shargill NS, Spiegelman BM. Adipose expression of tumor necrosis factor-a1pha: Direct role in obesity-linked resistance. Science 1993;259(5091):87–91. 53. Gottschling-Zeller H, Birgel M, Scriba D, Blum WF, Hauner H. Depot-specific release of leptin from subcutaneous and omental adipocytes in suspension culture effect of tumor necrosis factor-alpha and transforming growth factor-beta1. Eur J Endocrinol 1999;141(4):436–442. 54. Karlsson C, Lindell K, Ottosson M, Sjostrom L, Carlsson B, Carlsson LM. Human adipose tissue expresses angiotensinogen and enzymes required for its conversion to angiotensin II. J Clin Endocrinol Metab 1998;83(11):3925–3929. 55. Zechner R, Moser R, Newman TC, Fried SK, Breslow JL. Apolipoprotein E gene expression in mouse 3T3-L1 adipocytes and human adipose tissue and its regulation by differentiation and lipid content. J Biol Chem 1991;266(16): 10583–10588. 56. Gauthier B, Robb M, McPherson R. Cholesteryl ester transfer protein gene expression during differentiation of human preadipocytes to adipocytes in primary culture. Atherosclerosis 1999;142(2):301–307.

133 57. Crandall DL, Quinet EM, Morgan GA, Busler DE, McHendryRinde B, Kral JG. Synthesis and secretion of plasminogen activator inhibitor-1 by human preadipocytes. J Clin Endocrinol Metab 1999;84(9):3222–3227. 58. Samad F, Yamamoto K, Loskutoff DJ. Distribution and regulation of plasminogen activator inhibitor-l in murine adipose tissue in vivo. Induction by tumor necrosis factor-alpha and lipopolysaccharide. J Clin Invest 1996;97(1):37–46. 59. Ouchi N, Kihara S, Arita Y, Maeda K, Kuriyama H, Okamoto Y, Hotta K, Nishida M, et al. Novel modulator for endothelial adhesion molecules: Adipocyte-derived plasma protein adiponectin. Circulation 1999;100(25):2473–2476. 60. Cook KS, Min HY, Johnson D, Chaplinsky RJ, Flier JS, Hunt CR, Spiegelman BM. Adipsin: A circulating serine protease homolog secreted by adipose tissue and sciatic nerve. Science 1987;237(4813):402–405. 61. Scherer PE, Williams S, Fogliano M, Baldini G, Lodish HF. A novel serum protein similar to C1q, produced exclusively in adipocytes. J Biol Chem 1995;270(45):26746–26749. 62. Peake PW, O’Grady S, Pussell BA, Charlesworth JA. Detection and quantification of the control proteins of the alternative pathway of complement 3T3-L1 adipocytes. Eur J Clin Invest 1997;27(11):922–927. 63. Claffey KP, Wilkison WO, Spiegelman BM. Vascular endothelial growth factor. Regulation by cell differentiation and activated second messenger pathways. J Biol Chem 1992;267(23):16317–16322. 64. Fried SK, Bunkin DA, Greenburg AS. Omental and subcutaneous adipose tissues of obese subjects release interleukin-6: Depot difference and regulation by glucocorticoid. J Clin Endocrinol Metab 1998;83(3):847–850. 65. Smas CM, Sul HS. Pref-l, a protein containing EGF-1ike repeats, inhibits adipocyte differentiation. Cell 1993;73(4): 725–734. 66. Levine JA, Jensen MD, Eberhardt NL, O’Brien T. Adipocyte macrophage colony-stimulating factor is a mediator of adipose tissue growth. J Clin Invest 1998;101(8):1557–1564. 67. Halvorsen YD, Wilkison WO, Briggs MR. Human adipocyte  proteomics - a complementary way of looking at fat. Pharmacogenomics 2000;1(2):179–185. 68. Sugihara H, Yonemitsu N, Miyabara S, Yum K. Primary cultures of unilocular fat cells: Characteristics of growth factors. Differentiation 1986;31(1):42–49. 69. Van RL, Roncari DA. Complete differentiation of adipocyte precursors. A culture system for studying the cellular nature of adipose tissue. Cell Tissue Res 1978;195(2):317–329. 70. Van RL, Bayliss CE, Roncari DA. Cytological and enzymological characterization of adult human adipocyte precursors in culture. J Clin Invest 1976;58(3):699–704. 71. Zuk PA, Zhu M, Mizuno H,Huang JBS, Futrell W, Katz AJ, et al. Multilineage cells from human adipose tissue: Implications for cell-based therapies. Tissue Eng 2001;7(2):211–228. 72. Lott KE, Awad HA, Gimble JM, Guilak F. Clonal Analysis of Multipotent Differentiation of Human Adipose-Derived Adult Stem Cells. DukeMedNews, 8 Mar 2004 News Release. Available at: http://www.dukemednews.org/news/ article.php?id=7452 (accessed 3 May 2007).

Aesthetic Face-lift Using Fat Transfer

17

Anthony Erian and Aqib Hafeez

17.1  Introduction Fat transfer (autologous fat grafting) has increased in popularity for soft-tissue augmentation despite perceived drawbacks of unpredictable results. The concept of fat grafting existed since 1893 (1) and became popular over the last 25 years with the developments in liposuction techniques. It also gained recognition for being the natural approach to restore a youthful look to the face. It can be performed as an isolated procedure or in conjunction with different types of facial rejuvenation, surgical and nonsurgical procedures. In face-lifting and facial rejuvenation it has improved the authors’ aesthetic results tenfold. It deals with soft-tissue loss and atrophy that accompany aging which a standard face-lift does not address. Fat transfer is known by a variety of names, of which the commonly used are fat transfer, fat injections, fat grafting, micro-lipoinjection, and autologous fat grafting. It is considered safe because of the autologous property and fat graft longevity. Although it is more invasive and expensive than the available semipermanent and permanent synthetic fillers, it has the least reported complications and longer survivability. The credit of introducing the concept of fat transfer goes to Neuber who, in 1893 (1), reported using a small piece of upper arm fat to augment the depression on a

A. Erian () Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK e-mail: [email protected]

patient’s cheek caused by tuberculosis. In 1895, Czerny (2) reported breast augmentation by using a fatty tumor from a patient’s lumbar region, or lower back, to fill the breast defect. The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909 by Verderame (3). In 1919 Marchand (4) reported that the large central portion of grafted fat is nonviable by the tenth week, with proliferation from the peripheral fat. His study was based on the histological examination of the grafted tissue in humans. The idea of fat injection came into practice during the 1920s (5). Neuhof, in 1923 (6), claimed that transplanted fat adopts a similar course to transplanted bone, i.e., replacement of grafted fat with fibrous tissue or newly formed cells. Peer (7, 8) contradicted the findings of the earlier publication regarding the survival of grafted fat and believed that durable fat cells are more concentrated in the center. He also noted that a larger percentage of weight and mass loss in grafts were sectioned into multiple small segments rather than single autologous fat grafts of equal size. With innovations in the techniques of liposuction in the 1980s, the idea of fat transfer for facial rejuvenation readily flourished. Illouz (9) published the idea of the transfer of liposuction aspirate fat. Ellenbogen (10) introduced the technique of fat transfer, popularly known as free pearl fat autografts, in a variety of atrophic and posttraumatic facial deficits. Despite all the controversial reports regarding the survivability of a fat graft, the basic facts remain the same, i.e., patient selection, comorbid factors, blood supply of recipient site, and safe and reliable techniques. Despite the lack of hard evidence regarding the survivability and longevity of fat grafting, it is still a widely practiced procedure in the field of cosmetic surgery.

M.  A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_17, © Springer-Verlag Berlin Heidelberg 2010

135

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A. Erian and A. Hafeez

17.2  Anatomy and Pathophysiology The knowledge of anatomy is the key to any surgical procedure. A surgeon with sound anatomical knowledge can avoid certain iatrogenic complications related to the procedure. A detailed description of facial anatomy is beyond the scope of this chapter. However, one of the complications of fat transplant is injury to the nerves or another vital structure, namely parotid duct. Most anatomists agree that the face has six layers, namely skin, subcutaneous fat, superficial musculoaponeu­ rotic system (SMAS), muscular layer, parotideomasseteric fascia, and retaining ligaments (zygomatic osteofasciocutaneous ligaments, mandibular osseocutaneous ligament, and masseteric fasciocutaneous ligaments). The face is supplied blood mainly from branches of the external carotid (facial and superficial temporal artery) and internal carotid arteries (ophthalmic artery). The venous drainage runs along the arteries. The facial vein can communicate with the cavernous sinus through the ophthalmic vein or pterygoid plexus. Lymphatic drainage is effected mainly through superficial and deep cervical nodes (11–13). The terminal branches of trigeminal nerve divisions, i.e., the supraorbital branch of the ophthalmic nerve, the infraorbital branch of the maxillary nerve, and the mental branch of the mandibular nerve, emerge from the corresponding foramina on the face. A vertical line drawn from the supraorbital foramen through the interval between the two lower premolar teeth will pass through the infraorbital and mental foramina. The supraorbital foramen lies approximately 3 cm from the midline. The infraorbital foramen lies 1 cm below the infraorbital margin and the mental foramen lies midway between the upper and lower borders of the mandible in adults. It lies near the lower border in children and near the upper border in older people (Fig. 17.1). The surface marking of the parotid duct is the horizontal line from the lower end of the tragus to midway between the ala of the nose and the red margin of the lip. The duct is 5 cm long and ends opposite the upper second molar tooth (Fig. 17.1). The facial nerve divides into five terminal branches, namely temporal or frontal zygomatic, buccal, marginal mandibular, and cervical (Fig. 17.2). Among these, the frontal and marginal mandibular branches are more at risk of injury. The frontal branch lies along the line drawn from the infra-tragal notch to 1.5 cm above the lateral eyebrow. The zygomatic branch runs along

Fig. 17.1  Surface anatomy of trigeminal nerve branches and parotid duct

Fig. 17.2  Branches of the facial nerve

zygomatic arch. The buccal branch runs along parotid duct. The mandibular (or marginal) division lies along the body of the mandible (80%) or within 1–2 cm

17  Aesthetic Face-lift Using Fat Transfer

below (20%). The marginal branch lies deep in the platysma along most of its course. Approximately 2 cm lateral to oral commissure it becomes more superficial and ends on the under surface of the muscles. Injury to the marginal branch results in paralysis of the muscles that depress the corner of the mouth. The cervical branch supplies platysma and runs behind the posterior border of mandibular ramus. These nerves are likely to get injured when the fat graft is placed below the muscle or above periosteum (12, 14). Contrary to earlier views about fat being an inert and isolated tissue, it has been verified to be a wellvascularized tissue with high metabolic activity. Fat tissue consists of fat cells, which have thin cell membranes entangled in a fibrous network. These supporting fibers provide a network which prevents collapsing of the fat cells. Fat tissue not only serves as a reservoir for energy storage but also plays a structural role. On completion of adolescent growth the number of fat cells generally is believed to be stable. Changes in the volume of fatty tissue relate to the size of the cells and their overall lipid content. Cells removed by liposuction or other surgical procedures do not regenerate. The fat cells shrink with weight loss or may dedifferentiate and show redifferentiation with weight gain causing an increase in volume. The aging patients show progressive decrease in hypodermal facial fat. It is also accompanied by loss of underlying connective tissue causing sagging of skin. The intrinsic changes are characterized by decreased fat cell size, diminished adipocyte function, impaired fat cell differentiation, and redistribution with reduced collagen (15). The signs of aging or lipoatrophy (multiple facial shadows, sunken temples and cheeks, and prominent muscle/bony landmarks) are quite marked in HIV patients.

17.3  Advantages and Disadvantages As with every procedure one has to make sure that the advantages outweigh the disadvantages before practicing it. The obvious benefits of fat transfer include availability of fat, contouring of the harvested area, minimal complication in competent hands, easy to learn and practice, and autologous in nature, eliminating the risk of rejection (16). Although the survival duration is

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unpredictable (17) it still shows better survival than temporary fillers. The procedure is less invasive and comparatively safe. It is noncarcinogenic. For patients who do not want a foreign material in their body it is an ideal substitute. In comparison to advantages the shortcomings are few. It is not an office procedure and more invasive than ordinary filler. The client will need local blocks, sedation, or anesthesia. The downtime can be more than anticipated and the the survival and longevity of the graft are unpredictable.

17.4  Patient Selection Patient selection plays a vital role in success or failure of any procedure. It never pays to operate on patients with unrealistic expectations as they are never satisfied with the outcome. It is vital to have detailed history including their past, personal, and psychiatric history. In people with severe depression, facial outlook acts only as a part of the problem and probably will only help but not treat the cause of depression. It is quite often noticed during consultation that patients are not sure what the most appropriate procedure is for them. Once the decision is made about a procedure, it should be explained to the patient in nonmedical terms, along with its potential complications and alternatives. It is wise to ask the patient to repeat the vital part of information to make sure that he or she has understood it. Nowadays it is customary to provide patients with some form of written information so that they can make an informed decision. For fat transfer, patients with a history of underlying current infection, smoking, anticoagulants, coagulation disorders, herpes simplex, and marked acne scarring are not ideal candidates. Patients with gross rhytids and poor skin tone will need additional procedures for optimum results. One must be careful in dealing with patients having a history of poor or delayed wounds. An ideal candidate will be an individual in good health, with no active or preexisting medical condition, who is not on any immunosuppressive or anticoagulation therapy, and who has realistic expectations. Although the word patient is quite commonly used, it is the authors’ opinion that candidates for cosmetic surgery should be addressed as clients as they are not treated for any illness.

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Fig. 17.3  Potential areas for facial fat transfer

17.5 Potential Areas for Facial Fat Transfer Although fat transfer can be used to augment any depressed area on face, the most commonly addressed areas are the following (Fig. 17.3): 1. Nasolabial folds 2. Marionette lines 3. Cheeks 4. Trough area 5. Chin 6. Glabellar area (?) These areas can be addressed individually or sometimes more than one area is augmented to achieve the desired result. Although injecting in the glabellar area is quite simple, it has been related with cavernous sinus thrombosis as a rare complication. One has to be careful while augmenting this area as not to inject too much, stay superficial, and avoid puncturing the vessels.

17.6  Technique The procedure should be carried out after careful client selection and preoperative assessment for safe and optimum outcome. If the client is on aspirin or is a smoker, these practices should be stopped for at least 2 weeks before the procedure. The clients should be

A. Erian and A. Hafeez

advised not to use any nonsteroidal drug as it can act as a precipitating factor for bleeding or bruising. If they use warfarin, the INR should be between 1 and 1.5 before procedure and make sure that they have meticulous preoperative hemostasis. It is recommended to ensure that the clients have given informed consent. It is advisable to arrange for the consent form to be posted 2 weeks before surgery. This gives them ample time to read the consent form carefully and write their queries, which are answered before they sign the consent form on the day of surgery. Pre- and postoperative photographs are a must. The procedure can be performed under a local anesthetic (18) or intravenous sedation commonly known as twilight anesthesia or general anesthesia. Every approach has its own advantages. The authors prefer to do it under twilight anesthesia as this approach is safe, swift, and provides early post operative recovery. The patient has no subjective discomfort and yet can follow the instructions during the procedure, such as turning head and mimicking facial expressions. If you ask the patients after the procedure under twilight anesthesia, they always say they do not remember. Twilight anesthesia includes midazolam for induction, propofol for maintenance, and morphine for pain. Use of an antiemetic is optional. The harvesting sites which can be used include the following: 1. Neck 2. Abdomen 3. Flanks 4. Buttocks 5. Trochanteric area 6. Inner thigh 7. Medial knee 8. Sacral area The choice of site for harvesting fat is not evidence based and depends on personal preference. The study published in 2004 by Rohrich et al. (19) compared adipose viability in vitro among fat tissues removed from various body donor sites including abdomen, flank, thigh, and medial knee. No difference between the donor sites was reported, though analysis was performed on samples only during the first 5 h after harvest. Trepsat (20) reported his preference for the inner part of the knee for fat harvesting. He found it most

17  Aesthetic Face-lift Using Fat Transfer

suitable fat for the lower palpebral area because the fat was “less fibrous in nature, more supple, and provided smaller individual tissue particles.” High levels of adipose tissue lipoprotein lipase within adipocytes of the fat grafts harvested from lower abdomen or thigh have convinced some authors that these fat grafts may be more resistant to anoxia. In the authors’ opinion, if the procedure is combined with a face-lift, it is wise to harvest fat from the neck as it helps to rejuvenate the neck. It perks up the final outcome because it improves the mento-cervical angle and defines the jaw line. If performed as an isolated procedure, it is preferable to harvest from the upper abdomen. Fat from the upper abdomen seems to last longer as compared to that from the lower abdomen, periumbilical, or flank area.

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17.7  Fat Harvesting The whole area is marked preoperatively with a black marker. The highest point and the entry site are marked with red marker (personal preference) (Fig. 17.4). The entry site is infiltrated using 2% lignocaine with adrenaline (1:200,000). Make sure that client is not allergic to adrenaline. There have been patients who have had a history of adrenaline allergy. The area to be aspirated is infiltrated with tumescent fluid. A mixture of normal saline with 1% lignocaine (250 + 20 mL) and 1 mL of 1:1,000 adrenaline is used. The choice of tumescent fluid ingredients is also a personal preference. The various concentrations of lignocaine used are 0.5 (20), 1, and 2%. Similarly the different concentrations of adrenaline used include 1:1,000, 1:80,000, 1:100,000 and 1:200,000. Some plastic surgeons prefer to use bupivacaine as it is longer-acting compared to lignocaine. The amount infiltrated depends on how much fat is required. The authors prefer to inject 1–2 mL/mL of fat to be aspirated. Normally 20–30 mL of fat is sufficient. The tumescent fluid should always be injected beyond the marked area of aspiration. This will help in better postoperative analgesia and hemostasis. Different methods described in the literature for fat harvesting are vacuum extraction, syringe aspiration, and surgical excision of fat tissue. The most commonly practiced method is syringe aspiration (21–23). It is

Fig. 17.4  The whole area for fat harvesting is marked preoperatively with a black marker. The highest point and the entry site are marked with a red marker (personal preference)

preferred to vacuum extraction because the latter can cause up to 90% adipocyte rupture if high negative pressures are used (24). The size of cannula again depends on personal preference. Different sizes mentioned in the literature are 1.5-, 2-, and 3-mm cannulas. The authors prefer to use a 2-mm blunt Mercedes cannula as it only needs a stab incision for entry with size 15 scalpel. There is no hard evidence that fat aspirated by a larger cannula has better survival. The cannula is attached to a 10-mL Luer Lock syringe and flushed to confirm that it is patent. Before harvesting is commenced the syringe is filled with 1 mL saline to fill the dead space between the tip of cannula and plunger. After inserting the cannula, pull the plunger about 1 cm and you will get pure fat. It ensures that there is least structural damage to fat cells from suction. Aspiration from the deeper layers of fat not only allows bloodless

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Fig. 17.5  2-mm blunt Mercedes cannula

Fig. 17.6  Fat aspirated

17.8  Fat Injection Technique

aspiration but also prevents any obvious donor site deformity (Figs. 17.5 and 17.6). After the aspiration, the syringes are left in a syringe rack upside down to separate the fat from blood, tumescent fluid, and ruptured lipocytes. The syringes are left in the rack for 5–10 min to ensure separation of fat cells. Then the syringes are drained so that only fat is left behind. If required, the fat cells can be washed with normal saline to remove left over blood and oil, which failed to separate. The preparation of fat before injecting is a controversial issue. A number of authors recommend centrifuging the specimen at 3,000 rpm for 3 min to separate the usable fat tissue from ruptured lipocytes, blood, and tumescent solution (25, 26). Ramon et al. (27) recommend exposure of fat to air before injecting. The authors do not centrifuge the fat or expose it to the open air as there are no randomized trials to support that these practices prolong the longevity of transplanted fat. There are some published reports indicating that the addition of various nutrients or growth factors, e.g., insulin, insulin growth factors, thyroxin, or nonsteroidal anabolic steroids, is beneficial (28, 29). However, these reports still lack clinical evidence.

The technique of injecting fat may vary among plastic surgeons but the basic vital principle is the same, i.e., vascularity of recipient site is vital for graft survival. The fat injected in well-vascularized areas tends to have better survival than that injected in areas with compromised vascularity. Different techniques mentioned in the literature use different sizes of cannulas varying between 14, 16, and 20-gauge blunt needles or 1-, 1.5-, 2-, and 3-mm cannulas (20, 21, 30). The advantages of using blunt-end instruments are decreased incidence of injury to underlying structures and hematoma. The methods of injecting include fanning out technique, pearl method, tunneling, and placing fat as aliquots (10, 20, 21, 23, 31). Fat grafts can be injected within subcutaneous tissue, under SMAS, above or below the muscles. It is wise to run the cannula parallel to nerve pathways using the knowledge of surface anatomy. If the fat transfer is combined with face-lift surgery, no dissection should be done in those areas as it will compromise the blood supply. Also in such patients the incision made for face-lift surgery can be used for fat transfer, thus avoiding the need for a separate incision. The senior author prefers to use a 1-mm blunt cannula. The area is injected using pearl technique which comprises injecting fat in small aliquots (10). Fat grafts are injected into multiple layers. Fat is pushed using

17  Aesthetic Face-lift Using Fat Transfer

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Fig. 17.7  (a, b) Fat injection

a

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Fig. 17.8  (a) Preoperative. (b) Postoperative after fat transfer to marionette lines

steady pressure on plunger while pulling the cannula out. Before injecting, the plunger is pulled backward to ensure it is not in a vessel to avoid accidental hematoma or fat embolism (Fig. 17.7). The authors prefer to inject above and below the muscle and SMAS. If needed some of it is injected into subcutaneous tissue especially in chin and glabellar area. Finally the area is gently massaged and covered with skin color micropore tape.

17.9  Postoperative Patients are discharged in the evening if fat transfer is performed as an isolated procedure, and go home with

only paracetamol to be used as required. They are advised not to use nonsteroidal medications for at least 5–7 days. Aspirin should be recommenced after 3–5 days. Those on antihypertensive therapy are advised to take their medication regularly. Patients are seen after 1 week, 6 weeks, and 3 months for follow-up. Depending on the outcome, if the clients feel any lump, they are advised to massage it with a slight degree of pressure. If the area is viewed as under–corrected, it can be topped up but usually it can be avoided by overcorrection. Although the results are obvious immediately, the patients are warned that it will take 3–6 months to see the final outcome (Fig. 17.8–17.10). Postoperative photographs should be taken at follow-ups.

142 Fig. 17.9  Cheeks. (a) Pre­ operative. (b) After fat transfer

A. Erian and A. Hafeez

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Fig. 17.10  Brows and cheeks. (a) Preoperative. (b) After fat transfer

17.10  Graft Survival The longevity of grafted fat, though one of the important questions, is still awaiting a definite answer. There are very few human studies regarding survival of grafted fat and even those studies lack depth and number. A study by Rieck and Schlaak (31) concluded that fat transferred into subcutaneous tissue and muscle demonstrated 30 and 6% survival respectively after 6 months. Sadick and Hudgins (32) were only able to objectively demonstrate viable fat in one of six patients, who had gluteal fat grafts to the nasolabial fold, after

12 months. The study published by Kaminer and Omura (16) reported fat graft survival for more than 5 years. Nevertheless, they stressed the use of touch-up procedures to improve the quality and longevity of results. Few other studies reported mean survival of less than 2 years (17, 26, 33, 34). In the authors’ clinical experience the fat graft tends to last from 12 to 60 months. However, a slight overcorrection at the time of surgery is beneficial in the aesthetic outcome. Despite the clinical optimism associated with fat transfer, the uncertainty among practitioners regarding the viability of transferred fat still exists (35, 36).

17  Aesthetic Face-lift Using Fat Transfer

17.11  Other Indications Autologous fat grafts can be the ideal soft-tissue filler because they are abundant, easily available, inexpensive, and host compatible. They can be used for facial depressions caused by congenital underdevelopment, facial bone fracture, and sheet like scars. They are successfully used for mild or moderate hemifacial atrophy, or Romberg disease (37). Autologous fat transplantation is preferred to any type of free tissue transfer because of long-term problems of free tissue transfer, such as contracture or sagging. Autologous fat grafts have shown promising results in patients with HIVassociated lipodystrophy (38, 39). Complications: 1. More swelling 2. Lumpiness 3. Long-term results 4. Infection 5. Pain 6. Discomfort Though rare, there are unfortunately few case reports with grave consequences following fat grafting. These include fat emboli in the retinal and cerebral arteries, loss of vision, hemiplegia, global aphasia, blindness following fat injections, cerebral fat embolism, and acute fatal stroke immediately after autologous fat injection into the glabella region (40–45).

17.12  Discussion The replacement of atrophied soft tissues plays an elementary role in facial rejuvenation. Despite variable results, facial fat grafting is a well-accepted procedure and has a low morbidity. The three major age-related changes in the face are gravitational descent, soft-tissue atrophy, and loss of skin elasticity. In comparison to other reconstructive surgical procedures, fat grafting is an easier option. Controversies that exist regarding the long-term maintenance of autologous fat grafts may be related to the traumatic handling of the graft during harvesting and injecting. The technique of fat-grafting is critical to avoid possible injury to the adipocytes within fat parcels and for the success of autologous fat transplantation.

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More intact cell membranes of adipocytes were found by syringe aspiration. Therefore, if practiced, a low-speed centrifugation, i.e., less than 1,000 rpm, is recommended to minimize injury to fat cells. Purification of fat parcels is imperative as the contents that existed in the harvested material such as anesthesia drugs, dead cell fragments, and tumescent fluid are potentially harmful to the survival of fat parcels. Although the evidence is preliminary, some researchers demonstrated that the basic fibroblast growth factor, insulin, and anabolic steroids could increase the survival of fat parcels. Operative techniques of minimal injury are very important. These include the use of blunt suction cannula, lower suction and injection pressure to reduce mechanical injuries to fat parcels. Lipoinjection is a special form of fat tissue grafting. It should be treated like other grafts in plastic surgery. Therefore, the two basic principles, i.e., good blood supply of the recipient and reasonable postoperative immobilization should be observed. Patients should be advised to reduce or avoid unnecessary movements of facial muscles if possible, because these movements might interfere with angiogenesis around injected fat grafts. The authors recommend multitunnel and multilayer pearl technique injections to have the least amount of fat grafts distributed to the most possible space with the largest contact area. In this way, we believe transplanted fat grafts can gain the maximal amount of nutrition so that the chances of fat necrosis or absorption are minimal. Recent improvements in harvesting, purifying, and injecting autologous fat have made the process of facial fat grafting significantly more reliable. Future investigations concerning the variables that affect fat survival should yield even greater improvements in fat transplantation.

17.13  Conclusions Patient selection is important. Preoperative and postoperative photos should be taken. Fat harvesting should be performed using a 2-mm cannula after infiltrating with tumescent fluid. Fat is injected with a blunt 1-mm cannula using pearl technique with slight overcorrection. Proper patient follow-up is needed.

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References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Dtsch Ges Chir 1893;22:66.   2. Czerny V. Plastischer ersatz der brustdruse durch ein lipom. Chi Kong Verhandl 1895;2:126.   3. Verderame P. Ueber Fetttransplantation bei adharenten knochennarben am orbitalrand. Klin Monatsbl Augenheilkd 1909; 47:433–442.   4. Marchand F. Ueber die Veranderungen des Fettgewebes nach der Transplantation. Beitr Pathol Anat Allg Pathol 1919; 66:32.   5. Miller CG. Cannula Implants and Review of Implantation Techniques in Esthetic Surgery. Chicago, Oak Press 1926.   6. Neuhof H. The Transplantation of Tissues. New York, D. Appleton, 1923, p. 74.   7. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18(4):233–250.   8. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217.   9. Illouz YG. L’avenir d la reutilization de la graisse apres liposuccion. Rev Chir Esthet Lang Franc 1984;9:36. 10. Ellenbogen R. Free autogenous pearl fat grafts in the face–a preliminary report of a rediscovered technique. Ann Plast Surg 1986;16(3):179–194.. 11. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58(1):80–88. 12. Freilinger G, Gruber H, Happak W, Pechmann U. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 1987;80(5):686–690. 13. Larrabee WF, Jr, Makielski KH. Surgical Anatomy of the Face. New York, Raven Press 1993. 14. Schaitkin BM, Eisenman DJ. Anatomy of the facial muscles. In: May M, Schaitkin BM (Eds), The Facial Nerve. New York, Thieme-Stratton 2000, pp. 95–105. 15. Whitaker LA, Bartlett SP. Skeletal alteration as a basis for facial rejuvenation. Clin Plast Surg 1991;18:197. 16. Kaminer MS, Omura NE. Autologous fat transplantation. Arch Dermatol 2001;137:812. 17. Pu LL, Cui X, Fink BF, Cibull ML, Gao D. The viability of fatty tissues within adipose aspirates after conventional liposuction. Ann Plast Surg 2005;54(3):288–292. 18. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263–267. 19. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004; 113(1):391–395. 20. Trepsat F. Periorbital rejuvenation combining fat grafting and blepharoplasties. Aesthetic Plast Surg 2003;27(4): 243–253. 21. Nordstrom REA. “Spaghetti” fat grafting: a new technique. Plast Reconstr Surg 1997;99:917. 22. von Heimburg D, Hemmrich K, Haydarlioglu S, Staiger H, Pallua N. Comparison of viable cell yield from excised versus aspirated adipose tissue. Cells Tissues Organs 2004; 178(2): 87–92.

A. Erian and A. Hafeez 23. Tzikas TL. Lipografting: autologous fat grafting for total facial rejuvenation. Facial Plast Surg 2004;20(2):135–143. 24. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386. 25. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119. 26. Rubin A, Hoefflin SM. Fat purification: survival of the fittest. Plast Reconstr Surg 2002;109(4):1463–1464. 27. Ramon Y, Shoshani O, Peled IJ, Gilhar A, Carmi N, Fodor L, Risin Y, Ulmann Y. Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 2005;115(1):197–201. 28. Huss FR, Kratz G. Adipose tissue processed for lipoinjection shows increased cellular survival in vitro when tissue engineering principles are applied. Scand J Plast Reconstr Surg Hand Surg 2002;36(3):166–171. 29. Har-Shai Y, Lindenbaum ES, Gamliel-Lazarovich A, Beach D, Hirshowitz B. An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg 1999;104(4):945–954. 30. Brandow K, Newman J. Facial multilayered micro lipoaugmentation. Int J Aesthetic Restor Surg 1996;4:95–110. 31. Rieck B, Schlaak S. Measurement in vivo of the survival rate in autologous adipocyte transplantation. Plast Reconstr Surg 2003;111(7):2315–2323. 32. Sadick NS, Hudgins LC. Fatty acid analysis of transplanted adipose tissue. Arch Dermatol 2003;137:723. 33. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 34. Kaufman MR, Bradley JP, Dickinson B, Heller JB, Wasson K, O’Hara C, Huang C, Gabbay J, Ghadjar K, Miller TA. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results. Plast Reconstr Surg 2007;119(1):323–331. 35. Ersek RA, Chang P, Salisbury MA. Lipo layering of autologous fat: an improved technique with promising results. Plast Reconstr Surg 1998;101(3):820–826. 36. Niechajev I, Sevchuk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg 1994; 94(3):496–506. 37. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ, Cooper DA. A syndrome of peripheral lipoatrophy, hyperlipidaemia, and insulin resistance in patients receiving HIV protease inhibitors. AIDS 1998;12(7):F51–F58. 38. Nelson L, Stewart KJ. Experience in the treatment of HIVassociated lipodystrophy. J Plast Reconstr Aesthetic Surg 2008;61(4):366–371. 39. Fagrell D, Enerstrom S, Berggren A, Kniola B. Fat cylinder transplantation: an experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996; 98(1): 90–96. 40. Masaki F. Correction of hemifacial atrophy using a free flap placed on the periosteum. Plast Reconstr Surg 2003;111(2): 818–820.

17  Aesthetic Face-lift Using Fat Transfer 41. Strauch B, Baum T, Robbins N. Treatment of human immunodeficiency virus-associated lipodystrophy with dermafat graft transfer to the malar area. Plast Reconstr Surg 2004; 113(1):363–370. 42. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361. 43. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107(1):85–87.

145 44. Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993; 24(4): 615–616. 45. Thaunat O, Thaler F, Loirat P, Decroix JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 2004;113(7):2235–2236.

Fat Transfer to the Glabella and Forehead1

18

Felix-Rüdiger G. Giebler

18.1  Introduction Fat is a biogenetic material that may not be an ideal soft tissue filler as the stress of transfer may result in absorption of some of the tissue. Autologous fat is a compatible filler but anatomic and histologic factors should be respected when injected into the facial regions. Cosmetic surgeons have treated defects of the soft tissue with a variety of permanent fillers (1) including paraffin, Teflon, petrolatum, oil from fruits, lanolin, beeswax, autologous skin, silicone, Gore-Tex, collagen, and fat. To be successful as an injectable implant a filler must have certain qualities such as the following: 1. No side effects 2. Replaceable 3. No allergic potential 4. Easy handling 5. Wide spectrum of usage 6. Availability 7. Inexpensive 8. Normal to palpation 9. No functional changes 10. Long-lasting Most alloplastic materials partially dissolve or are absorbed within the aggressive milieu of the body. They lead to prolonged foreign body reaction and this “bland process” is the space filler. Biogenetic implants feel more natural and the space is filled by the material Reprinted with permission of Lippincott Williams and Wilkins.

1

F-R. G. Giebler Vincemus-Klinik, Brückenstrasse 1a, 25840 Friedrichstadt/ Eider, Germany e-mail: [email protected]

itself but there is regression of the material and foreign body reaction as well. Hyaluronic acid, collagen (acting as a biological sponge) (2), and fat are natural materials found within the skin. There is a choice of homologous material or xenograft. Autologous fat transfer has questionable long-term effects and the vulnerability of the fat cells has not been solved. Mechanical stress and prolonged contact of the fat cells with different surfaces in the syringes and the cannulas may be some of the causes. Another problem is how the transplanted adipocytes come into contact with the vascular supply. Fat cells should be transplanted from a less vascular area to a more vascular area of the body and the fat for transfer should be obtained from regions of the body that are persistent deposits (alpha 2 receptors that do not respond to diet) (3). Before filling a soft tissue defect, the physician must have an exact anatomical diagnosis of the defect and should determine if the anatomic defect is expandable. Each defect has to be corrected with an appropriate filler, such as, collagen, hyaluronic acid, fat, tissue reconstruction, or alloplastic implant. Fat is not an adequate filler for either the dermis or epidermis but is adequate for the subcutaneous layer. Fat can only be placed into a prepared space.

18.2  Glabella and Forehead The folds on the forehead are functional folds caused by contraction of the muscularis frontalis, muscularis corrugator, and muscularis procerus. In these forehead folds, “bands” are attached from the fascia to the dermis. Apart from this, the soft tissue is stretched flatly over a bony prominence so that persistent pressure is easily applied on the transplant. Fat is not the ideal

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_18, © Springer-Verlag Berlin Heidelberg 2010

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material for forehead or glabellar augmentation as a space must be prepared for the fat transfer, a special stab wound must be made, and the fat should be placed in different layers with a blunt cannula. Indications for fat transfer to the face include the following (modified Skouge) (4): 1. Central cheek depression 2. Diffuse age-related lipoatrophy 3. Facial hemiatrophy 4. Flattened chin 5. Flattened upper and lower lips 6. Nasolabial grooves 7. Supra-eyebrow grooves 8. Glabellar depression

18.3  Equipment The equipment the author uses is modified from Fournier (5). A 13- or 14-gauge blunt needle is attached to a 10-mL Luer-Lock syringe previously washed with sterile saline, leaving a residual of 0.5 mL in the syringe for better suction and preventing contact of the fat with air. Negative pressure is applied to the syringe after the needle is inserted under the skin by retracting the syringe plunger mechanically with the help of the thumb and fingers. The harvested fat is decanted after 5–15 min and only the yellow fat is used. Specimens streaked with blood should be discarded. The same syringe is used for harvesting and injecting. There is minimum handling of the graft with diminished risk of possible contamination.

18.4  Anesthetic For local tumescence of the donor site (hip or trochanteric area), a modified Klein’s solution (6) is used, which consists of 1,000 mL saline, 50 mL Xylonest (prilocaine hydrochloride) with epinephrine at 1:200,000, 10 mL sodium bicarbonate (8.4%), and 10 mg triamcinolone. For the recipient site, 0.5% Xylonest without epinephrine is used (7). Other equipments include a spinal needle, #11 blade (for stab incision), a blunt stab preparatory (for subcutaneous space), a blunt transplantation needle

F-R. G. Giebler

with one hole, a top-open blunt transplantation needle (14 gauge), and a blunt stab dissector. The injection site of the glabella is infiltrated using a spinal needle containing 0.5% Xylonest without epinephrine (so that the vascularization in the recipient site is not diminished). Access is through a stab incision that is cranial to the groove in order to prevent injury to the vasculature and the innervation on the saddle of the nose.

18.5  Injection Technique A multilayered fanning technique is used for fat transfer with injecting while retracting the needle. Overcorrection of up to 30% would be wise. After implantation into the furrow, the fat is pushed into place. The finger tip should be lubricated to slide easily on the skin, otherwise the fat can be pushed back out of the stab incision. Ice packs are used to prevent bruising and no bandages are applied. The patient is encouraged to remain quiet with the head in an upright position to prevent ecchymosis and displacement of the graft.

18.6  Results Loss of volume is often noted within the first 14 days but becomes stable for the next few months (Fig. 18.1). A touch-up is planned 1–3 months after the first injection using excess patient fat that is stored in a freezer at −30°C.

18.7  Expectations of Fat Survival The author found a survival rate of up to 2 years but most of the patients had a large loss of volume after 3 months so that there was a need for touch-up to sustain a “stable” result. Various reports claim a wide range of fat survival on the basis of clinical impressions. Peer (8) and Wetmore (9) claimed a survival of 40–60% after transplantation. The different aspects of survival rates were discussed by Shiffman (10), who came to the conclusion that there could be consistently good results.

18  Fat Transfer to the Glabella and Forehead

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Fig. 18.1  (a1, a2) A 62-year-old female patient with a hollow appearance in the glabella area. (b1, b2) Immediately after injection of 1.8 mL of fat into the glabellar region with adjunctive

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a2

b2

d

lipoaugmentation of the malar region (3-mL each side). (c) One month after fat injection. (d) Three months after lipocontouring of the glabellar fold

150

F-R. G. Giebler

18.8  Complications

18.9  Discussion

1. Fat embolism

The forehead, with the glabella lines and the movement of the eyebrows, is the most important framework for the eyes and the expression of the face. Mostly we see the signs of stress and aging in this part of the face. All of the forehead lines are functional lines caused by the motion of the specified muscle traction (18). The best way to treat these grooves is to treat the motor of the folds – the muscle. To reach a permanent effect the muscle can be excised, which leaves holes and dimples in the front area of the face (regardless of whether you take the muscle out endoscopically or directly) (19). It is possible to get a long lasting effect by injecting Botox into the muscle (20). The first injection may even have an effect up to 4–12 months, and repeated injections, after the relapse of the muscle function, weaken the muscle to a considerable extent. It is a mistake not to inject enough Botox or to do the touch up too early (e.g., after 3 months). The dosage for big furrows is up to 10 units (21); the Botox should be placed deeply into the muscle. After the muscles are weakened, the remaining folds have to be filled out to get a good aesthetic result. There is no perfect material for the augmentation of the glabella, but with implanting fat there is no allergic or foreign body reaction potential. Fat is used when there is a conspicuous allergic history and when there is hypersensitivity to collagen (bovine collagen). In the aging face there is generally a loss of soft tissue so that augmentation is the answer (22). Nowadays, there are a number of fillers for the skin and the appendages of the skin. For correction of the defect, it is wise to use fat in the fat layer and collagen or hyaluronic acid in the skin. Longevity is only guaranteed by a permanent foreign body reaction around an alloplastic material. Within the face, with its complicated mimic structure, these foreign body reactions may interfere with the swinging lightness of the facial lines. The fluent interaction of muscles should not be impaired by a persistent lump of a foreign body.

Injectingfat into a vessel in the nose or glabellar area may result in unilateral blindness and even central nervous system damage (11–15). The glabellar area is highly vascularized and injections leading to collagenrelated embolism have been reported (16). 2. Hematoma and ecchymos is Hematoma and ecchymosis may be caused from disruption of vessels in the angioarchitecture of the glabellar area, from the extra incision, or from blood remaining in the unwashed fat for transfer. 3. Overcorrection There should be overcorrection up to 30% but the patient should be adequately informed that this will probably subside over time (weeks to months). If a true lasting overcorrection occurs, it can be corrected by pressure, the use of ultrasonic pressure application, or local syringe liposuction. 4. Sliding of the graft Sliding of the graft into the adjacent nasal portion of the upper lids, an infrequent complication, can be corrected by liposuction removal. 5. Infection Infection is rare. This may be because of the influence of the local anesthetic that acts as an antibacterial (17). 6. Calcifications 7. Oil cysts 8. Short-lasting effect The expectation of survival of the adipocytes depends upon a number of factors that include the following: 1. Contact of the adipocyte with foreign materials 2. Pressure within the syringes 3. Temperature 4. Angioarchitecture of the donor and recipient sites 5. Diameter of the harvest and donor cannulas 6. Duration of the transplant operation 7. Pressure in the recipient site 8. Amount of the concomitant hematoma 9. Fat storage of the cells

References   1. Giebler FRG. Injizierbare Implante Aest Chirurgie. Reinbek, Einhorne-Presse 1996, pp. 387–390.   2. Giebler FRG. Vor- Und Nachteile des Biogenen Implantates Collagen Plast Und Wiederherstellungschir. Reinbeck, Einhorn-Presse 1996, pp. 319–323.

18  Fat Transfer to the Glabella and Forehead   3. Hiragun A, Sato M, Mitsui H. Establishment of a clonal clel line that differentiated into adipose cells in vitro. In Vitro 1980;16(8):685–693.   4. Skouge JW. Autologous fat transplantation. In: Coleman WP, Hanke W, Alt TH, Asken S (Eds), Cosmetic Surgery of the Skin: Principles and Techniques. Philadelphia, B.C. Decker 1991, pp. 206–216.   5. Fournier PF. Liposculpture: The Syringe Technique. Paris, Arnette 1991.   6. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263–267.   7. Sattler G, Rapprich S, Hagedorn M. Tumescent local anesthesie untersuchung zur pharmakokinetik von prilocaine. Z Hautkr 1997;72(7):522–525.   8. Peer LA. The neglected free fat graft, its behavior and clinical use. Am J Surg 1956;92(1):40–47.   9. Wetmore SJ. Injection of fat for soft tissue augmentation. Laryngoscope 1989;99(1):50–57. 10. Shiffman MA. A complication of liposuction surgery. Am J Cosm Surg 1997;14:349–350. 11. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361. 12. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107(1):85–87. 13. Coleman SR. Problems, complications, and postprocedure care. In: Coleman SR (Ed), Structural Fat Grafting. St. Louis, MO, Quality Medical Publishing 2004, pp. 75–102.

151 14. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993; 24(4):615–616. 15. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face. J Neurol 1998;245(1):53–54. 16. Zyderm collagen implant. Inrmed Aeotetics, Anklow, Co Wichkow, Ireland. Physician instructions for use. 17. Thompson KD, Welykyj S, Massa MC. Antibacterial activity or lidocaine in combincation with a bicarbonate buffer. J Dermatol Surg Oncol 1993;19(3):216–220. 18. Putz HG. Sobotta Atlas der Anatomie des Menschen, Band 1. München, Urban & Schwarzenberg 1999, pp. 133–134. 19. Howard PS, Gardner PM, Vasconez LO, Core GB. Com­ plications in endoscopic plastic surgery. Clin Plast Surg 1995; 22(4):791–796. 20. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992;18(1):17–21. 21. Carruthers A, Carruthers J, Said S. Dose-ranging study of botulinum toxin type A in the treatment of glabellar rhytids in females. Dermatol Surg 2005;31(4):414–422. 22. Henderson JL, Larrabee WF, Jr. Analysis of the upper face and selection of rejuvenation technique. Facial Plast Clin N Am 2006;14(3):153–158.

Eyebrow Lift with Fat Transfer

19

Giorgio Fischer

19.1  Introduction Traditional eyebrow lift has been performed with surgical incisions involving the eyebrow area, coronal ap­­ proach, or endoscopic lift with smaller incisions. The surgery might have to be repeated in 5–10 years because of continued skin relaxation, fat absorption, or shifting with the aging process. Autologous fat can be easily obtained and is inexpensive. Fat can be utilized from concomitant bodycontouring procedures. Autologous fat is an ideal filler to lift the eyebrows. Aging of the face involves skin laxity and loosening of the fat in the forehead and eyebrow regions, which result in drooping of the ­eyebrows. Injecting fat into the proper areas will reverse the aged appearance and can be repeated as often as necessary without scarring.

19.2  Technique Botulinum toxin A is injected into the upper portion of the forehead 1 month prior to fat transfer and is repeated 1 month before each follow-up reinjection. Intravenous sedation with modified tumescent anesthesia is utilized for harvesting the fat. A limited amount of solution is injected to allow a more concentrated aspirate. Donor sites include the cervicofacial area, lateral and medial thighs, abdomen, flank, and

G. Fischer Via della Camiluccia, 643, 00135 Rome, Italy e-mail: [email protected]

medial knees. A small single-hole cannula or 18-gauge needle is used for the harvest, and the fat is retrieved in 1- or 3-mL Luer-Lock syringes. It is not necessary to transfer the fat prior to injection so that there is limited fat manipulation, decreasing the chance of fat cell damage. Slow, continuous, and gradual negative pressure is applied while the cannula or needle is directed in a spokewheel fashion to prevent depression in the skin overlying the donor site. The syringes with fat are placed in an upright position. The aspirate is allowed to settle into two distinct layers over a period of 5–6 min. The bottom layer, consisting of lidocaine and Ringer’s solution, is decanted and discarded. The recipient site is marked and prepped sterile. The entry sites, along the margin of the hairline, are injected with 2% lidocaine containing 1:100,000 epinephrine. Nerve blocks are useful to prevent distortion of the soft tissues caused by infiltration of anesthetic into the recipient area. Small amounts of fat are injected in herringbone fashion, in tunnels that are oblique and lateral to the medial part of the forehead and oblique to the temporal region. The cannulas used are curved to follow the contour of the frontal bone. When contraction occurs during the healing process, an upward lift and shrinkage of the skin result. The grafts are placed up to 1 cm above the eyebrow since a downward pull occurs if the fat is placed in close proximity to the eyebrow. Three separate sessions are usually necessary, injecting 2–3 mL of fat each time, at 3-month intervals. Patients over 40 years of age require a larger amount of fat. It is advisable to fill the dark shadows under the eyes with 0.5 mL of fat to obtain a better overall cosmetic result.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_19, © Springer-Verlag Berlin Heidelberg 2010

153

154 Fig. 19.1  (a) Preoperative; (b) following fat transfer

G. Fischer

a

a

b

b

Fig. 19.2  (a) Preoperative; (b) following fat transfer

19.3  Postoperative Care The forehead implants are not massaged, although the implants under the eyes are massaged gently for a few seconds each day to avoid contraction of the implant.

19.4  Discussion Fat transfer to the forehead is an excellent method to lift the eyebrows (Figs. 19.1 and 19.2). With the use of

small quantities of fat, approximately 29% resorption has been noted. Ptosis of the eyebrow does not occur with the use of botulinum toxin A if the injection is in the medial and upper portion of the forehead. Combined fat transfer with botulinum toxin A prevents muscular contraction that tends to pull down the skin of the eyebrow and forehead. Filling the lower eyelids to improve the dark shadows improves the total result.

Treatment of Sunken Eyelid

20

Dae Hwan Park

20.1  Introduction Sunken eyelid is a deformity of the upper eyelid due to atrophy of periocular fat tissue, loss of skin elasticity, natural aging process, facial trauma, complication of previous periocular surgery, etc. (Fig. 20.1). It causes retraction of the eyelid skin and unfavorable folds. In people with less orbital fat, the general facial appearance is often seen as tired and irritated. Moreover, multiple folds are formed in the upper eyelids, so for social image and cosmetics purpose many methods are available to treat sunken eyelid such as repositioning, refilling, and their combination (Table 20.1). Historically, as cited by Billings and May (1), van der Meulen was probably the first to use fat in human autotransplantation, with Neuber (2) receiving priority. Lexer (3–4) popularized the technique, and Peer (5) was seminal in his studies, presenting caveats on graft size and resorption rates, which were confirmed both before and after. Lexer and Stevenson (6) used rather larger fat grafts to cover defects in the face, with reasonably good success, and accepting a 50% resorption rate. Dermofat grafts, although not completely analogous, have been used with arguably more success than pure fat grafts in orbital reconstruction and elsewhere. A number of authors, most notably Coleman (7), have set about refining these techniques and achieving greater consistency of take. Haltingly, out of this dissatisfaction grew the current single-piece (lumbrical) fat graft technique (8).

a

b

Fig. 20.1  Sunken lid after blepharoplasty: (a) Excessive resection of tissue or fat in double fold surgery or blepharoplasty; (b) acceleration of the involutional physiological process and early appearance of deep orbito-palpebral sulcus. Preservation of soft tissue as much as possible is important in upper blepha­roplasty

20.2  Refilling 20.2.1  Fat Graft

D. H. Park Department of Plastic and Reconstructive Surgery, College of Medicine, Catholic University of Daegu, 3056-6 Daemyung 4-dong Namgu, Daegu, 705-718, Korea e-mail: [email protected]

In case of depressed upper eyelids due to lack of orbital fat, depression is seen in the inferior aspect of the circumorbital area. This type of eyes is more

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_20, © Springer-Verlag Berlin Heidelberg 2010

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Table 20.1  Methods for sunken eyelid correction Repostioning

Refilling

Combination

Orbital fat or soft tissue transposition Double eyelid operation Aponeurosis plication, advancement, or tucking Ptosis correction Alloplastic – Restylene or Juviderm Autogenous – fascia, cartilage, dermis, fat or dermofat graft Refilling and repositioning

distinguishable when looking up rather than looking down. While the patient is looking up, mark the depressed area, and upper–lower border. Then design the general extent of the injection site. Inject minimum amount of lidocaine with 1% epinephrine (Tumescent: 1 L normal saline with 2% lidocaine 25 mL and 1:1,000 epinephrine 1 mL) in the a

c

injection site and incision site. Cautious progress with the syringe needle is required because of the abundant vasculature in the circumorbital area. Make an incision using 18-gauge needle in the lateral orbital aspect, then proceed slightly so that the cannula can easily progress into the injection site. If a second injection is considered, harvest at least 10 mL from abdomen, thigh, buttock, flank area, etc. Fat oil from destroyed adipose cells, tumescent solution, and blood components in the harvested fat are primarily irrigated with normal saline, then filtered, and centrifuged at 3,000 rpm for 3 min (9). Carefully discard the tumescent solution, fluid, and blood component in the lowest section, then remove the fat oil in the uppermost section using a fat absorber or sterilized cotton swab. Carefully transport the separated fat in the 10-mL syringe to 1-mL syringes. Be careful not to let air come in between the fat (Fig. 20.2). b

d

Fig. 20.2  Preparation of fat injection–liposuction: (a) Fat from both buttocks; (b) filtering; (c) after centrifugation; (d) cannula

20  Treatment of Sunken Eyelid Fig. 20.3  Schematic dia­ gram of Suborbicularis fat graft: (a) before fat graft; (b) post fat graft

157

a

The skin in the upper eyelids is thinner than in other areas of face. This feature makes it easy for the upper eyelids to look uneven compared to other regions. Use a small cannula and inject deep in the subcutaneous layer as close as possible to the circumorbital muscle. It is recommended to inject a minimal dose evenly. In order to obtain a natural look, the injection has to be made right beside the margin of the upper eyelid. Attention must be given not to inject too much or too deeply because the patient may complain of heaviness of the eyelids when opening his/her eyes. After the injection, if the outer appearance looks even and natural while the eyes are closed, the procedure is considered successful (Figs. 20.3–20.5). Fat graft has the benefit of autologous tissue without risk of allergy, rejection, and possible transmission of viral or retroviral infection (10). The ease of procedure, rapid patient recovery, and minimal morbidity make this technique popular (11). The fat graft is stabilized after 60 days and remains as long as 10 years. Fat graft has a longer-standing effect in augmentation of the chin, cheek­bones, and buccal fat pad and has a  more transient result in the lips and nasolabial folds due to the mobility in these areas (11). Patients sometimes complain of visible swelling and bruising, local discom­fort, notice­able incision, and skin contour

b

a

b

Fig. 20.4  Fat graft with upper blepharoplasty: (a) Preoperative; (b) postoperative

depression after operation (12). Fat graft is generally a safe, straight­forward procedure, but serious side effects also exist such as ocular embolism, parotitis, persistent edema, lipoma, calcification, bacterial infection, and overcorrection (11). In fat graft, no local anesthesia is recommended because of the changes in the anatomic structure of the

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tissue. Fat manipulation should be delicate to avoid the destruction of the fat globules. Only injections of good tissue quality should be done. Broken-down fat cells, oil, or blood should be separated from the previous liposuction procedure (12). Some fat is likely to be absorbed during the healing phase, so it is necessary to harvest more fat than is needed and to freeze the remnant because of the possibility of a second or third procedure (11). No special postoperative care is required; only routine control, antibiotics, analgesics, and anti-inflammatory medication are needed. Delicate local massage to distribute the fat in its bed is beneficial. Heat also can be used for 1–2 weeks to reduce tissue absorption (12).

a

b

20.3  Dermofat Graft (Fig. 20.6)

Fig. 20.5  Fat graft with upper blepharoplasty: (a) Preoperative; (b) postoperative

a

Fig. 20.6  Schematic view of dermofat graft Suborbicularis approach for correction of sunken eyelid: (a) Preoperative; (b) postoperative

The skin that needs to be resected is designed to include the scar from prior surgery, and when an incision scar is present at an appropriate distance

b

20  Treatment of Sunken Eyelid

from the lid margin, only the planned incision line is drawn. Local anesthesia with 1% lidocaine, including epinephrine (1:100,000), is used. An incision is made down to the subcutaneous tissue layer with a #15 blade. The anterior adhesion between the orbital septum and skin orbicularis muscle flap and the posterior fibrotic adhesion between the orbital septum and aponeurosis of the levator palpebral muscle are carefully released. Scar tissue and fibrotic ­septal structures are removed. Some of the extruded preaponeurotic fat is spread thinly into where the adhesion is eliminated between the orbicularis oculi muscle and aponeurosis of the levator palpebral muscle to prevent secondary adhesion. The skin orbicularis muscle is raised near the ciliary margin, and pretarsal fat is removed (13). The graft is harvested with the avoidance of scalp and pubic hair follicles to the

a

b

Fig. 20.7  Dermofat harvesting from intergluteal fold: (a) Inter­ gluteal fold marking; (b) Dermofat graft

159

Fig. 20.8  Dermofat harvesting during lower blepharoplasty

greatest degree possible (14). A frequent source to harvest dermofat is the intergluteal fold (Fig. 20.7) and lower eyelid fat (Fig. 20.8). There are two graft methods to locate dermofat: suborbicularis oculi muscle or subseptal (Fig. 20.9) (15). To ensure that the graft is fully paid out, it is gently moved to and fro. Final in situ trimming of any unwanted fullness or irregularity is performed. Each end is tacked in place with 6–0 fast absorbable suture to prevent untoward movement or bunching (Fig. 20.10) (9). The skin is closed using a continuous 6–0 black silk suture (Fig. 20.11). The results are usually satisfactory (Figs. 20.12 and 20.13). In dermofat graft, the graft is harvested and prepared with a minimal amount of dermis to act as the vasoinductive element for fat survival. Grafts are prepared with a limited thickness of fat for maximal take and with virtually no “overcorrection.” The fat component within most grafts ranged from 2 to 6 mm in thickness, with a maximum of 10 mm. Grafts are placed with the dermal side against the more nutritive substrate, the subjacent subcutaneous tissue; thus, all grafts must be placed dermal side down. Dermofat grafts generally stabilize between 9 and 12 months but suction-harvested particle fat grafts seem to take less time, on the order of 3 months (9). The graft is immobilized for 6 days to minimize postoperative hematoma using a large, padded mild compression dressing for 2 days, followed by a small minimal compression dressing for an additional 4 days without washing hair or face (15).

160 Fig. 20.9  (a) Skin and OOM incision; (b) The appearance of dermogat graft from inter­ gluteal fold; (c) Trimming and setting of dermofat graft; (d) Suturing of dermofat graft to the surrounding soft tissue

D. H. Park

a

b

c

d

a

c

Fig. 20.11  (a–c) Dermofat preparation; (d) Dermofat graft, bolster dressing and skin suture

b

d

20  Treatment of Sunken Eyelid

161

a

b

Fig. 20.10  Dermofat fixation with 6–0 fast-absorbable suture

Fig. 20.13  Dermofat graft to treat sunken left eyelid: (a) Pre­ operative; (b) Postoperative

a

b

Fig. 20.14  Correction of sunken eyelid using double eyelid surgery

Fig. 20.12  Dermofat graft to treat sunken eyelid: (a) Preoperative. (b) Postoperative

20.4  Others Artificial filling materials like Restylane or Alloderm can be used to treat sunken eyelid.

20.5  Repositioning Sunken eyelid can occur as a complication of double eyelid surgery and is caused by excessive excision of skin, orbicularis oculi muscle, or orbital fat, or damage of the orbital septum. So repositioning of the ­tissue  after loosening the adhesion can remove the scar. Repositioning of orbital tissues by double eyelid ­operation (Fig. 20.14), ptosis correction such as

162

D. H. Park

a

b

Fig. 20.15  Correction of sunken eyelid by aponeurosis plication

Fig. 20.16  Correction of sunken eyelid by aponeurosis advancement

a

a

b

Fig. 20.18  Sunken eyelid correction by double eyelid surgery: (a) Preoperative; (b) postoperative

b

a

b

Fig. 20.19  Sunken eyelid correction by aponeurosis plication: (a) Preoperative; (b) postoperative

20  Treatment of Sunken Eyelid Fig. 20.17  Aponeurosis advancement

163

a

aponeurosis plication (Fig. 20.15), and aponeurosis advancement (Figs. 20.16 and 20.17) can be used in the treatment of sunken eyelid (Figs. 20.18–20.20). Sometimes a combination of repositioning and refilling is used to treat sunken eyelid if necessary.

b

a

20.6  Conclusions There are many methods to treat sunken eyelids. Among the many methods, fat graft is the most popular procedure as it is more effective and convenient than the others. Fat or dermofat grafts make sunken eyes thicker and eliminate the multiple folds in the upper eyelids giving a younger look. If a double eyelid line is present, it can be expressed as a well-organized double eyelid line, and many patients are satisfied with the result.

b

Fig. 20.20  Sunken eyelid correction by aponeurosis advancement: (a) Preoperative; (b) postoperative

164

References   1. Billings E, Jr, May JW. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2): 368–381.   2. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   3. Lexer E. Freie Fettransplantation. Deutsch Med Wochenschr 1910;36:640.   4. Lexer E. Ueber freie fettransplantation. Klin Therap Wehnschr 1911;18:53.   5. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217.   6. Stevenson TW. Fat grafts to the face. Plast Reconstr Surg 1949;4(5):458–468.   7. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119.   8. Frileck SP. The lumbrical fat graft: a replacement for lost upper lid fat. Plast Reconstr Surg 2002;109(5):1696–1705.

D. H. Park   9. Kim YK, Lim SY, Lee SJ. Correction of sunken upper eyelid using autologous microfat graft. J Korean Soc Plast Reconstr Surg 2006;12:79. 10. Kaminer MS, Dover JS, Arndt KA. Soft tissue augmentation. In: Kaminer MS, Dover JS, Arndt KA (Eds), Atlas of Cosmetic Surgery. Philadelphia, Saunders 2002, p 271. 11. Chajchir A, Benzaquen I. Fat-grafting injection for soft-­tissue augmentation. Plast Reconstr Surg 1989;84(6):921–934. 12. Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast Reconstr Surg 2007;120(1): 295–302. 13. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfactory blepharoplasty: removing multilaminated septal structures and grafting of preaponeurotic fat. Plast Reconstr Surg 2000;106:1399. 14. Little JW. Applications of the classic dermal fat graft in primary and secondary facial rejuvenation. Plast Reconstr Surg 2002;109(2):788–804. 15. Park JI, Toriumi DM. Revision double eyelid operation. In:  Cho IC, Park JI (Eds), Asian Facial Cosmetic Surgery. Phila­delphia, Saunders 2007, p 79.

Fat Graft Postvertical Myectomy for Crow’s Feet Wrinkle Treatment

21

Fausto Viterbo

21.1  Introduction The first sign of the aging process is the appearance of wrinkles around the eyes, known as “Crow’s feet” wrinkles. The treatments of these wrinkles include the use of botulinium toxin (1–4) injection. This treatment has a disadvantage that it is effective only for a short period. Among the surgical treatments, release of the orbicular muscle is an option. This muscle can be laterally stretched or even split with its ends tractioned and fixed with sutures (5–7). Recurrence of wrinkles is a problem in this case. For a more satisfactory result, the orbicular muscle can be partially removed. This muscular resection can be performed during a facial lift or blepharoplasty (5, 8, 9).

an SMAS graft from the preauricular region, during a face-lift. When the skin is already elevated, the SMAS approach is very easy (Fig. 21.4). In that region a rectangular fat graft is removed (Fig. 21.5). For a perfect replacement, this graft must have the same dimensions as the removed muscle. The donor area is closed with running suture.

21.2  Technique For an effective and also definitive result, we have developed a new technique named vertical lateral orbicularis occuli myectomy (10, 11). This method consists of a resection of the lateral portion of the orbicular muscle during temporalis lifting or blepharoplasty. This surgery is done under local anesthesia with sedation. After the muscle removal, it is possible to get a depression area caused by muscle resection (Figs. 21.1–21.3). It is very important to fill this area with some fat tissue. This fat tissue can be obtained from four areas. The first one, considered the simplest method, is by removing

F. Viterbo Rua Domingos Minicucci Filho, 587, Botucatu – SP18607-255, Brazil e-mail: [email protected]

Fig. 21.1  Resultant area post orbicularis muscle removal

Fig. 21.2  Visible depression post orbicularis oculi muscle removal

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_13, © Springer-Verlag Berlin Heidelberg 2010

165

166

Fig. 21.3  Visible depression in the right paraorbital area post orbicularis oculi muscle removal

Fig. 21.4  Preauricular region. Selection of SMAS area for fat tissue removal and posterior grafting

Fig. 21.5  Removed SMAS graft

F. Viterbo

Fig. 21.6  Myectomy via temporal face-lift

Fig. 21.7  Fat tissue from the inferior abdomen area for grafting

When the myectomy by blepharoplasty is performed, the fat graft donor area is from the inferior part of the abdomen, through a 2-cm incision in the pubic region, by removing two rectangular fat tissues for later grafting (Figs. 21.6 and 21.7). In cases of myectomy performed with a temporal face-lift, when the incision is made in the temporal region and the skin is elevated, the graft tissue is obtained from the resultant cutaneous excess. The excess skin is eliminated and only the fat tissue under the skin is saved for grafting (Figs. 21.8–21.11). Another option for temporal lifting is to make a temporal incision and superficially detach the skin, preserving the fat tissue in that area. At the end, this strip is removed and grafted in the paraorbital region (Figs. 21.12–21.15).

21  Fat Graft Postvertical Myectomy for Crow’s Feet Wrinkle Treatment

Fig. 21.8  Temporal lift myectomy. Cutaneous excess at the end of the surgery

167

Fig. 21.11  Fat graft for posterior fixation under the skin

Fig. 21.12  Temporal lift approach and prepilose incision for muscular resection of the orbicularis muscle area Fig. 21.9  Cutaneous excess eliminated portion, saving fat tissue

Fig. 21.10  Fat tissue for posterior fixation under the skin

Fig. 21.13  Orbicular muscle near the final detachment

168

F. Viterbo

Fig. 21.17  Grafted muscle fixed with 6–0 Mononylon sutures Fig. 21.14  Portion of the orbicularis oculi muscle dissected

a

b

Fig. 21.15  Myectomy via temporal face-lift. Superficial detachment saving the adipose tissue in front of its incision

Fig. 21.18  (a, b) Post fat fixation. Depression disappearing

Fig. 21.16  Planned fat tissue grafting in the paraorbital area

21  Fat Graft Postvertical Myectomy for Crow’s Feet Wrinkle Treatment

169

The adipose tissue is attached with local 6–0 nylon sutures or even transfixing it in the skin (Figs. 21.16 and 21.17). The fat graft does not become absorbed owing to the total absence of pressure over the adipose cells (Fig. 21.18). Graft removal from eyelid bags is not recommended because that usually suffers from gravity action with possible displacement and consequent bulges in the inferior portion.

21.3  Conclusions The results have been very interesting with total satisfaction to the patients (Figs. 21.19–21.21). Vertical myectomy with SMAS fat graft gives excellent results in the resolution of “Crows’ feet.” Fig. 21.19  Post operation without depression area in front of the hairline or orbicularis region

a1

b1

Fig. 21.20  (a1, a2) A 59-year-old patient before operation. (b1, b2) Two months after operation

a2

b2

170 Fig. 21.21  (a1, a2) A 49-year-old patient before operation. (b1, b2) Twelve days after operation

F. Viterbo

a1

b1

a2

b2

References   1. Carruthers A, Kiene R, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol 1996;34(5 Pt 1):788–797.   2. Carruthers A, Carruthers J. Cosmetic uses of botulinum A exotoxin. Adv Dermatol 1997;12:325–347.   3. Guyuron B, Huddleston SW. Aesthetic indications for botulinum toxin injection. Plast Reconstr Surg 1994;93(5): 913–918.   4. Matsudo PK. Botulinum toxin for correction of fronto-glabella wrinkles: Preliminary evaluation. Aesthetic Plast Surg 1996;20(5):439–441.   5. Skoog TG. The aging face. In: Skoog TG (Ed), Plastic Surgery, New Methods and Refinements. Philadelphia, Saunders 1974, pp. 317.

  6. Aston SJ. Orbicularis oculi muscle flaps: A technique to reduce crow’s feet and lateral canthal skin folds. Plast Reconstr Surg 1980;65(2):206–216.   7. Connell B, Marten T. Surgical correction of the crow’s feet deformity. Clin Plast Surg 1993;20(2):295–302.   8. Camirand A. Treatment of dynamic crow’s feet while performing a blepharoplasty. Aesthetic Plast Surg 1993;17(1): 17–21.   9. Bonatto A Jr, Freitas AG, Mélega JM. Myectomy of the orbicularis oculi muscle: A new procedure associated to blepharoplasty. Rev Soc Bras Cir Plást São Paulo 2002;17:27. 10. Viterbo F. New treatment for Crow’s feet wrinkles by vertical myectomy of lateral Orbicularis Oculi. Plast Reconstr Surg 2003;112(1):275–279. 11. Viterbo F, Lutz BS. Extended “C” Myectomy of the lateral orbicularis oculi muscle – A safe and successful method for  treatment of “Crow’s Feet”. Aesthetic Surg J 2006;26: 131–135.

Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer

22

Allison T. Pontius and Edwin F. Williams III

22.1  Introduction The aged face is the consequence of several concurrent factors, including skin laxity, soft tissue ptosis, and volume loss. Improving the condition of the skin is most commonly done with resurfacing procedures, laser and light therapy, daily skin care, and ultraviolet (UV) protection. Correction of soft tissue ptosis is usually surgically treated with a brow lift, midface lift, and lower face rhytidectomy. Correction of volume loss can be obtained with injectable facial fillers, most notably by autologous fat transfer procedures. Ideally, all these elements should be considered in order to provide complete facial rejuvenation. We have written extensively on the importance of addressing the midface in facial rejuvenation procedures (1, 2); however, despite repositioning of the ptotic soft tissues of the midface, facial rejuvenation may remain incomplete due to the persistent loss of volume seen in these patients. Despite the excellent surgical results obtained from the midface lift, we found that our rejuvenation procedures needed to evolve to include the correction of facial volume loss. In 2004, we began introducing fat transfer to patients undergoing a midface lift to improve aesthetic results. Fat transfer in patients undergoing a midface lift was specifically utilized because the key areas of volume loss are centered around the midface (the tear trough

A. T. Pontius () The Williams’ Center for Plastic Surgery, 1072 Troy Schenectady Road, Latham, NY 12110, USA e-mail: [email protected]

and infraorbital complex, the malar eminence, the ­submalar region, and the nasolabial crease). These are the areas where volume loss is most prominent. Additional areas where volume loss is present in some patients include the temporal fossa, the jawline, the glabella, the lateral brow, and the perioral region. The aesthetic findings in the initial group of patients treated with a combination of a midface lift and fat transfer were compared with those of a randomly selected group of patients who underwent a midface lift without concurrent fat transfer.

22.2  Methods All patients underwent either a midface lift alone or in conjunction with fat transfer performed by the senior surgeon (EFW). A total of 40 patients with complete photographic and chart records and a minimum of 6 months follow-up were included in the study. Group 1 consisted of 30 patients randomly selected (from over 650 potential patients) who underwent a midface lift without fat transfer. Group 2 consisted of the initial 10  patients who underwent a midface lift with fat transfer. The degree of aesthetic improvement of the four zones was assessed by three independent, blinded evaluators. Zone I represents the tear trough and infraorbital rim, zone II the malar eminence, zone III the submalar region, and zone IV the nasolabial crease. Each zone was given a rating from 0 to 2 (0 for no improvement, 1 for mild improvement, and 2 for marked improvement). The two groups were compared with four Chi-square tests of independence.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_22, © Springer-Verlag Berlin Heidelberg 2010

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22.3  Surgical Technique 22.3.1  Fat Retrieval The patient is placed under monitored anesthesia care with intravenous sedation or general anesthesia. When fat transfer is performed as the sole procedure, oral sedation is an option; however, because the patients in this study are undergoing a concomitant midface lift, general anesthesia or MAC (monitored anesthesia care) anesthesia is necessary. Prior to any surgical manipu­ lations or infiltration of local anesthesia, the areas of planned injection are delineated with a surgical marking pen and the estimated amount of fat needed is determined. Typically, for the four areas examined in this study a total of 40 mL of aspirated fat is sufficient. Next, the fat harvest sites are delineated with a surgical marking pen. The ideal place for fat aspiration is the inner thighs; however, the outer thighs and the abdomen are also commonly accessed. In thin patients, any areas of fat accumulation may be accessed, including the flanks and lateral buttocks. Once the entry sites for aspiration are determined, a single stab incision is made with a No. 11 blade. A long liposuction aspiration cannula is attached to a 20-mL syringe filled with the tumescent solution (1 mL 1% lidocaine with 1:100,000 epinephrine, 4 mL 1% plain lidocaine, and 15 mL saline). The long cannula is placed through the stab incision and directed out from the injection site in a fan-like pattern. A first pass is performed as a tunneling maneuver and the second pass is when the tumescent solution is infiltrated. This is repeated in the other fat  aspiration sites. Typically, a total of four 20-mL syringes are used to infiltrate the abdomen (two per side, from periumbilical stab incisions), and two 20-mL syringes of tumescent solution are used per inner or outer thigh. The total amount of tumescent solution utilized in a case is dependant on the number of aspiration sites; however, the total amount of lidocaine infiltrated is always carefully recorded. Ten minutes is allowed to elapse for maximal vasoconstrictive effect of the epinephrine. Next, the same liposuction aspiration cannula is affixed onto a 10-mL Luer-lock syringe. The nondominant hand is used to elevate the skin and superficial fat away from the aspiration cannula, and the dominant hand is used to perform manual aspiration of the fat (Fig. 22.1). A vigorous forward and backward movement of the cannula is used for optimal aspiration.

Fig. 22.1  The nondominant hand is used to elevate the skin and superficial fat away from the aspiration cannula and the dominant hand is used to perform manual aspiration of the fat

When aspirating in the abdominal area, one must be careful to stay in a relatively superficial plane to avoid any trauma to the underlying rectus muscle or untoward peritoneal entry, especially in patients with a previous history of abdominal surgery. The nondominant (or “smart” hand) can be used to guide the aspiration cannula in the proper plane. Following aspiration of the fat in multiple 10-mL syringes, the stab incisions are closed with a single 5–0 fast-absorbing gut suture. If the abdominal area is accessed, an abdominal binder is placed. The inner and/or outer thighs are wrapped with a 6-in. Ace wrap.

22.4  Fat Processing The plungers on the 10-mL syringes filled with aspirated fat are removed and a metal stopper is placed at the ends of the syringes. The syringes are then passed off the table to the circulating nurse who places them into a centrifuge. The centrifuge must always be “counterbalanced,” i.e., an even number of syringes should be placed in a centrifuge directly across each other. The fat is centrifuged for 3–5 min at 3,500 rpm. After centrifugation, the fat separates into three dis­tinct layers: the top layer consists of oil from ruptured adipocytes; the central area is the usable fat; and the bottom layer contains lidocaine, saline, and blood (serous fluid) (Fig. 22.2). The stoppers are

22  Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer

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Fig. 22.2  After centrifugation, the fat separates into three distinct layers: the top layer consists of oil from ruptured adipocytes; the central area is the usable fat; and the bottom layer contains lidocaine, saline, and blood (serous fluid)

then removed from the syringes to allow drainage of the serous fluid. The oil layer is then partially removed by carefully pouring it out from the top of the syringe. The remaining oil layer is removed by placing moist 4  × 4 gauze sponges (opened up lengthwise) into the top of the syringes to wick out the remaining oil layer. Once the usable fat is isolated in the syringes, they are placed in a refrigerator until the conclusion of the midface procedure.

22.5  Fat Transfer Procedure As the midface lift (1) portion of the procedure approaches completion, the surgical technician transfers the fat from the 10-mL syringes into individual 1-mL syringes using a Luer-lock transfer device. Either a straight or slightly curved 16-gauge blunt cannula is placed on the 1-mL syringes, depending on the anatomical site being injected. Attention is then turned to the previously marked out areas on the face: the tear trough, the malar eminence, the submalar region, and the nasolabial crease. An 18-gauge NoKor needle is used to create small stab incisions at the sites of entry. Beginning with the tear trough, the stab incision is made just inferior to the infraorbital rim and lateral to the infraorbital nerve. The 16-gauge blunt cannula is used to inject fat along the tear trough using multiple passes and laying down a minimal amount of fat (ideally about 0.03 mL per pass). The fat is injected at many different angles; however, at this location the fat is injected only in the deep plane just superior to the periosteum. Next, attention is turned to the malar eminence. Injection at this site is focused on injecting into and along the zygomaticus major, zygomaticus minor, and levator labii superio-

Fig. 22.3  Injection in the malar region is focused into and along the zygomaticus major, zygomaticus minor, and levator labii superioris muscles as well as into the malar fat pad

ris muscles as well as into the malar fat pad (Fig. 22.3). The entry incision is made with the NoKor needle at the inferior region of the muscles. A similar technique of inserting the blunt cannula and injecting a small amount of fat upon withdrawal is performed. Multiple passes with the cannula and injection into multiple tissue levels are performed. The submalar region is addressed next with injections targeting the buccinator and risorius muscles. Finally, the nasolabial creases are addressed by making the entry stab incision at the inferior-most point of the nasolabial crease. The same technique is utilized here, except that the injection is performed solely into the subcutaneous tissue layer and not into a specific muscle. After the conclusion of fat injections the face is cleansed with saline and a small amount of antibiotic ointment is placed on each of the stab incisions, and a typical face-lift/brow-lift pressure dressing is placed (solely for the midface lift). The injected areas are aggressively iced for the first 48 h in order to decrease edema and ecchymoses.

22.6  Complications The most common complication, or sequela, from the fat transfer was prolonged postoperative edema. The edema is thought to be due to the multiple tunneling performed with the fat transfer as well as from the

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concurrent midface lift. The second most common complication was ecchymoses from the stab incisions used to pass the injection cannula through the skin and from the multiple tunnels created to lay down the fat. Other reported complications of fat transfer include undercorrection, overcorrection, tissue irregularities and asymmetries, migration of the placement of the fat, and hematoma.

Table 22.3  Chi-square between group and submalar region ratings Rating

Nonfat transfer Fat transfer

No improvement

Mild Marked improvement improvement

6 0

64 19

20 11

Table 22.4  Chi-square between group and nasolabial ratings Rating

22.7  Results Four Chi-square tests of independence were conducted to compare the findings between Group 1 and Group 2. The first Chi-square test revealed a significant difference on “Tear Trough” ratings by the groups: P2 (2) = 73.59, p < 0.01 (Table 22.1). Group 1 participants were more likely to receive a “No Improvement” rating than those in Group 2 (25.56% and 0%, respectively). Additionally, participants in Group 2 were more likely to receive a “Marked Improvement” rating than those in Group 1 (66.67% and 0%, respectively). The second Chi-square did not reveal a significant difference on “Malar Eminence” ratings by the groups: P2 (2) = 3.10, ns (Table 22.2). One cell had an expected frequency less than five. The results from this test may not be valid because the small expected frequency can increase the risk of committing a Type II error. The third Chi-square test failed to reveal a significant difference on the submalar region by the groups:

Table 22.1  Chi-square between group and tear trough ratings Rating

Nonfat transfer Fat transfer

No improvement

Mild Marked improvement improvement

23  0

67 10

 0 20

Table 22.2  Chi-square between group and malar eminence ratings Rating

Nonfat transfer Fat transfer

No improvement

Mild Marked improvement improvement

7 0

51 16

32 14

Nonfat transfer Fat transfer

No improvement

Mild improvement

44  3

46 27

P2 (2) = 4.01, ns (Table 22.3). Two cells had an expected frequency of less than five, thereby increasing the probability of committing a Type II error. The final Chi-square test revealed a significant difference on the “Nasolabial Ratings” by the group: P2 (2) = 14.28, p < 0.01 (Table 22.4). Overall, both Group 1 and Group 2 participants were more likely to receive a “Mild Improvement” rating than a “No Improvement” rating. However, participants in Group 2 had a higher proportion of “Mild Improvement” ratings than their Group 1 counterparts. There were no participants in either group who received a “Marked Improvement” rating.

22.8  Discussion The use of fat to fill facial defects has been in practice since 1893, when Neuber (3) used pieces of fat to reconstruct facial scars due to tuberculosis. Since that time multiple reports have verified that fat can be ­transplanted and survive in various areas of the body (4–8). In 1926, Miller (9) described the infiltration of fat via a cannula. Although he described good results, the technique did not obtain much popularity at the time. The breakthrough in fat transplantation occurred with the development of liposuction in the 1970s (10) and its widespread use in the 1980s. Illouz (11–13) was a pioneer of liposuction who also studied the effects of  fat transplantation to the face. In 1988 he studied the  long-term results of facial fat injection in 167 cases  (12). Despite finding somewhat disappointing

22  Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer

results in the long-term correction of facial wrinkles, he remained optimistic in the possibility of fat-cell survival and encouraged further research in this area. In 1985 Fournier (14) first began extracting fat via a syringe and needle and confirmed the integrity of the  fat harvested by syringe aspiration. In the 1990s Coleman (15–16) contributed significantly to our current techniques and understanding of fat transfer by emphasizing the need for gentle removal and handling of fat and the injection of very small volumes of fat per pass combined with multiple passes in order to improve fat vascularization and therefore aesthetic outcome and longevity of results. In 1999 Amar (17) described “FAMI” (fat autograft muscle injection) in which fat is harvested via syringe aspiration, refined via centrifugation, and injected into the muscles of facial expression with specific anatomically curved cannulas. In the present study we attempted to determine the aesthetic benefit of combining the extended-minimal incision midface lift with fat transfer by having three independent evaluators rate the aesthetic improvement on a three-point scale. The study group was compared with a control group of 30 randomly selected patients who had previously undergone a midface lift alone. Only patients with a minimum of 6 months of chart documentation and photographic follow-up were studied. Four areas of the face were concentrated on that had shortcomings with the midface lift alone: the tear trough/infraorbital complex, the malar eminence, the submalar region, and the nasolabial crease. The 10 patients presented in Group 2 represent the initial group of patients in which a midface lift and fat transfer were combined. Fat volumes injected in these patients were somewhat modest (average 21.5 mL per patient), and all patients underwent only one fat transfer procedure at the time of their midface lift. The findings demonstrated that there was a statistically significant difference between Group 1 (no fat transfer) and Group 2 (fat transfer) in the tear trough region (p < 0.01) and the nasolabial fold (p < 0.01). The most impressive results were seen in the tear trough/infraorbital region where the majority of patients in Group 2 (66.67%) had a marked improvement rating. No patients in Group 1 received a marked improvement rating (0%) in this area. The tear trough demonstrated excellent aesthetic improvement and long-term correction as noted at 6 months. In the tear trough region the injection is performed in a deeper plane, just superficial to the periosteum in an area of

175

minimal mobility, which may account for the more dramatic results seen in this area as compared to the other studied areas. After seeing these initial impressive results in the tear trough area, we are now increasing the volume of fat transferred to this region. In this study, all patients received 1 mL of fat transfer to the tear trough/infraorbital rim (per side); however, 2–3 mL per side is now injected with even more impressive results and no apparent increase in morbidity. In the nasolabial fold, there was a statistically significant difference between groups (p < 0.01). Patients in Group 2 received a higher proportion of mild improvement ratings than Group 1; however, no patient in either group received a marked improvement rating. The nasolabial crease continues to be a challenging area to correct in the long term. Most commonly, the initial correction observed with fat transfer is only a mild improvement by the 6-month follow-up. This may in part be due to the mobility of the region and the more superficial plane of injection. In the malar and submalar regions there were no statistically significant differences between groups; however, because the values in these groups were not normally distributed around the expected frequency, a Type II error might have occurred. In other words, there may, in fact, be a clinical difference which is not statistically discernable. Regardless, the possible reasons for the minimal improvements noted in the malar and submalar region may be related to the midface lift itself. We perform a subperiosteal midface lift that elevates the origin of the zygomaticus major muscle off of the underlying bone. This creates a potential space in the subperiosteal plane, which is much easier to enter when injecting fat than is the belly of the zygomaticus muscles themselves. Additionally, the midface structures are suture-suspended to the temporalis fascia, and therefore one must also be extremely cautious not to break these sutures when injecting the midface. The edema and occasional bleeding that incurred during the midface lift also might be playing a role in fat resorption and obscuring tissue planes of injection. Potential alterations in technique that may yield more significant results in the malar and submalar regions may include staggering the midface lift and fat injection procedures to eliminate the effects of tissue edema seen immediately following the midface lift and providing more static planes of injection. Additionally, a second fat transfer procedure may be indicated in certain patients at 3–6 months to restore complete correction.

176 Fig. 22.4  (a1–a4) Preoperative patient from Group 2; (b1–b4) Post operation of a midface lift with fat transfer. Note the improvement in the tear trough region and nasolabial creases secondary to the fat transfer

A. T. Pontius and E. F. Williams III

a1

a2

a3

a4

This study supports the use of fat transfer to correct the tear trough deformity and the nasolabial crease at the time of the midface lift. Many patients who undergo a midface lift have a significant tear trough deformity and infraorbital skeletonization (either from previous blepharoplasty or aging), which can be emphasized with a midface lift alone. By combining fat transfer to the tear trough and infraorbital rim with the midface lift, a youthful, convex contour between the lower-lid and the cheek can be created that provides superior aesthetic results and long-term correction (Fig. 22.4).

In addition, the nasolabial crease can be improved with fat transfer. In the initial group of patients this resulted in modest long-term improvement; however, as the fat transfer technique is evolving, more impressive results are anticipated in the future. Acknowledgment  The statistical analyses in this study were performed by Statistics Solutions, Inc. The principal investigator (ATP) had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

22  Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer Fig. 22.4  (continued)

b1

b2

b3

b4

References   1. Pontius AT, Williams EF. The extended minimal incision approach to midface rejuvenation. Facial Plast Surg Clin N Am 2005;13(3):411–419.   2. Williams EF, 3rd, Vargas H, Dahiya R, Hove CR, Rodgers BJ, Lam SM. Midfacial rejuvenation via a minimal-incision brow-lift approach: critical evaluation of a 5-year experience. Arch Facial Plast Surg 2003;5(6):470–478.

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  3. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutshe Gesellsch Chir 1893;22:66.   4. Lexer E. Freie Fettransplantation. Deutsch Med Wochenschr 1910;36:640.   5. Cotton FJ. Contribution to technique of fat grafts. N Engl J Med 1934;211:1051–1053.   6. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217.   7. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233.

178   8. Ellenbogen R. Free autogenous pearl fat grafts in the face: a preliminary report of a rediscovered technique. Ann Plast Surg 1986;16(3):179–194.   9. Miller CG. Cannula Implants and Review of Implantation Tech­ niques in Esthetic Surgery. Chicago, Oak Press, 1926, p. 15. 10. Fischer G. Surgical treatment of cellulitis. IIIrd Congress of the International Academy of Cosmetic Surgery, Rome, Italy, May 31, 1975. 11. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 12. Illouz YG. Present results of fat injection. Aesthetic Plast Surg 1988;12(3):175–181.

A. T. Pontius and E. F. Williams III 13. Illouz YG. Adipoaspiration and “filling” in the face. Facial Plast Surg 1992;8(1):59–71. 14. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir Esthet Lang Fr 1985;10:36–40. 15. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367. 16. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119. 17. Amar RE. Microinfiltration adipocytaire (MIA) au niveau de la face, ou reconstruction tissulaire par greffe de tissue adipeux. Ann Chir Plast Esthet 1999;44(6):593–608.

23

Autologous Fat Transfer to the Cheeks and Chin Steven B. Hopping

23.1  Introduction Cheeks and chin provide three key “pillars” that define and aesthetically enhance the face. Patients blessed with strong cheeks and chin are often considered more photogenic and attractive (Fig. 23.1). Patients possessing these same characteristics also seem to age “more gracefully.” One of most common areas for autologous fat injections is the cheek and midface. In many patients, loss of volume from this region is an early sign of aging. Aging is impacted by gravity but also equally adversely affected by atrophy (Fig. 23.2). This is particularly true for the medial cheek area at the junction with the lower lid referred to as the “tear trough.” Tear trough depression from loss of fat can make a patient appear tired or prematurely older. One of the most rejuvenating procedures in cosmetic surgery is reversing this early sign of aging by filling the tear trough depression with autologous fat. Many times, one side is initially corrected and the patient is astounded at the difference when compared with the untreated side. One millimeter improvement on the face can feel like a kilometer in the mind of many patients. Cheek-midface volume almost always shrinks during the aging process and in some patients loss of fat in this area is the first sign of aging (1). Restoring volume with 5–10 mL of autologous fat can restore youthfulness to the face. Patients will appreciate improvement in the appearance of their eyes as well. Even the difficult-to-treat “malar bags” can be improved by filling in the malar area around them with autologous S. B. Hopping George Washington University, Washington, DC, USA The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington, DC 20037, USA e-mail: [email protected]

a

b

Fig. 23.1  The cheeks and chin form the “pillars” of an attractive face. (a) Preoperative. (b) Postoperative

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_23, © Springer-Verlag Berlin Heidelberg 2010

179

180

S. B. Hopping

Fig. 23.2  Facial proportions and aging

a

Fig. 23.3  (a) Preoperative. (b) Neck liposuction and chin augmentation with fat

fat (1). Guerrerosantos (2) first popularized autologous fat transfer as a routine adjuvant to rhytidectomy. It is the author’s practice to routinely include volume enhancement with fat to nearly every facial cosmetic procedure. All procedures simply look better when accompanied by autologous fat transfer. It is now well understood that a significant part of facial aging is secondary to loss of volume. The facial “balloon” shrinks and tissue “sags” in response. We experience this restoration phenomenon in patients every day whether in procedures of filling with synthetic fillers or fat. One needs only to fill one side of the face, hand the patient a mirror and observe the ­satisfaction expressed when he or she compares the treated to the untreated side. Autologous fat can provide greater volume enhancement than synthetics and in the author’s experience enjoys enhanced longevity. The argument can also be made that the utilization of fat as a facial filler is more cost-effective milliliter per milliliter than synthetic fillers (3). Autologous fat is also very effective in reducing facial wasting secondary to HIV medications. Often these patients do not have adequate amounts of donor fat, but if they do, fat transfers to the cheeks and midface can provide significant improvement. The chin also loses volume with aging but much less significantly than the midface. Nonetheless, many patients benefit from enhancing the chin with either b

23  Autologous Fat Transfer to the Cheeks and Chin

181

alloplastic implants or autologous fat. A sufficient chin volume is necessary to balance the profile and to provide for an adequate neckline and cervical mental angle (Fig. 23.3). The geniomandibular groove (GMG) can be exaggerated in some patients and autologous fat works well to restore this area. Utilizing a blunt cannula for injection can minimize any risk to important nerve and vascular structures in this area and is strongly recommended.

23.2  Anatomy The soft tissue of the cheeks and chin consists primarily of fat and muscle. The muscles are layered and are involved in mimetic action of smiles and expressions. The subcutaneous fat and malar fat contribute significantly to cheek volume. In contrast, the soft tissues of the chin are principally comprised of muscles. The fat component of the soft tissues of the cheeks and chin is primarily subcutaneous. An MRI scan demonstrates these structures (Fig. 23.4). The musculature of the cheeks and chin is demonstrated in Fig. 23.5. Fat is most successfully transferred into and beneath these facial muscles if longevity of survival is to be achieved.

Fig. 23.4  MRI showing cheek and buccal fat

Fig. 23.5  Vascular rich musculature of cheeks and chin

23.3  Technique Fat is harvested from any area that resists weight loss. In men, this is usually the abdomen or flanks. In women, it could be thighs, buttocks, knees, or arms as well. The donor area is infused with 100–200 mL of tumescent anesthesia (modified Klein’s solution consisting of 1,000 mL saline, 2 mg epinephrine, and 100 mL lidocaine 1%). “Gentle” fat harvesting is recommend with a 10-mL syringe primed with 2 mL of saline utilizing a #14 or #16 gauge cannula (Fig. 23.6). Three to four syringes are filled and then allowed to decant by gravity in a test-tube holder for 10 min. If there is excessive blood in the tube, this can be serially rinsed with tumescent solution. The infranatant fluid is decanted and excess supernant oils can be “wicked” out as well

Fig. 23.6  Harvesting fat with 10-mL syringe and blunt #14 cannula

182

(usually this is not necessary). Fat is then transferred from the 10-mL syringes to 3-mL syringes using a standard stopcock. Some authors have recommended a 1-mL syringe. The smaller syringes provide more control and less injection pressure than the larger 10 mL one. Autologous fat is best transferred via a blunt cannula. Fat survival is best when a #14 or #16 transfer cannula is utilized. A larger bore cannula creates less trauma to fat cells as they are transferred and is associated with better fat cell survival. When injecting the cheek, a multilayer concept should be envisioned, depositing micro aliquots of fat (one to two tenths of a milliliter) in multiple layers, always starting submuscular and moving more superficially. Care must be taken in the tear trough periorbital area not to place fat superficially. Not only is such fat unslightly, but is very difficult to remove. In this area, limit fat transfers deep to the orbicularis muscle. Each case is unique but in general 4–10 mL of fat are transferred to each cheek, 1–2 mL in each tear trough and 2 mL are placed in each myolabial fold. In the chin, 2–6 mL is injected depending on the extent of correction desired. One to two milliliters are usually transferred to the GMGs always staying deep and always utilizing a blunt cannula. A blunt cannula (14 or 16 gauge) is used to effect the transfer with 3-mL syringes. A #18 gauge needle is used to make the entry point. Usually, this is either on or just lateral to the corners of the mouth. All areas of the face, midface, and lips can be accessed through this one approach. No suturing is performed (Fig. 23.7). The cannula should be withdrawing as the fat is injected in “micro” aliquots at multiple layers of the soft tissues. Fulton and Parastouk (4) stated that “The best augmentation was achieved with a multiple-layer procedure.” The use of a blunt cannula cannot be overemphasized. It allows facial enhancement with fat to virtually any area without fear of permanent nerve or vascular injury. The author freezes fat and performs subsequent injections at 3 or 6 months under local anesthesia. In the operating room, fat is transferred to 3-mL syringes previously marked with the patient’s name, date of birth, and date of procedure. Reinjection of this frozen fat at 3 or 6 months depends on the patients’ needs. Fat is not stored frozen for more than 6 months because of housekeeping considerations. Any frozen fat is automatically discarded at 6 months unless labeled otherwise. This system

S. B. Hopping

Fig. 23.7  Fat injection of face with blunt #14 cannula

Fig. 23.8  Dedicated frozen fat freezer

keeps the volume of frozen fat manageable but it important to make patients well aware of this time table. The information regarding fat storage is also included in their consent (Fig. 23.8).

23.4  Complications 23.4.1  Bruising Bruising is the most common postoperative sequela. Bruises usually last a few days but rarely can last weeks which can be most disconcerting to patients. The author suggests prophylactic arnica Montana and

23  Autologous Fat Transfer to the Cheeks and Chin

Vitamin C, 1,000 mg/day. Fat is injected with a #18 or #16 gauge needle so it is potentially more traumatic than synthetic fillers.

23.4.2  Infection Infection is extremely rare even with frozen fat. Routine prophylactic antibiotics for fat transfer are not used. In 10 years, we have had only two documented infections, both found to be pseudomonas by culture and traced to come from a contaminated centrifuge. We no longer centrifuge fat as we prefer a “no touch” technique.

23.4.3  Asymmetry Certainly asymmetry can occur because of differential survival. Asymmetry can also be secondary to swelling so it is important to wait at least 6 weeks before reinjecting frozen or fresh fat.

23.4.4  Loss of Volume The author consistently achieves between 30 and 50% correction. Some patients do better, some worse. Fresh fat survives better than frozen and that survival seems better when the fat is injected through larger bore cannulas (#18 or #16).

23.4.5  Neuralgia Temporary neuralgia of the inferior orbital nerve has been observed. These sensory abnormalities have resolved spontaneously in all cases.

23.4.6  Fat Cysts or Fibrosis These sequelae (5) although rare can be difficult to resolve. Kenalog, 5 or 10%, injections have helped in some cases. Some situations require surgical intervention (4).

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23.5  Discussion Loss of volume in the midface is often the earliest sign of aging in men and women of all ethnicities. Fillers in this area can restore youthfulness and reduce the “tired” look about which patients most often complain. Most commonly, this condition is due to loss of volume (fat) rather than gravitational aging. Consequently, a very effective and natural way to reverse this condition is by restoring volume with autologous fat. There are many advantages to using patient’s own fat over synthetic fillers. The exact tissue that has been lost is being replaced, so it is very natural. Since fat supplies are abundant, autologous fat clearly allows more volume than can be achieved with fillers. Milliliter for milliliter, fat is more cost effective than synthetics. In the cheeks, adequate volume is the key to success. One or two ml of synthetic filler is often just not sufficient. A significant percentage of the fat correction can be considered permanent or long lasting. Many patients are convinced of the antiaging benefits of volume restoration with their own fat. They will present every 1 or 2 years for autologous fat to maintain a more youthful appearance (Fig. 23.9). Fat transfer to the cheeks, midface, and chin are a routine step in every rhytidectomy the author performs. Autologous fat can enhance midface lifting procedures and even cheek implants if there are asymmetries or tear trough depressions (Fig. 23.10). Facial wasting secondary to HIV medications can also be improved with autologous fat transfer. The abdominal or flank fat that is transferred seems resistant to the same drugs that cause atrophy of the facial fat. This “donor dominant” characteristic of fat allows the transferred fat to survive and even enlarge with weight gain in these patients.

23.6  Conclusions Volume loss of the cheeks and chin is a universal sign of aging. Volumetric rejuvenation of the cheeks, tear troughs, and chin is ideally achieved with autologous fat. The procedure is safe, cost effective, and can produce long term aesthetic improvement. Although there are many synthetic fillers available, autologous fat is perhaps the best option for volumetric enhancement of the cheeks and chin.

184 Fig. 23.9  (a) Preoperative. (b) Following fat transfer to cheeks

S. B. Hopping

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Fig. 23.10  (a) Preoperative. (b) Ten years after rhytidectomy with fat transfer to cheeks and chin

References 1. Berman M. The aging face: A different perspective on pathology and treatment. Am J Cosmet Surg 1998;15(2): 167–172. 2. Guerrerosantos J. Simultaneous rhytidectomy and lipo­ injection: A comprehensive aesthetic surgery strategy. Plast Reconstr Surg 1998;102(1):191–199.

3. Shippert RD. Building your practice with fillers. Am J Cosmet Surg 2007;24(2):95–100. 4. Fulton J, Parastouk N. Fat Grafting. Dermatol Clin 2001; 19(3):523–530. 5. Khawaja H, Hernandez-Perez E. Lipomatose formation after fat transfer. Int J Cosmet Surg 1998;6(2):144–145.

Nasal Augmentation with Autologous Fat Transfer

24

Jongki Lee

24.1  Introduction Nasal augmentation has traditionally used an implant. Diverse filler materials have been applied for partial nasal shape correction and augmentation (1). Nasal shape correction using autologous fat has also been attempted by many operators (2). Skin composing the nasal envelope and subcutaneous tissue has much lesser thickness above the osteocatilagenous layer. Because of this thin layer, not only has nasal augmentation’s indication of fat injection had a negative view, but also the results have been skeptical so far (3). The development of fat-handling techniques and much more experience from various cases are resulting in satisfactory consequences (4).

a

b

24.2  Surgical Technique A minor tranquilizer is administered orally preoperatively to calm any nervous patient. Choose the donor site for fat harvest. Most proper places for harvesting are the inner knee, medial and lateral thigh, and lower abdomen. After infiltrating the modified Klein’s solution at the donor site, fat has to be harvested by 10-mL syringes. Harvested fat should be put into specially made Lipokit® (A centrifugation device, Medikan Corp., Seoul, Korea) and its special syringes (Fig. 24.1). The syringes are centrifuged for 2 min at 1,200 gravities (Fig. 24.2) and free oil, blood, and tumescent solution should be decanted.

J. Lee In & In Apt. 101-Dong 903-Ho, 834 Jijok-Dong Yooseong-Gu Daejeon-City, Korea 305-330 e-mail: [email protected]

Fig. 24.1  (a) Lipokit®, a centrifugation device (Medikan Corp., Seoul, Korea). (b) Specially made syringes for centrifugation of harvested fat (Medikan Corp., Seoul, Korea)

Prepared fat is placed into 1-mL syringes. The patient is placed in a supine position and the injection entry points (nasal tip and glabella) are marked for nasal augmentation and shape. The area is sterile-draped and wide local anesthesia injected for pain control avoiding

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Fig. 24.4  The glabella area is the entry point for injection of the nasion Fig. 24.2  Centrifuged fat in the syringe. Free oil (upper), condensing fat (middle), bloody fluid (lower)

disturbance of its shape. Local anesthesia is injected into the entry point and the skin punctured with an 18-gauge needle. Prepared fat is injected by the withdrawal technique from the 1-mL syringes using an injection cannula that has one hole and a blunt point (Fig. 24.3). The fat is spread as much as possible while injecting according to the subcutaneous layer so as not to make lump the fat. Be cautious not to inject too much or too little. Injected fat volume is mostly not over 5 mL. If it is hard for the cannula to access the nasal-root part, inject inferiorly from the glabella to the nasal tip

(Fig. 24.4). After injection, check for unevenness of any part of the skin. Suture the injection entry with nylon 7–0 to prevent infection. Make a light skin mold and put tape on the skin for fixation.

24.3  Postoperative Problems Remove the skin suture and tape 3 days after surgery. Advise patients not to smoke, or to touch or press the nose with glasses. Inform patients to visit in a month and check the possibility of touch-up. Touch-up or secondary injection is generally performed after 3 months following the first injection. Postoperative complication is the same as other facial fat injections.

24.4  Conclusions

Fig. 24.3  The nasal-tip area is the entry point for injection of the dorsum of the nose

Patients are usually highly satisfied, especially because the nasal root is less indented. Satisfaction measurement of the consequence is high when the depression deformity of the nasal dorsum is improved (Fig. 24.5). Most patients need to get additional injections every 6 months several times to maintain the satisfaction. Wellinjected fat is not reduced easily but fat decreases about 50% from a single injection. To estimate patients’ satisfaction, measurement and the operation’s effect in the long term follow-up and many case studies are needed.

24  Nasal Augmentation with Autologous Fat Transfer Fig. 24.5  (a1–a4) Preoperative. (b1–b4) One year postoperative after fat augmentation

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References   1. de Maio M. The minimal approach: An innovation in facial cosmetic procedures. Aesthetic Plast Surg 2004;28(5): 295–300.   2. Cardenas JC, Carvajal J. Refinement of rhinoplasty with lipoinjection. Aesthetic Plast Surg 2007;31(5):501–505.   3. Kaufman MR, Millet TA, Huang C, Roostaein J, Wasson KL, Ashley RK Bradley JP. Autologous fat transfer for facial

J. Lee recontouring. Is there science behind the art? Plast Reconstr Surg 2007;119(7):2287–2296.   4. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, Yoshimura K. Influences of centrifugation on cells and tissues in liposuction aspirates: Optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg 2008; 121(3):1033–1041.

Lipotransfer to the Nasolabial Folds and Marionette Lines

25

Robert M. Dryden and Dustin M. Heringer

25.1  Introduction Autologous fat transfer for facial rejuvenation is becoming increasingly popular among cosmetic surgeons. This rise in popularity has paralleled the increased appreciation of the role of soft tissue volume loss and contour irregularities associated with facial aging. The majority of volume loss is attributed to fat atrophy; therefore, autologous fat represents the ideal replacement material, despite the growing range of nonautologous fillers. Many surgeons use autologous fat transfer as a stand alone procedure or in combination with other facial rejuvenation procedures. For instance, by combining fat transfer with a rhytidectomy, the surgeon can address the problem of loss of soft tissue volume along with the problem of loss of skin elasticity and gravitational effects associated with the aging face. Two of the most common areas for fat augmentation are the nasolabial folds and marionette lines. In order to diminish the depth of the nasolabial folds and soften the rhytids in the marionette lines, musculodermal attachments must be released and fat transferred to the areas. This is accomplished with subcision surgery followed by fat transfer. Subcision surgery is a subcutaneous dissection that severs fibrous ties between the skin and underlying structures without a skin incision (1). This dissection frees the skin and creates a pocket for fat transfer. The combination of subcutaneous dissection with fat transfer has an additive effect and is useful in correcting facial rhytids and folds. The authors present their technique for subcision surgery

R. M. Dryden () Arizona Centre of Plastic Surgery, Tucson, AZ 85712, USA e-mail: [email protected]

and fat transfer along with a short discussion on the possible complications in the following section.

25.2  Technique 25.2.1  Preparation of Donor Site Preoperative photographs of the areas to be treated are taken. A permanent marker is then used to identify areas for fat augmentation. The patient is then prepped and draped in the sterile fashion. The authors’ favorite donor site is the periumbilical area because it is easily accessible. Other sites that can be used include the medial or lateral thighs, buttocks, or waist. Buffered 1% lidocaine is then used as a local block in the umbilicus inferiorly and an incision is made with an 11 blade. Tumescent solution (50 mL of 1% lidocaine, 12.5 mL 8.4% sodium bicarbonate, 1 mL of epinephrine 1:1,000, and 0.25 mL of 40 mg/mL triamcinolone acetonide in 1 L of normal saline) is then injected subcutaneously into the donor site using a 14 gauge Capistrano cannula attached to a 60 mL Luer-Lok syringe (Fig. 25.1). Usually 100–200 mL

Fig. 25.1  Tumescent solution being injected subcutaneously into the donor site using a 14-gauge Capistrano cannula attached to a 60-mL Luer-Lok syringe

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of tumescent solution is injected and then allowed to work for 20 min before harvesting the fat to ensure vasoconstriction and local anesthesia.

25.2.2  Preparation of Recipient Site Attention is then turned to the nasolabial folds or marionette lines. Buffered 1% lidocaine followed by 0.5% Marcaine with 1:200,000 epinephrine is used as a local block. An 11 blade is then used to make a stab incision at the alar groove when treating the nasolabial folds and in the oral commissure at the vermilion border, when treating marionette lines. Subcision dissection is performed with a Wire Scalpel (Kolster Methods, Inc., Corona, CA) to release the deep attachments and create a pocket beneath the nasolabial fold and marionette lines. The Wire Scalpel instrument is a 50-cm number 2-0 elastic-stranded metal wire connected to a 10-cm straight needle (1). For the nasolabial fold, the needle

R. M. Dryden and D. M. Heringer

at the end of the Wire Scalpel is inserted into the previously made stab incision in the alar groove. It is then passed inferiorly into the subcutaneous tissue on one side of the previously marked line and exits at the base of the nasolabial fold (Fig. 25.2). This same needle is then re-inserted into the exit site, passed back superiorly into the subcutaneous tissue on the opposite side of the previously marked line, and out through the stab incision at the alar groove (Fig. 25.3). Both ends of the

Fig. 25.3  The needle end of the Wire Scalpel is re-inserted into the exit site and passed back superiorly into the subcutaneous tissue on the opposite side of the previously marked line and out through the stab incision

Fig. 25.2  The needle end of the Wire Scalpel is inserted into the stab incision in the alar groove. It is then passed inferiorly into the subcutaneous tissue on one side of the previously marked line and exits at the base of the nasolabial fold

Fig. 25.4  Using a to-and-fro sawing motion, the Wire Scalpel is used to create a tunnel and release the deep attachments

25  Lipotransfer to the Nasolabial Folds and Marionette Lines

Wire Scalpel are then grasped and using a to-and-fro sawing motion, a tunnel is created and the deep attachments are released (Fig. 25.4). In regard to the marionette lines, a Wire Scalpel is used to create a tunnel in a similar fashion as outlined above for the nasolabial folds. When performing fat transfer in conjunction with a rhytidectomy, it is unnecessary and can be detrimental to carry the facelift dissection under the nasolabial folds or marionette lines.

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allow it to separate into its two layers (Fig. 25.7). The infranatent is a serosanguinous layer comprising, primarily, tumescent solution and a small amount of blood. The supernatant is composed of adipocytes with a thin layer of lipid on top. The lowest layer is drained and the supernatant is left in the syringe for later use (Fig. 25.8).

25.3  Harvest After letting the tumescent solution work for 20 min the fat is harvested utilizing a blunt 12 gauge Capistrano cannula attached to a spring loaded 60 mL Luer-Lok syringe. The cannula is inserted into the incision site in the inferior umbilicus and the spring loaded plunger is pulled back and locked into position to create a gentle vacuum. Using the dominant hand, a back and forth motion is used to curette fat parcels into the cannula while the nondominant hand acts as a guide (Fig. 25.5). When the barrel of the syringe is full, it is removed from the cannula and a plug is placed on the Luer-Lok end (Fig. 25.6). The syringe is then let standing for 20 min to

Fig. 25.7  The harvested fat is allowed to sit and separate

Fig. 25.5  Fat is harvested from the periumbilical area utilizing a blunt 12 gauge Capistrano cannula attached to a spring loaded 60 mL Luer-Lok syringe

Fig. 25.6  Full syringe of autologous fat with plug placed on the Luer-Lok end

Fig. 25.8  The infranatent is discarded

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25.4  Processing of Fat Two 3-mL Leur-Lok syringes are then attached to a three or four-way stop cock. One syringe is then filled with the harvested fat (Fig. 25.9). The fat is then gently passed from one syringe to the next 5–7 times in order to break-up interlobular adhesions (Fig. 25.10). The fat is now ready for injection.

Fig. 25.11  Fat is injected into the nasolabial fold using a 14-gauge lipoaugmentation cannula attached to a fat filled 3 mL Leur-Lok syringe

25.5  Injection of Fat

Fig. 25.9  A 3 mL Leur-Lok syringe is attached to a four-way stop cock and is filled with the harvested fat

A 14 gauge blunt tipped lipoaugmentation cannula is attached to the fat filled 3-mL Leur-Lok syringe. The cannula is inserted into the previously made subcutaneous pocket and the fat parcels are injected as the cannula is withdrawn (Fig. 25.11). It is important to inject small amounts at multiple tissue levels including the facial musculature in order to increase fat survival. Usually 1–3 mL of autologous fat is injected into each nasolabial fold and 1–2 mL for each marionette line overfilling the area slightly. Any excess fat at the stab incision sites is then removed and the site is closed with a simple interrupted 6.0 Prolene suture.

25.6  Complications

Fig. 25.10  Fat is gently passed from one syringe to the next five to seven times in order to break-up interlobular adhesions

Fat transfer is generally regarded as a relatively safe procedure with minimal risks. Having said that, there are only a few reports in the literature of fat emboli to the cerebral and retinal vessels causing stroke symptoms and blindness (2–6). The worst reported complication happened in a 39-year-old woman who suffered an acute

25  Lipotransfer to the Nasolabial Folds and Marionette Lines

fatal stroke immediately after autologous fat injection into the glabellar region (7). The most common complications associated with this procedure include over or under correction, uneven texture, loss of fat and lumps in areas of fat transfer. Excessive bruising, edema, infection, bleeding and nerve damage are also potential risks. In the authors’ hands, no serious complications have occurred.

25.7  Discussion Fat transfer is an effective technique to address soft tissue volume loss associated with facial aging. The nasolabial folds and marionette lines can often be resistant to adequate correction because of attachments to underlying tissue (8). Without releasing these areas, soft tissue augmentation in these tightly tethered areas can sometimes lead to elevation around the depression which will accentuate rather than correct the crease or rhytid (8). Subcision dissection with a Wire Scalpel (Kolster Methods, Inc., Corona, CA) helps to release these musculodermal attachments without a skin incision and creates a pocket for fat transfer allowing for improved correction of these depressions. Sulamanidize et al. (9) showed the power of subcision dissection by treating 54 patients with Wire Scalpel dissection and reporting “good” and “satisfactory” results in 79.7 and 16.6% of patients respectively. Filling the pocket with autologous fat not only enhances the correction, but may also prevent new attachments from forming providing a lasting cosmetic correction (1). Other similar instruments that can be used for subcision dissection include the Diamond Wire (Nutec International, Tucson, AZ) and SurgiWire (Coapt Systems, Palo Alto, CA). Autologous fat, nonautologous dermal fillers, or implantable grafts can be used to restore soft tissue volume loss in the aging face. When compared to other soft tissue fillers, autologous fat is virtually the ideal filler. It is readily available, inexpensive, easy to harvest, avoids a host immune response, is noncarcinogenic, nonteratogenic, and if viable lasts indefinitely (10). Autologous fat is also relatively safe with minimal downtime and reported high patient satisfaction. Unlike other fillers, viable fat remains soft and is dynamic, changing size as patient’s weight changes (11). The main drawbacks include the additional surgical procedure required to harvest the fat and the question of fat longevity and survival. Studies utilizing

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various techniques quote anything from 10 to 80% long term survival (12–14). When reviewing the literature many techniques are discussed among cosmetic surgeons regarding the best technique for harvesting, handling and injecting fat in order to improve survival. Some of the more poplar techniques described in regard to harvesting fat include atraumatic liposuction (15–20), en bloc fat harvesting (21), or fat cylinder or core grafts (22, 23). In regard to the handling of autologous fat, some authors advocate washing harvested fat (13, 24–26), centrifugation (19, 27, 28), or incubating autologous fat with bioactive agents (29, 30) to increase survival. Injection techniques vary, but most of these involve a “fanning-out” technique to lay down small particles of fat in multiple tunnels (11, 31) and tissue layers (17, 18, 27, 32). More recently, studies have focused on performing fat injections into the facial muscles because of their rich vascular supply (33). At this time there is no consensus as to which techniques yield the best results regarding ultimate fat graft survival. Recent review articles do make recommendations and attempt to establish “current practice guidelines” (31, 34) regarding autologous fat transplantation. In a recent review article by Kaufman et al. (31), they state that the most recent scientific data and clinical experience supports harvesting abdominal fat with a “nontraumatic” blunt cannula technique, processing by means of centrifugation without washing or the addition of growth factors, and then immediate injection of small amounts of fat with multiple passes. Another review article by Locke and de Chalain (34) claims the donor site to be unimportant in autologous fat graft survival. They also recommend harvesting fat by excision or gentle aspiration, processing by short and gentle centrifugation, and then injecting small amounts of fat in multiple passes as the needle is withdrawn. The authors agree and follow these recent recommendations with minor variations except that they disagree with the need for centrifugation. Rohrich et al. (35) found no quantitative difference between noncentrifuged fat and centrifuged fat survival. In addition, Ramon et al. (36) used a nude mouse model and found no difference at 16 weeks in fat graft survival between centrifuged and non centrifuged fat. Also, Rose et  al. (37) showed that cell counts of intact adipocytes and nucleated adipocytes were significantly higher in samples processed by sedimentation for 1 h, compared to those by centrifuging or washing. Therefore, we believe this step to be unnecessary and that this view is supported by the literature above and by our clinical results.

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25.8  Conclusions

and marionette line rejuvenation (Fig. 25.12–25.13). Although there is controversy in medical literature about fat survivability and predictability (31), the authors have found the technique presented above to  be a straightforward procedure achieving rela­ tively consistent and reliable results with high patient satisfaction.

Autologous fat transfer is an increasingly used technique in facial rejuvenation and addresses the problem of tissue volume loss in the aging face. The additive effect of combining subcision dissection with fat ­transfer provides a powerful tool for nasolabial fold

a2

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Fig. 25.12  (a1, a2) Preoperative. (b1, b2) One week postoperative after fat transfer to nasolabial folds along with a full facelift

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Fig. 25.13  (a) Preoperative. (b) One month postoperative after fat transfer to nasolabial folds and a full facelift

25  Lipotransfer to the Nasolabial Folds and Marionette Lines

References   1. Kotlus BS, Dryden RM. Periocular rhytidolysis with the wire scalpel. Ophthal Plast Reconstr Surg 2007;23(5):355–357.   2. Feinendegen DL, Baumgartner RW, Vuadens P, Schroth G, Mattle HP, Regli F, Tschopp H. Autologous fat injection for soft tissue augmentation in the face: a safe procedure? Aesthetic Plast Surg 1998;22(3):163–167.   3. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthal­ mol 1989;107(1):85–87.   4. Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro J. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993; 23(4):615–616.   5. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361.   6. Thaunat O, Thaler F, Loirat P, Decroix JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 2004;113(7):2235–2236.   7. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 2003;61(8):1151–1152.   8. Graivier M. Wire subcision for complete release of depressions, subdermal attachments, and scars. Aesthetic Surg J 2006;26:387.   9. Sulamanidze MA, Salti G, Mascetti M, Sulamanidze GM. Wire scalpel for surgical correction of soft tissue contour defects by subcutaneous dissection. Dermatol Surg 2000;26(2):146–150. 10. Kaminer MS, Omura NE. Autologous fat transplantation. Arch Dermatol 2001;137(6):812–814. 11. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg 2007; 120(6 Suppl):89S–97S. 12. Murillo WL. Buttock augmentation: case study of fat injection monitored by magnetic resonance imaging. Plast Reconstr Surg 2004;114(6):1606–1614. 13. Niechajev I, Sevc´uk O. Long term results of fat transplantation: clinical and histological studies. Plast Reconstr Surg 1994;94(3):496–506. 14. Ersek RA. Transplantation of purified autologous fat: a 3-year follow up is disappointing. Plast Reconstr Surg 1991; 87(2):219–227. 15. Fournier P. Who should do syringe liposculpturing? J Dermatol Surg Oncol 1988;14(10):1055–11056. 16. Fournier P. Why the syringe and not the suction machine? J Dermatol Surg Oncol 1988;14(10):1062–1071. 17. Fournier P. Facial recontouring with fat grafting. Dermatol Clin 1990;8(3):523–537. 18. Fournier P. Reduction syringe liposculpturing. Dermatol Clin 1990;8(3):539–551. 19. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425. 20. Coleman SR. Facial recontouring with lipostructure. Facial Cosmet Surg 1997;24(2):347–367.

195 21. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217. 22. Fagrell D, Enëstrom S, Berggren A, Kniola B. Fat cylinder transplantation: an experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996; 98(1):90–96. 23. Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast Reconstr Surg 2007;120(1): 295–302. 24. Fournier P. Fat grafting: my technique. Dermatol Surg 2000; 26(12):1117–1128. 25. Jones J, Lyles M. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997; 14:275. 26 Carpaneda C, Ribeiro M. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17(1):43–47. 27. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119. 28. Rubin A, Hoefflin SM.Fat purification: survival of the fittest. Plast Reconstr Surg 2002;109(4):1463–1464. 29. Har-Shai Y, Lindenbaum ES, Gamliel-Lazarovich A, Beach D, Hirshowitz B. An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg 1999;104(4):945–954. 30. Yuksel E, Weinfeld A, Cleek R. Increased free fat-graft survival with the long-term, local delivery of insulin, insulinlike growth factor-I and basic fibroblast growth factor by PLGA/PEG microspheres. Plast Reconstr Surg 2000;105(5): 1712–1720. 31. Kaufman MR, Miller TA, Huang C, Roostaien J, Wasson KL, Ashley RK, Bradley JP. Autologous fat transfer for facial recontouring: is there science behind the art? Plast Reconstr Surg 2007;119(7):2287–2296. 32. Butterwick KJ, Lack EA. Facial volume restoration with the fat autograft muscle injection technique. Dermatol Surg 2003;29(10):1019–1026. 33. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P. Long-term survival of free fat grafts in muscle: an experimental study in rats. Aesthetic Plast Surg 1996;20(5):403–408. 34. Locke MB, de Chalain T. Current practice in autologous fat transplantation: suggested clinical guidelines based on a review of recent literature. Ann Plast Surg 2008;60(1): 98–102. 35. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004; 113(1):391–395. 36. Ramon Y, Shoshani O, Peled I.J, Gilhar A, Carmi N, Fodor L, Risin Y, Ulmann Y. Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 1005;115(1):197–201. 37. Rose JG Jr, Lucarelli MJ, Lemke BN, Dortzbach RK, Boxrud  CA, Obagi S, Patel S. Histologic comparison of autologous fat processing methods. Ophthalmic Plast Reconstr Surg 2006;22(3):195–200.

Autologous Fat Transplantation to the Lips

26

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

26.1  Introduction The lips have always been the focus of beauty and even eroticism. Many cultures have shown interest in enhancing the lips. Lips have been elongated, pierced, painted, tattooed, made fuller, made thinner and even caricaturized. The current enthusiasm for full voluptuous lips has resulted in a significant demand on the cosmetic surgeon to provide such results. This is true certainly in our female patients, but even male patients desire this more youthful lip fullness. Contemporary male and female models and icons possess full, voluptuous lips and patients desire a similar look (Fig. 26.1).

There have been various techniques of lip augmentation. Many different filler devices have been utilized to create full lips. The US Food and Drug Administration (FDA) have discouraged companies from marketing filler materials, such as collagen and Gore-Tex (Flagstaff, AZ), that are suitable for lip augmentation, Presently, there are no synthetic fillers specifically approved by the FDA for lip augmentation (1). Injection of 350 centistrokes of microsilicone to the lips in the past was a common practice that effectively provided fuller lips. Silicon 1,000 centistrokes is the only liquid silicon presently approved by the FDA for intraocular use (2). The material may be cautiously used in an “off label” manner for lip augmentation. Bovine collagen has been used in the past for lip enhancement and has given rise to the popular marketing term “Paris Lip.” The many hyaluronic injectables now available have supplanted bovine collagen as the primary lip enhancer today. Gore-Tex, SoftForm, and Alloderm are other materials that have been used to augment lips. There are numerous others. Autologous fat is an obvious choice for lip filling owing to its accessibility, low cost, non antigenicity and ease of placement. Autologous fat is the most frequently utilized material for lip augmentation in our practice. Indications for fat transplantation to the lips include cosmetic enhancement, refilling lost tissue or wrinkles resulting from aging, and the correction of trauma-related or congenital deformities such as cleft lips (3).

Fig. 26.1  Contemporary icon with full, sensuous lips

S. B. Hopping (*) George Washington University, Washington, DC, USA The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington, DC 20037, USA e-mail: [email protected]

26.2  Preoperative Evaluation In evaluating the patient preoperatively, it is important that the patient be appropriately counseled in terms of

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proper expectations from lip augmentation. Patients with thin lips, regardless of filling technique, are always going to have somewhat thin lips. It is difficult to change the size of the lip, and lip augmentation with any material merely enhances the natural lip shape. There is a definite limit to how much augmentation can be performed in any given lip before the results look unnatural and distorted. Asymmetries of the lip, associated with smiling, can be improved upon but not resolved with lip augmentation. It is important to observe the patient when smiling and in repose. These limitations must be emphasized to the patient preoperatively. In evaluating the patient’s lips, a judgment should be made in terms of the length of the lower third of the face in relationship to the upper two thirds of the face (rule of thirds) (Fig. 26.2). The length from the columella to the vermillion border of the upper lip should be noted. In some patients, this length is excessive and would be ideally shortened with a lip lift. According to Juri (4), the ideal length of the upper lip from the base of the columella to the cupid’s bow in a woman is 14 mm. The relationship of the lower lip to the upper lip should be evaluated. In general, the lower lip should have 25% more volume or fullness than the upper lip. The shape of the upper lip should have fullness of the Cupid’s bow and should have two definite anatomical mounds at the highest point of the Cupid’s bow on each side of the midline. The lower lip should have more subtle mounds on either side of the midline. The normal vertical distance of the upper lip should be approximately 10 mm and of the lower lip 12–14 mm.

Ideal Proportions of the Female Lip The ideal length of the Upper Lip is 14mm. The ideal width of the Upper Lip is 10mm. The ideal width of the Lower Lip is 12mm.

Fig. 26.2  Ideal proportions of the face and lips

26.3  Technique Harvesting of fat can be easily accomplished under local tumescence type anesthesia in an office setting. Certainly, patients can be sedated with oral or intramuscular medications as well. In our practice, anxious patients receive 5 mg of Versed and 50 mg of Demerol intramuscularly 1 h before the procedure. Most elect local anesthesia alone.

26.4  Harvesting of Fat Fat is best harvested from the lower extremities (lateral thigh, knee, or buttocks). First to gain, last to lose areas seem to provide the most long lasting results. Fat can be harvested from the abdomen, but occasionally abdominal fat can be somewhat fibrous and the harvesting process somewhat bloody. This is especially true for multiparous women or patients with a history of abdominoplasty or liposuction. A 10–15-min massage of the abdomen post infusion of tumescent anesthesia helps minimize the bloody aspirate problem. Fat harvested from the neck is generally scant and too fibrous to be effectively utilized for fat transfer. The donor area is injected with a modified tumescent solution (1,000 mL of saline mixed with 50 mL of lidocaine 1% plain and 2 mL of epinephrine 1:1,000). It is important to allow a 10–20-min interval to achieve maximum hemostasis and anesthesia prior to proceeding with fat harvesting. Gentle massaging of the donor region for 10 min improves hemostasis, reduces bleeding and effectively diffuses the tumescent solution more uniformly to the tissues. This is particularly helpful when the abdomen is selected as the donor area. Harvesting is most easily accomplished with a 14-gauge blunt cannula with one or two small ports (Fig. 26.3). The cannula is attached to a 10-mL syringe, which provides the best system for collecting fat. The 10-mL syringe should be “primed” with a small amount of saline or tumescent solution to avoid an “air lock” and allow the creation of a continuous vacuum and liquid interface. The 10-mL syringe is easily utilized by pulling the plunger backwards and holding it in position with one thumb to achieve the desired vacuum effect. Larger syringes are often more difficult to use in this manner without a lock. The cannula is gently moved

26  Autologous Fat Transplantation to the Lips

Fig. 26.3  Harvesting system (10-mL syringe primed with tumescent solution and a 14-gauge cannula)

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be washed with the same tumescent solution until all visible red cells are gone. This is easily accomplished by adding 2 mL of the same tumescent solution to the syringe and then turning the syringe back and forth to allow the solution to rinse through the fat. The syringe is then replaced in its vertical orientation to again allow the separation of the cleaner fat from the infranatant fluid. The fluid is then decanted, allowing pure fat to remain in the syringe. The fat, once cleaned, floats to the top of the syringe and separates from the fluid, red cells, and debris. This allows a no-touch technique in cleaning and separating the fat from the infranatant, which is then discarded. The fat is then transferred, again using a notouch technique, to 3-mL syringe transfer adaptor or three way stopcock (Fig. 26.5). The 3-mL syringe is ideal for performing fat injections through an 18-gauge sharp needle or blunt cannula (Fig. 26.6). The surgeons have abandoned spinning the fat for a number of reasons. It does not appear to be advantageous or necessary. Two documented Pseudomonas aeruginosa infections occurred which were traced back to the

Fig. 26.5  “No Touch” transfer from 10 mL “harvesting” syringe to 3 mL “injecting syringe” Fig. 26.4  A test tube stand facilitates separation of fat and infranatant

through the tissues to collect fat with a minimum of trauma, which is exceedingly important. An attempt is made to harvest between 30 and 50 mL of fat at each harvesting session. A minimum of two fat transfer sessions are planned for each patient and spaced approximately 3–6 months apart. Patients are informed that between 15 and 50% of the fat on the average will survive with each treatment; necessitating a series of treatments to achieve the desired results. There is tremendous individual variation in the amount of surviving fat. The 10-mL syringes are placed vertically in a test tube carrier with the plunger at 12 o’clock. They are oriented vertically to allow fat to separate from the infranatant fluid and blood (Fig. 26.4). The fat, if bloody, can

Fig. 26.6  A 3-mL syringe and a Blunt #16 cannula allows safe, controlled “microdroplet” technique of fat transfer

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centrifuge device as the source of contamination. No further clinical infections have be reported since centrifugation of fat has been discontinued. The less manipulation and handling of the fat, the more riskfree the procedure.

26.5  Injection Technique Utilizing a 16-gauge or 14-gauge blunt cannula with 3-mL syringe system allows for the safe placement of small aliquots of fat at literally any level anywhere on the face. Fat can be layered into the muscle of the lip, and into the vermillion borders. Fat is also injected into the marionette depressions below the corners of the lips. It is important to inject very small quantities of fat, 0.25–0.5 mL at a time, in multiple areas. Conceptually, successful microlipotransfers create multiple, isolated droplets of fat, not puddles or lakes of fat. Keeping this concept in mind will help maximize the number of fat cells, achieving vascularity and therefore viability. On the average, 2–3 mL of fat is placed in the upper and lower lips. An 18-gauge needle is used to create a small stab incision at the lateral commissures, through which the 18-gauge blunt cannula can be easily placed. It is important in microlipoaugmentation of the lip that a blunt cannula be used to avoid laceration of the labial vessels and resultant hematoma. Moving the cannula and depositing microdroplets of fat at various planes along the lip will give the best results. Fat is deposited as the cannula is being withdrawn to prevent inadvertent injection into a vessel. Injecting with the right hand, the upper lip is injected from the patient’s right commissure and the lower lip is injected from the patient’s left commissure. This allows the left hand to control the recipient lip and guide the cannula to the desired level. An 18-guauge NoKor (Becton Dickinson & Co., Franklin Lakes, NJ) needle is ideal for creating the entrance site for the 18-gauge blunt cannula (Fig. 26.7), but an 18-gauge needle works equally well. It is not necessary to suture the injection incision left with the NoKor needle or 18-gauge needle. The incision heals quite inconspicuously as compared to #11 or #15 blade incision. Massage of the injected lip is very important to improve symmetry and reduce lumpiness. Fulton and Parastouk (5) describes a similar technique. “The best augmentation was achieved with a

Fig. 26.7  A #18 needle is ideal for creating a skin entrance for the #16-gauge blunt cannula. No suturing is required

multiple-layer procedure, starting on the mucosa side of the lip and working around the lips into the muscle and to the vermillion border.” A combination of fat transplantation and mucosal advancement (FATMA) have been used to correct inversion and both augment the lips as well as control the shape and these have had more permanent results than those of fat transplantation alone (6).

26.6  Fat Storage The remaining fat not utilized at the first fat transfer session is placed in 3-mL syringes. Each syringe is individually labeled and then all of them placed in a labeled, sealed cellophane package. The patient’s names, date of injection, and birth date are also included. The sealed plastic bags are then stored alphabetically in a freezer solely designated for fat storage. It is ideal that the freezer have a backup power source to ensure against a defrosting disaster in the event of a power outage. The freezer should be checked every day by the staff, and a freezer log is kept to ensure the integrity of the system. Alarms and date meters are available for freezers and have been advocated by some practitioners. The authors always plan a minimum of three microlipotransfers to the lip, scheduled 3–6 months apart, depending on the patient. A 15–50% survival with each treatment is anticipated. Therefore, three treatments should translate into approximately a 45–90% correction rate depending on the individual patient. Obviously, some patients have a better long-term fat survivability than others and may require fewer injections to achieve the desired results. The patient must be committed to repeat injections if the long-term results are to be achieved.

26  Autologous Fat Transplantation to the Lips

When patients return for the treatment, the amount of fat required for each individual treatment is taken from the freezer and allowed to defrost slowly to room temperature. The areas to be infused are anesthetized with either 1% lidocaine (Xylocaine) or 1% lidocaine with 1:200,000 epinephrine. Once the fat is thawed, it is injected using a 16-gauge blunt cannula. An effort is made to minimally overcorrect (approximately 10%) so as not to distort the patient’s features and to maximize long-term fat survival. Freezing and storing of fat is not permitted in some states without a special license and certification. One must review local regulations overseeing such activities. The alternative to storing frozen fat, of course, is repeat treatments with fresh fat transfers. Such a technique can certainly achieve equally good clinical results.

26.7  Complications Fortunately, the complications with fat compared to other alloplastic material is quite low. The most common problem encountered with fat is when it does not give the desired long-term results. The second most common problem with fat is that the lips are sometimes distorted for days following the fat injection procedure. This may be avoided by injecting less rather than more at each session. This technique improves survivability and also results in less distortion in the immediate postinjection phase. It also results in fewer hysterical calls from patients or their family members on the evening of fat transfer. The majority of the patients having a fat treatment return to their usual activities either that day or certainly the following day. Bruising is another possibility and is best avoided by the use of a blunt cannula for injection and immediate pressure on the injection areas following treatment. Ice treatments post injection are also helpful. Infections are a significant complication in fat injections and can cause tissue loss, tissue scarring, and necrosis. The authors have experienced two infections, both involving culture-proven Pseudomonas aeruginosa. Both of the infections were traceable to a contaminated centrifuge. After stopping centrifuging of the fat, further difficulties with infection of fat have not been

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encountered. Patients are not routinely given antibiotics or pain medication for this procedure. Hematomas can certainly happen in the richly vascularized lip and can be minimized by using the blunt needle injection technique. Asymmetry is certainly not uncommon, but it is easily corrected with further fat injections. Scarring is possible but has not been a problem utilizing the 18-gauge NoKor needle and 18-gauge blunt cannula. Hypesthesia or anesthesia has not been a problem when utilizing fat as it is in some of the other augmentation materials. Lipomatous formation after fat transfer has been seen in a number of cases (7). This presents as cystic lumps of the lip that must be distinguished from a mucocele of the minor salivary glands. Treatment is incision and drainage. A cholesterol-like secretion is usually encountered, and no further treatment is generally necessary. Mucocele or cyst formation can also occur and is related to blockage of one of the more minor salivary glands. These are best treated by simple incision and drainage, and a yellow fluid is often expressed. No further treatment is generally necessary.

26.8  Discussion Fat is an ideal material for lip augmentation, since it is readily accessible, is well tolerated in the lip, and has a natural feel. Voluptuous full lips are a desirable esthetic quality. There is a large demand on the part of patients to achieve such results. Fat is an excellent material to augment lips and is our lip augmentation treatment of choice. Patients must be made aware of the alternatives, of the limitations, and of the long-term sequelae of fat as well as other techniques. Fat absorption remains the biggest challenge in lip augmentation with autologous fat. In elective surgery, we must always weigh the risks against the advantages of each treatment. Fat augmentation of the lips has the marked advantage of natural look, soft feel, and few complications (Figs. 26.8 and 26.9). Therefore this treatment option is always our first recommendation to patients expressing an interest in lip enhancement.

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Fig. 26.8  (a) Preoperative patient desiring fuller lips. (b) After three autologous fat treatments

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Fig. 26.9  (a) Preoperative. (b) After one lip augmentation treatments

References 1. Injectable Cosmetic Wrinkle Fillers. US Food and Drug Administration. Accessible at: < www.fda.gov/cdrh/ wrinklefillers/>Accessed on July 4, 2008. 2. Snider S. FDA Approves Silicone Oil for Retinal Reattach­ ment. US Food and Drug Administration. 1994 Retrieved June 29, 2008 from
4. Juri J. Personal communication, October 1998. 5. Fulton J, Parastouk N. Fat grafting. Dermatol Clin 2001;19 (3):523–530. 6. Haworth RD. Customizing perioral enhancement to obtain ideal lip aesthetics: combining both lip voluming and reshaping procedures by means of an algorithmic approach. Plast Reconstr Surg 2004;113(7):2182–2193. 7. Khawaha H, Hernandez-Perez E. Lipomatose formation after fat transfer. Int J Cosmet Surg 1998;6(2):144–145.

Three Dimensional Facelift

27

Sid J. Mirrafati

27.1  Introduction In an aging face there are four factors that must be addressed in order to achieve the most rested and rejuvenated appearance. Each of these four factors must be treated individually. 1. Actinic damage (sun damage). This affects the skin resulting in facial rhytids and lentigenes. The skin collagen and elastins are damaged resulting in the laxity of the skin. 2. Muscle laxity. When the skin loses its tensile strength this will eventually lead to laxity of the subcutaneous musculoaponeurotic system (SMAS). 3. Facial and fat atrophy. With aging there is loss of volume in the face. This includes loss of fat volume in the cheeks resulting in a prominent nasal jugular groove, loss of fat in the eyebrow that results in eyebrow ptosis, and loss of fat in the lips that results in perioral rhytids. 4. Alveolar bone loss. This is another form of volume depletion.

27.2  Rejuvenation The actinic damage is only a dermal problem. Just by lifting the skin does not change the lines or the collagen of the skin. Some level of skin peeling is necessary.

S. J. Mirrafati 3140 Redhill Avenue, Costa Mesa, CA 92626, USA e-mail: [email protected]

There are different levels of skin peeling. If the patient has fine lines or minimal sun damage of the skin then doing a medium depth Jessner/TCA chemical peel would be sufficient. There are also different modalities available such as IPL or radiofrequency treatment. If the patient has greater sun damage with deeper lines then a more aggressive peeling with deeper penetration should be used. The author uses the Ultrapulse CO2 laser (Coherent) on the face and does the Jessner/ TCA peel on the neck.

27.3  Muscle Laxity Muscle laxity can be treated with some form of facelift. Plication of the superficial musculoaponeurotic system (SMAS) in a facelift treats the muscle laxity.

27.4  Volume Depletion Correction of volume depletion plays an important role in facial rejuvenation. In some patients if facelift is utilized without filling the depleted volume, the result would be a nicely tight but still an aged face. In treating a patient with depleted volume (Fig. 27.1) only performing a facelift vertically or horizontally would make the patient appear flatter and not rejuvenated. With volume replacement such as autologous fat transfer to the cheeks, the nasal labial fold, eyebrow, marionette area, and the perioral area, the patient appears younger and rejuvenated (Fig. 27.1).

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_27, © Springer-Verlag Berlin Heidelberg 2010

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204 Fig. 27.1  (a1, a2) Patient with facial volume depletion. (b1, b2) Postoperatively following fat transfer to the cheeks, nasal labial fold, eyebrow, marionette area, and the perioral area

S. J. Mirrafati

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27.5  Patient Consultation The patient is first evaluated for the different forms of the facelift from the suture lift to the modified and full facelift and the three dimensional face lift. Each procedure has its own risks and the benefits involved. The invasiveness of the procedure and health conditions of the patient are discussed as well as: 1. Time off from work for the recovery period. 2. The budgeting allowed for the procedure. 3. The patient expectations of the procedure. The surgeon should weigh in all the factors before deciding as to what kind of a lift is appropriate for the patient. Obviously the three dimensional face lift is the best that can be done to the face and attend to all the factors involved in the rejuvenation of a face, but it is more invasive and requires a longer recovery period i.e. 10–14 days. When explaining the three dimensional facelift do not exaggerate the results to the patient.

27.6  Procedure The patient has preoperative photos and there are no markings done on the face because the markings will

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disappear during laser resurfacing of the face and chemical peeling of the neck. The patient is placed in a supine position and an intravenous line established. Foam padding is applied under the patient’s bony parts to secure any pressure soreness. Sequential compressors are applied to the legs. The patient’s face and neck are prepped with Phisohex and draped in a sterile manner. Apply three (3) passes of Jessner’s solution to the neck up to the jawline followed by three (3) passes of 20% TCA. Generalized frosting of the neck up to the jaw line should be noted. Laser resurfacing is then started on the face area using the Coherent CO2 Ultrapulse laser. The setting is at 300 mJ with 60 W of power with the density set at five. Three (3) passes are made at this setting for most of the face but the setting is changed to 250 mJ, 50 W and density set at four for the upper and lower eyelids for two passes. Fat is then harvested using a stab incision in the area, usually the lateral thighs, inner thighs, or lower abdomen. Tumescent fluid is infiltrated into the subcutaneous fat tissues of the area. After 5 min, fat harvesting is started using 2.5 mm Mercedes cannula on a 20-mL syringe, vented 5 mL. A total of 100 mL of fat is usually harvested. The fat is washed in normal saline three times and 1 cc of Albumin is added to each 10-mL

27  Three Dimensional Facelift

of fat that is then transferred into 1-mL syringes. The excess fat is then stored in the freezer for future use. An incision is made along the preoperative marking in the submental crease and the ear lobe and tumescent fluid is infiltrated into the subcutaneous fat of the neck and jowl and face area. Using a 2.5-mm Mercedes cannula on a 20-mL syringe, liposuction of the neck and jowl is performed leaving a fat layer in the subdermis. An incision is made in the submental crease and is extended 1.5–2.0 cm from the midline. The skin is raised on top of the platysma muscle. A previously sized mesh that is soaked in antibiotic solution is placed on top of the muscle. Using a 5-0 Nylon, the mesh is sutured to the platysma. In the middle of each lateral border of the mesh a 2-0 Nylon is used to grab the mesh and the muscle. The 2-0 Nylon is passed on top of the platysma and brought out behind the ear by the mastoid fascia. The 2-0 Nylon is sutured to the mastoid fascia and pulled for proper tightening and suspension of the platysma muscle. Proper lifting and tightening of the platysma is evaluated and care is made to pass the suture below the jowl line. The patient’s face is turned to the side and the facelift procedure started on the right side. Incision is made along the preoperative marking. The flap is raised on top of the parotid fascia in a supra SMAS plane. The skin flap is raised to the jowl area and 3.5 cm lateral to the nasal labial fold. Extra caution has to be used in this area because the buccal and marginal mandibular branch of the facial nerve becomes superficial in this region. Plication of the SMAS is performed with 2-0 Prolene. A series of a 5.0 nylon suspension sutures are used medially from the jowl area laterally to anchor the skin flap to the SMAS. These sutures keep tension off the incision line and increase the longevity of the result. 2-0 Nylon is used for the cheek lift and the skin is lifted vertically, the excess skin resected, and the incision is closed using 4.0 Monocryl for the dermal closure and 5.0 Prolene of the skin closure. The fat is transferred with a 16-gauge needle to the cheeks and the jugular groove. The fat is transferred in a retrograde fashion in 0.1 cc aliquots on top of the bone in a deep plain and then injected into the superficial layer. Generally 5 cc in each cheek area, 2 cc in each eyebrow, 1.5–2 cc in each nasal labial fold, 1.5 cc in each marionette area and 4 cc in the lips are injected. Aquaphor ointment is applied to the neck for the chemical peel and Silon dressing is applied to the face with foam on the neck and compression dressing to hold every thing together.

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27.7  Postoperative Care Patients are started on an antibiotic (Keflex) and antiviral (Valtrex) the day before surgery and they will continue for 9 days after the surgery. The patient is advised to drink something light and after 20 min to start taking the pain medication. The patient is to avoid taking the antibiotic or the Valtrex the day of the surgery but is asked to continue the following day. The patient is advised to sleep with the head elevated and not to touch the bandages.

27.7.1  First Postoperative Day The patient is to see the surgeon in the office for a change of dressing. The patient is advised to take Valtrex, antibiotics, and other medications. The patient is to eat foods that do not require much chewing. The Silon dressing is adjusted to cover all lasered skin but if needed, the dressing is changed. The patient should continue to keep the head elevated.

27.7.2  Second Postoperative Day The patient is advised not to touch the dressings and to apply Aquaphor ointment to any lasered or chemically peeled area that is exposed to the air. The head is to be kept elevated and the patient is to continue on soft foods.

27.7.3  Third Postoperative Day Dressings are removed and Aquaphor ointment applied to all lasered and chemically peeled areas. Patient is to wash the face and neck three times today with Cetaphil Cleanser using the finger tips to remove all Aquaphor thoroughly in the shower or over the sink without rubbing too hard, pat dry, and apply a new coat of Aquaphor ointment.

27.7.4  Fourth Postoperative Day Patient is to wash the face and neck three times today with Cetaphil Cleanser using the finger tips to remove all Aquaphor thoroughly in the shower or over the sink

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without rubbing too hard, pat dry, and apply a new coat of Aquaphor ointment to the lasered areas only, not the chemically peeled area. This area needs to become dry and peel and then an application of Aquaphor is needed only for the area that has already peeled (new skin). This may take a couple of days.

moisturizing sunscreen if it is not too agitating to the skin. If it is burning or agitating then reapply Aquaphor until the skin is ready for sunscreen. Avoid sun at all times. Normally patients are ready to apply make up to cover up some of the remaining redness but again this depends on the skin being ready or not.

27.7.5  Fifth and Sixth Postoperative Days

27.8  Discussion

Patient is to wash the face and neck two times a day with Cetaphil Cleanser using the finger tips to remove all Aquaphor thoroughly in the shower or over the sink without rubbing too hard, pat dry, and apply a new coat of Aquaphor ointment to the lasered areas only.

27.7.6  Seventh Postoperative Day The patient is to see the surgeon in the clinic. The patient will start washing once a day and apply light coat of Aquaphor or enough to keep the skin moist or the next.

27.7.7  Tenth Postoperative Day The patient is to stop using the Aquaphor but still wash with the Cetaphil. He/She is to start applying

Fig. 27.2  (a1, a2) Preoperative. (b1, b2) Two months postoperatively following three dimensional facial rejuvenation

Most facelifts that are described in the literature involves some sort of plication of the SMAS. Plication is a two dimensional procedure in the vertical or horizontal plane. The problem is that the face is three dimensional in shape and when it is pulled only in two dimensions the result is a flatter, pulled, and unnatural look. SMAS plication and platysmaplasty involves the two dimensions but the fat transfer or implant placement would take care of the third dimension which makes the result very natural. The author prefers to use fat transfer because it works the best although cheek implant or chin implant can be utilized. Both of these ways has its benefits and disadvantages. Using the fat transfer would have to be repeated one or two more times during the next few years but the result is very natural. Also using fat is very safe and the shape can easily be sculpted for every individual patient. Enough fat is harvested for fat transfer for a portion to be saved in the freezer in 1 cc syringes for up to 5 years.

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27  Three Dimensional Facelift

Patients are advised that during this 5 year period they can have repeat injections of the fat to different parts of their face. Fat transfer is cost effective, safe, and it is way to continue looking rejuvenated through out the years.

27.9  Complications There has been no infection, hematoma, or skin necrosis (by limiting the medial dissection in the facelift) in 50 three dimensional facial rejuvenation procedures. There was one buccal nerve injury that resolved in 9 months. There were two marginal mandibular nerve injuries in which one resolved in 3 weeks and the

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other in 2 months. Since these problems occurred the author has limited the facelift dissection medially.

27.10  Conclusions Because of the laser resurfacing and fat transfer to the medial section of the face there is no need for extensive facelift flap dissection that may result in a nerve injury and excessive swelling. Overall the patient satisfaction has been very high (Fig. 27.2). The results give more of a youthful appearance than any one of the techniques alone.

Complementary Fat Grafting of the Face

28

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

28.1  Introduction Autologous fat transfer has become an increasingly important method of facial rejuvenation both as a standalone procedure as well as in combination with traditional rejuvenative methods, like face-lifting, brow lifting, and blepharoplasty. In certain respects, fat grafting stands in contradistinction to previous efforts at rejuvenation in which the face is augmented with tissue rather than subtracted by lifting, pulling, and excising. A simple analogy to understand the benefits of fat grafting is looking at a full and ripe grape that becomes prune-like (wrinkled, puckered) over a period of time like a convex, youthful face that undergoes contraction and involution with age. Rather than remove what appears to be redundant tissue and transform that raisin into a pea, perhaps it would be better to reinflate that tiny raisin back into a grape. Obviously, any analogy can suffer from the obvious problem of being overly reductionistic. Although many surgeons have approached fat grafting as the only correct method to rejuvenate the face (and have demonstrated wonderful results by doing so), the authors contend that fat grafting can serve more effectively as a complement to other rejuvenative techniques. For example, if a patient has significant neck descent and platysmal dehiscence, a cervico-facial rhytidectomy would provide a more assured method of rejuvenation than copious fat grafting into the neck to mask the unfavorable contours. Fat grafting could then be combined simultaneously with face-lifting to enhance the midfacial, periorbital, and prejowl depression to attain

R. A. Glasgold () Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA e-mail: [email protected]

an overall improved aesthetic result (Fig. 28.1). A conservative transconjunctival blepharoplasty or skin-only a

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Fig. 28.1  (a) Preoperative. (b) Postoperative following face-lift autologous fat transfer to the midface

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_28, © Springer-Verlag Berlin Heidelberg 2010

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upper blepharoplasty combined with fat grafting can provide reliable rejuvenation and limit morbidity associated with higher volumes of fat grafting that would otherwise be necessary without concomitant excisional-based surgery. This focused and cogent chapter will elucidate the methodology that has proven effective for autologous fat grafting over a 10-year experience. Details of lifting procedures (like face-lift, blepharoplasty, etc.) are assumed and not described herein.

28.2  Technique The operative technique is outlined as a surgeon would approach a patient the day of the procedure: marking the recipient sites, selecting donor site, donor-site harvesting, processing the fat, injection techniques, and immediate postoperative care.

28.3  Marking the Recipient Sites On the day of surgery the surgeon should establish or reestablish with the patient the areas for facial augmentation with fat grafting. A permanent marker, e.g., a Sharpie (Gentian violet is too tenacious and will remain on the patient’s face for several days, which can be a nuisance; eyebrow crayons/pencils are wiped off too quickly to be useful) is the most effective tool to outline the targeted areas with the patient in the sitting position when the effects of gravity are the most apparent. The anatomic zones that are typically enhanced are as follows: the lateral brow, the inferior orbital rim, the nasojugal groove, the anterior cheek, especially the depression along the malar septum, the lateral cheek, the buccal recess, and the prejowl region (Fig. 28.1). Other areas that can be enhanced as well are the precanine fossa, the lateral mandible (the lateral mandible can only be addressed if a concurrent face-lift is not performed, as a face-lift typically undermines the soft tissue overlying the lateral aspect of the mandible), and the temple. The patient should confirm with the surgeon the areas for augmentation in a mirror before proceeding. Another useful resource is a patient’s old photograph that can help the surgeon and the patient

S. M. Lam et al.

achieve mutually agreed-upon objectives in terms of volume and distribution of that volume.

28.4  Selecting Donor Site The easiest method to determine the most favorable donor site for fat harvesting is to ask the patient where he or she has the greatest difficulty losing fat or where the patient thinks the most adipose reserve resides. While most men are predominantly truncal dominant, women can be either truncal or extremity dominant (or both) with regard to fat distribution. If the patient has had prior liposuctioning, the surgeon should know where, as the quality of fat harvested from the areas of previous liposuctioning can be less than desirable. Prior abdominal surgery does not usually prevent harvesting of the abdomen. As most fat is harvested from the lower lateral quadrants, midline and “bikini” incisions are generally not in the field of harvesting and should not pose a hindrance. Even lower lateral quadrant incisions are not a contraindication as long as the surgeon carefully palpates for any signs of herniation in these areas during valsalva. In general, the lower abdomen and inner thighs are the easiest sites for harvesting as the patient does not require full-body repositioning. However, the hip, the waist roll that descends along the lower back, the outer thigh, the anterior thigh, and sometimes the inner knee are alternative sites that are excellent but require patient repositioning. The area of the triceps are another source for fat harvesting that is easy to undertake but requires the assistant to hold the arm extended during harvesting. Although fat harvesting from only one side should very rarely cause any noticeable asymmetry between the two sides of the body, it is always wiser to extract fat symmetrically in order to allay the patient’s anxiety about this unlikely occurrence.

28.5  Donor-Site Harvesting The donor site is anesthetized with a mixture of 1/4% lidocaine with 1:400,000 epinephrine by mixing 5 cc of 1% lidocaine/1:100,000 epinephrine with 15 cc of saline in a 20-cc syringe and fitted with a 22-gauge spinal needle for infiltration. The donor site is anesthetized by placing the anesthesia above (in the superficial

28  Complementary Fat Grafting of the Face

subcutaneous plane below the dermis) the fat pad and in the deeper aspect of the fat pad leaving the central portion of the fat pad itself relatively free of any anesthetic. A total of 20 cc of anesthetic is delivered to each site except for the abdomen that receives 10 cc per lower lateral quadrant. For optimal patient comfort, the procedure should be performed under intravenous sedation (or general anesthesia if so desired but which is typically unnecessary). If the patient is under light anesthesia or if surgery is performed with just a local anesthetic, a mixture of 10 cc of 1% lidocaine with 1:100:000 epinephrine and 10 cc of saline should be used in order to lessen discomfort. The key to successful harvesting is a less traumatic extraction of donor fat. Several principles should be elaborated to achieve this objective. First, only hand suctioning should be undertaken, i.e., not liposuctioning with wall or machine suction. Second, only 1–3 cc of negative pressure on the syringe plunger should be manually applied to minimize traumatic injury to the fat cells. Third, proper centrifugation, not over- or underspinning the fat, should be performed so as to preserve the fat cells while still purifying the fat from other non-fat constituent elements, respectively. Entry sites to pass the harvesting cannula are made with a 16-gauge Nokor needle or an abbreviated stab incision with a No.11 Bard-Parker blade in an anatomically discreet location. For example, the lower abdomen can be easily accessed bilaterally from a simple stab incision along the inferior aspect of the umbilicus. The inner thigh can be approached from a stab incision along the inguinal line, and the lateral thigh accessed from the lateral infragluteal fold. Harvesting is undertaken with a blunt harvesting cannula from any number of reputable manufacturers of fat harvesting equipment (Tulip Medical Inc., San Diego, CA; Miller Medical Inc., Mesa, AZ; Byron Medical Inc., Tucson, AZ). A 10-cc Luer-Lok syringe is ideal for harvesting. During harvesting, the surgeon should focus on the middle of the fat pad layer. If the surgeon is harvesting only the superficial layer, tethering of the skin will be noted as the cannula approaches the dermis, which can in turn lead to potential contour deformities as well as elicit the patient’s discomfort. Similarly, harvesting deeper near the fascial layer can also provoke pain in the patient and under light anesthesia will not be easily tolerated. As the surgeon harvests fat, he or she should be cognizant of the cannula passage in the following ways. First, the cannula tip is where fat

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enters the cannula and thereby the syringe for collection. Accordingly, the surgeon should always be mindful of where the cannula tip is situated in the fat pad. The neophyte surgeon may unwittingly pass the cannula tip too far beyond the fat pad, which would limit potential harvest and also increase patient discomfort as the tip abrades unanesthetized structures (e.g., fascia, muscle, dermis, etc.). Secondly, after channeling of the cannula several times in a specified area of the fat pad, the surgeon should consciously withdraw the cannula all the way back almost to the entry site before reorienting the cannula to pass into another part of the fat pad. Simply turning the cannula direction without first withdrawing the cannula back to the entry site can lead to over harvesting in one place since the cannula often remains exactly in the same place that it was previously. Use of the nondominant hand to stabilize the fat pad can be helpful to increase harvesting ease and efficiency. However, the surgeon should resist the temptation to squeeze the fat pad with the nondominant hand, as this maneuver can lead to the potential for uneven contours. Another tip that is useful concerns harvesting from the inner thigh. The patient should have the contralateral side frog-legged to facilitate harvesting from the straightened leg. It is important not to harvest from the frog-legged side, which can lead to possible contour irregularities. Also, the cannula must first pass through an initial fascial layer before harvesting commences. If the surgeon works on it superficially, the cannula can be easily seen to tent and deform the overlying skin, which is too superficial a passage. The surgeon will feel an initial pop or release of tension when entering the correct fascial layer for the inner thigh.

28.6  Processing the Fat The entire procedure, including fat processing, should be completed in a sterile fashion to minimize risk of infection. The donor and recipient sites are prepared with povidone-iodine, or equivalent solution, and draped sterilely. Similarly, centrifugation of the fat should be done sterilely as well. There are many models of centrifuges that permit sterility to be maintained. For instance, the entire centrifuge hub into which the syringes are inserted can be removed and sterilized. Alternatively, the authors use a model in which the syringes are placed

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into individual sterilized sleeves (Miller Medical, Inc.), which are in turn placed into the circular centrifuge hub, which remains nonsterile. The 10-cc syringe containing harvested fat is prepared by removing the syringe plunger and affixing a cap and the Luer-Lok side, a Luer-Lok style plug – both of which can be purchased from the aforementioned manufacturers. It is important to emphasize that the small plastic cap that comes packaged with the syringe should never be used for centrifugation, as it is not secure enough to hold the contents. The fat is then spun in the centrifuge in a balanced manner (i.e., the syringes are spaced equally around the centrifuge to avoid damage to the machine and poor centrifugation). Generally speaking, the fat is spun at around 3,000 rpm for 3 min ± 1 min or about 1,000 rpm either way. The syringes are then removed, and the supranatant (from the plunger side) is poured off into a waste basin on the sterile field to remove the fat free oils and also release it from lysed fat cells. The bloody infranatant is then allowed to drain off the bottom of the syringe into the waste basin. Any remaining supranatant is then wicked away with uncut 4 × 4 gauze tucked into the exposed plunger side to make contact with the fat. Five to ten minutes are allowed to transpire for complete wicking of the supranatant to occur. Then, the contents of the syringe are poured from the exposed plunger side into the back end (exposed plunger side) of a 20-cc Luer-Lok transfer syringe. Doing so expedites transfer into the 1-cc Luer-Lok infiltration syringes and also allows removal of any remaining bloody infranatant in the original 10-cc syringe. The 20-cc transfer syringe is filled to the 15 cc mark, and air is gently removed through the Luer-Lok side taking care not to spill any of the fat contents through the aperture prematurely. A Luer-Lok transfer hub is then affixed on one side to the 20-cc syringe and the other side to the 1-cc Luer-Lok syringe and the fat contents transferred in a slow deliberate fashion. It is important to push the fat all the way to the back of the 1-cc syringe so that the plunger is actually removed from the back of the 1-cc syringe and reinserted to the 1.0 cc mark. There is always a tiny air bubble that remains at the base of the syringe, and this maneuver removes the bubble. The assistant then continues to refill each 1-cc syringe, as the surgeon continues to infiltrate the face systematically. Generally, four 1-cc syringes are sufficient for continual refilling without a wait time between the fills.

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28.7  Injection Techniques 28.7.1  General Principles Use of blunt cannulas throughout the infiltration procedure can minimize hematoma formation and thereby aid fat-cell viability. In addition, blunt infiltration cannulas limit the potential for nerve damage, as tissue planes are followed more naturally and less traumatically disturbed. Besides direct injection of the three proposed entry sites with local anesthesia, almost all of the anesthetic should be delivered with the same blunt infiltration cannula used for fat infiltration to minimize hematoma and swelling prior to starting injection of the fat. The three ports of entry are as follows (Fig. 28.2): 1. The base of the malar septal depression in the midcheek of the face (Port A) 2. Lateral to the lateral canthus (Port B) 3. Posterior to the prejowl sulcus (Port C) Each of these ports of entry is made with a stab incision using a standard 18-gauge needle through which the blunt cannula can be inserted for both anesthetic delivery and fat infiltration. Placing only tiny parcels of fat – either 3–5 passes per tenth of a cubic centimeter (in unforgiving areas)

Fig. 28.2  Preoperative markings on a patient undergoing autologous fat transfer. The three planned entry sites for fat infiltration are marked in red and are referred to as Ports B, A, and C respectively from superior to inferior

28  Complementary Fat Grafting of the Face

or a full tenth of a cubic centimeter per pass (in more forgiving areas) – is the key to successful fat transfer. In the past, larger boluses of fat were used that led to potential visible contour irregularities and could compromise fat viability. It is important for the surgeon to visualize the depth of infiltration basically into the following three zones: 1. Deep (immediately supraperiosteal) 2. Intermediate (in the musculo-fascial layer) 3. Superficial (in the subcutaneous plane) For the supraperiosteal plane, the nondominant hand can be used to provide tactile feedback during infiltration and to guide supraperiosteal placement. In addition, the dominant hand can feel that the cannula tip is gently abutting the bony surface. For the intermediate and superficial planes, the cannula passage is less precise and the surgeon must simply visualize that the cannula is passing through the central thickness of the soft tissue or more superficially.

28.7.2 Systematic Site-Specific Infiltration 28.7.2.1  Inferior Orbital Rim (from Port A) The most difficult area to inject safely and accurately is the inferior orbital rim, and this is where most complications can arise. Therefore, only small amounts (a total of 2–3 cc total for the entire inferior orbital rim) should be placed per session when beginning. As comfort with the technique is gained, maximal infiltration in this area should still not exceed 4–5 cc per session. Moreover, only small quantities of fat per pass (3–5 passes per tenth of a cubic centimeter) should be delivered into the deep supraperiosteal plane. Injection of the inferior orbital rim from the inferiorly positioned entry site (Port A) at a perpendicular angle greatly reduces the incidence of complications. The nondominant hand should be used to protect the globe and to provide tactile feedback so that the cannula tip is dancing gently across the inferior orbital rim. It is very important that if the cannula tip feels plugged the cannula be entirely withdrawn and cleared external to the body before continuing to avoid an inadvertent large bolus of fat into an unforgiving area like the inferior orbital rim. It is easier to divide the inferior orbital rim into a medial and a

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lateral half and place 1 cc of fat into each side as a way of being systematic and precise.

28.7.2.2  Nasojugal Groove (from Port A) The nasojugal groove can be more recessed in some individuals than others. Nevertheless, it is almost always of empiric benefit to place some fat along this bony triangular recession that resides between the medial inferior orbital rim and the nasal sidewall, as youthful individuals tend to exhibit some degree of favorable convexity here. Placement of 1 cc of fat into the supraperiosteal plane can be undertaken a bit more aggressively passing a tenth of a cubic centimeter per pass without significant risk of contour irregularity.

28.7.2.3  Lateral Canthus (from Port B) If the patient exhibits some lateral-canthal hollowing, the surgeon can place 0.5 cc into the supraperiosteal plane from the laterally positioned entry Port B. There tends to be considerable fibrous attachments that must be broken to insert the fat in this area. These fibers must be gently and gradually severed with the cannula tip, as a hematoma can arise from the traumatic disruption.

28.7.2.4  Lateral Brow (from Port B) The lateral brow tends to be an excellent area for fat infiltration to achieve a balanced frame around the eye with fat. The lateral brow is approached from lateral entry Port B and placement is undertaken in either a deep or intermediate plane (Fig. 28.3). More realistically, the cannula should simply be passed in the plane of least resistance. As this area is more forgiving, a tenth of a cubic centimeter per pass can be undertaken to place a total of 1 cc of fat, in most cases. If a cigar roll appears at the end of infiltration, this deformity should not raise concern as it typically dissipates over time.

28.7.2.5 Anterior Cheek/Malar Septum (from Port B) The anterior cheek, which often exhibits a linear depression that runs supero-medially down infero-laterally and

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cheek above. The buccal hollow can accommodate a generous amount of fat on the order of 5–8 cc without difficulty. Placement of fat is into the intermediate and superficial tissue planes from entry site A. If the entry site is too proximal to the buccal region, the more distally situated Port B can be used as an alternative or together with Port A in a cross-hatching fashion.

28.7.2.8  Prejowl Sulcus (from Port C)

Fig. 28.3  Fat placed along the inferior orbital rim

which corresponds with the ligamentous malar septum, should be addressed next. The cannula is passed from Port B that is supero-lateral to the malar septum so that the cannula can break through the malar septum in a perpendicular orientation to it. Individuals exhibit varying degrees of resistance when the cannula passes through the malar septum. The goal is to place fat in the malar septal depression and on either side of it to raise the anterior cheek along with the unsightly depression. Generally, 2–3 cc of fat can be placed into the intermediate and superficial planes. The deep plane can also be addressed, but the surgeon need not hug the bony contour. A generous tenth of a cubic centimeter per pass can be undertaken with impunity. The surgeon should be careful in aggressively enhancing the anterior cheek in men, as this characteristic can be somewhat feminizing.

28.7.2.6  Lateral Cheek (from Port A) The lateral cheek is more easily elevated in continuity with the anterior cheek from an infero-medial position of entry Port A. The bony zygomatic arch can serve as a helpful guide over which the fat can be placed. The placement of 2–3 cc of fat into the lateral cheek can be undertaken with a generous tenth of a cubic centimeter per pass into all tissue depths but again the cannula need not pass immediately in the supraperiosteal plane.

28.7.2.7  Buccal Recess (from Port A) The buccal recess can be quite hollow with aging and can be even more exacerbated by augmenting the

The prejowl sulcus is an important area to augment to achieve a more youthful facial contour but also to enhance a face-lift result by straightening the jawline further with fat enhancement. Fat should be infiltrated into all three tissue planes described previously with a generous tenth of a cubic centimeter per pass without difficulty. We generally start with 3 cc. It is important to conceptualize the prejowl sulcus three-dimensionally with fat placed along the anterior border of the mandible, the inferior border of the mandible, and the transition between these two borders. Doing so will provide a more even and complete fill of the prejowl depression. Additional fat can be feathered into the mental sulcus and anterior chin as aesthetically mandated.

28.8  Immediate Postoperative Care As no actual incisions are made, there is no need for any suturing of the entry sites. Also, no dressings for the body or face are required either. Simply head elevation and icing are sufficient to expedite the recovery process. The patients are discharged after adequate postoperative observation.

28.9  Complications Obviously, the best situation is to avoid a complication altogether, as complications can be difficult to correct. It is important to be more conservative when starting out with autologous fat transfer, especially in the periorbital region, as it is a relatively simple task to add more fat but an arduous one to remove an excess. The first order of business when approaching a complication is to identify the nature of the complication to permit an accurate treatment protocol. For simplicity, we have

28  Complementary Fat Grafting of the Face

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divided the complications that can arise into the following four categories: lumps, bulges, overcorrection, and under-correction. Each type of complication mandates a different, unique treatment strategy.

conservative policy of enhancement, especially for the inexperienced surgeon. Overcorrection is best handled with an 18-gauge Klein-Capistrano micro liposuction cannula (HK Surgical, Inc., San Clemente, CA).

28.9.1  Lumps

28.9.4  Undercorrection

A lump refers to a discrete, contour deformity that arises from either placement of too much fat into a specific locus or too superficially near the skin in an unforgiving anatomic region, like the periorbital region. Although steroid injections may help, we have found that removal of the offending lump through a direct, cutaneous incision is the most effective method of resolving the problem.

Undercorrection is the most favorable situation, as additional fat can be easily harvested and infiltrated into the deficient areas. Unlike in face-lift surgery, “hitting a double” and not trying for a “homerun” should be the goal in fat grafting. This conservative policy should be a useful guiding philosophy, especially for the starting surgeon. Some patients also tend to absorb fat more quickly, and an additional session 6 months after fat infiltration may be required to restore an optimal result.

28.9.2  Bulges A bulge refers to a wider zone of fibrotic fat that can arise like a cigar-roll deformity along the inferior orbital rim due to imprecise placement of a large quantity of fat in an unforgiving area. Since we have migrated away from injecting the inferior orbital rim from a lateral entry site now to exclusively an inferior-based entry site (i.e., perpendicular to the rim itself), we have encountered significantly fewer such complications. A bulge can also arise when a patient gains a considerable amount of weight after fat transplant, making the areas of fat grafted literally bulge due to fat hypertrophy. In these cases, we have found that micro liposuction and direct excision to be less favorable when compared to repeated, intralesional steroid injections. The authors typically inject the area with low-dose triamcinalone acetonide (10 mg/cc) and gradually increase on a monthly basis if needed to a full 40 mg/cc concentration until resolution. Conservative aliquots of steroid using only 0.05–0.1 cc per problem area help to minimize the risk of dermal atrophy and unfavorable divots that arise from steroid use.

28.9.3  Overcorrection Overcorrection can be most apparent in the lateral cheek, which manifests as a roll that appears when the patient smiles. It is always wiser to start with a more

28.10  Discussion Autologous fat transfer has come to be recognized as an important, if not indispensable, tool in the facial aesthetic surgeon’s armamentarium. The question arises whether traditional blepharoplasty has yielded the optimal rejuvenation for the patient. Removal of skin and fat around the eye alone during blepharoplasty can actually hollow the eye and thereby age the patient even more dramatically rather than serve to rejuvenate. If one studies the hallmarks of a youthful face, the periorbital region can be seen richly padded rather than hollow and that aging only serves to deplete the volume around the eye further. Conservative removal of some prolapsed fat in the lower eyelid should in most cases be combined with periorbital fat transfer to achieve the best aesthetic results. At times, fat transfer alone to the periorbital region will suffice. As hair restoration provides a frame for the face, autologous fat transfer should be thought of as a way to frame the eye and thereby bring back the luster of youth (Fig. 28.4). A youthful face is heart-shaped, with a prominent cheek which tapers down to the chin area which forms the apices of the heart. As aging occurs, the face becomes more deflated and gravity accentuates the heaviness of the jowls and lateral mandible. Accordingly, the face becomes not only more aged but more masculinized with a rectangular/square shape. The goal of autologous fat transfer is to return the face back to a more ideal heart

216 Fig. 28.4  Fat injection of prejowl sulcus

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a

b

a

b

Fig. 28.5  (a) Preoperative. (b) Postoperative after periorbital and midface fat transfer which provided a frame for the eye

shape that is both youthful and feminine (Fig. 28.5). When dealing with male patients the anterior cheek augmentation is done to a lesser degree so as to avoid the risk of feminizing the male face. Another feature of the aging face that is observed is the rise of depressions, concavities, and shadows, e.g., along the inferior orbital rim, the malar septum, the lateral brow, and the prejowl sulcus. The objective in autologous fat transfer is to return the face toward a more youthful convexity free of these shadowed concavities. Although fat transfer is an excellent method to restore facial contour, it is not ideal for addressing the perioral lines like the nasolabial and labiomandibular folds or the lips. The authors prefer the use of soft-tissue fillers, other than fat, to achieve restoration of these areas, as correction of these kinds of lines with fat tend to be shorter lived in our hands and also less than ideal. The lips are also an area that is more difficult to correct with any degree of longevity and the recovery time for lip enhancement with fat transfer can be considerable. Fat transfer, when combined with other traditional rejuvenative procedures like blepharoplasty and/or

face-lifting, can more effectively restore the aging face than any procedure alone in many cases. The authors advocate using the appropriate combination of procedures to arrive at the most targeted solution to the problem at hand. Using fat grafting as a complement to traditional rejuvenative procedures can possibly enhance patient satisfaction and reduce morbidity associated with aggressive fat grafting alone.

28.11  Conclusions This chapter is intended, first and foremost, to challenge the surgeon to rethink his or her aesthetic perspective about the aging face. The operative technique outlined is suggested to provide a simplified and systematic approach to autologous fat transfer and thereby facilitate ease of the operation and minimize morbidity. Volume enhancement should continue to become an increasingly important method for facial rejuvenation and to restore facial harmony.

Fat Transplants in Male and Female Genitals 1

29

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

29.1  Introduction Fat transplants have been used in reconstructive and cosmetic surgery for more than a century (1–3). For many years, however, this procedure was practically forgotten. With the advent of liposuction as one of the most common procedures in cosmetic surgery, fat transplantation began receiving renewed interest approximately 15 years ago, and (2) it has been used with good results for the correction of facial wrinkles or for improving facial or body defects, either congenital (hemifacial atrophy) or acquired (usually traumatic). There have been important developments, over the years, with fat transplants to various areas of the body. Satisfactory results have been obtained by injecting fat into female breasts, buttocks, and calves (4, 5). The use of autologous fat for penile enhancement was first reported in 1993 (4). Fat transplant to the female genitals was described in 1996 (6).

29.2  Preoperative Preparation The operation is performed only on highly motivated healthy adults having realistic and reasonable expectations. Patients are informed that this is not an operation to treat impotence, frigidity, or anatomical deformi­ties of

Reprinted with permission of Lippincott Williams and Wilkins.

1

E. Hernández-Pérez (*) 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA e-mail: [email protected]

any type. In the case of patients with redundant foreskin or true phimosis, a circumcision must be considered first. The patient is prepared prior to surgery by obtaining a careful psychiatric history and giving him or her, a thorough explanation of the procedure and possible problems. It is very important to avoid patients with significant psychiatric disorders. On examination, the genitals must be normal, and free from any disease. Most male patients are concerned with the diameter of the penis and the degree of sexual satisfaction they can give to their partner. Though on examination, the penis may appear to be of adequate size to the physician, the patient may feel that his penis is smaller when a large deposit of fat exists in the pubis. It is necessary to in­­ form him that aspiration of fat from this area will also be performed, simultaneously. Evaluation of size of the genitals is certainly more difficult and possibly more subjective in females, but it is evident that fat atrophy (noticeable in the labia majora and pubis) occurs with aging and with loss of weight and in some instances may be genetic in origin. In these cases, the form of the vulva seems to have a more important role in self-esteem of the female than the size of the organ (6). The ideal patient for this surgical procedure is an individual who, knowing that the size of his or her genitals is within the normal range, believes that the relationship with one’s partner could improve if the size of the orgFan could be increased. The patient is counseled about the fact that sexual satisfaction depends upon love and mutual understanding, as well as the use of caressing and not specifically on the size of the penis or vulva. However, if the increase in diameter of the organ can improve the patient’s security, the operation may be undertaken (4, 6). Regardless of age, all patients are sent to a cardi­ ologist for a complete cardiovascular checkup before

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_29, © Springer-Verlag Berlin Heidelberg 2010

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surgery. For medical and medicolegal reasons, it is advisable to have a written permission from the cardiologist to perform this type of surgery when using epinephrine. Other presurgical tests include fasting blood sugar, human immunodeficiency virus (HIV), and coagulation tests. The authors prefer patients falling into categories I or II according to the criteria of The American Society of Anesthesiology (7). Patients are instructed to wash the operative area with povidoneiodine or chlorhexidine for 3 days prior to surgery. One day before surgery they are given an oral wide-spectrum antibiotic. Patients are instructed to avoid aspirin and some antidepressants such as sertraline and beta blockers before the operation and to stop smoking (8).

29.3  Technique The patient is advised to take nothing orally starting at midnight prior to surgery. In the operating room, the areas to be treated are marked. The operation is performed as an ambulatory procedure using local anesthesia and intravenous (IV) sedation (Midazolan plus fentanyl). The authors prefer using sedation together with local anesthesia. The procedures are performed in a fully equipped operating room under the care of a certified anesthesiologist. Most cases of fat transfer are performed as a part of liposuction procedure or in combination with other cosmetic procedures. If the blood pressure is above 100/60 and the pulse rate is above 60 /min, Clonadine 0.1 mg should be given (by mouth) orally 1 h before in order to prevent any arrhythmia provoked by epinephrine. Thirty minutes before starting the operation, a widespectrum prophylactic antibiotic (ceftriaxone 1 g) is given intramuscularly (IM). The dose is repeated if the procedure takes longer than 3 h. Intravenous (IV) dexamethasone (8 mg) is given in an attempt to prevent the cascade of arachidonic acid and diphenhydramine 50 mg is administered orally to avoid postoperative nausea. The surgeons have abandoned the use of metoclopramide, because of the possibility of provoking extrapyramidal effects. Preoperative and postoperative photographs of the patients are taken. A modification of Klein’s formula is used in the donor area. The solution consists only of lidocaine (0.05%) plus epinephrine (1:1 million) in saline solution (9).

E. Hernández-Pérez et al.

Sodium bicarbonate is not used, because the pati­ents are under IV sedation and pain from the injection is not of concern. Sodium bicarbonate seems to increase the inflam­mation and lessen the duration of the anesthesia (10). The local anesthetic used is at refrigerator temperature (cryoanesthesia) (10). In certain body areas recognized for their excessive sensitivity, either larger volumes of the anesthetic solution are used or the amounts of the IV analgesics and sedatives are increased. The modified Klein’s solution is infiltrated into the donor area up to tumescence. For harvesting purposes, nonfibrous sites such as the lower abdomen, trochanteric areas, pubis, submental area, medial thigs, and inner knees are preferred. How­ ever, by far the preferred sites are trochanteric areas, the best ones that provide us with almost pure, yellowish and thick fat, practically ready to inject. While the patient is being monitored, the anesthesiologist administers IV sedation (Midazolan plus fentanyl). The total dose of Midazolan varies from 15 to 20 mg (0.3 mg/kg). The total dose of fentanyl varies from 300 to 500 mg (5–10 mg/kg). In the case of fat transfer alone, 50 mg of fentanyl, and 5 mg of Midazolan are used as a starting dose. This is usually the only sedation needed. Both drugs are for a short duration, and if administered over a prolonged period of time, there is no risk to the pati­ ent, especially with monitoring. After antisepsis with povidone-iodine, tumescent anesthesia is infiltrated in the donor areas, which are generally the trochanteric areas or the lower abdomen. After waiting for 15 min for the vaso-constrictive effect of the epinephrine, fat is harvested using 60-mL syringes with a snapper and small cannulas (Toomey or Tulip system) (Fig. 29.1). The fat is manipulated very gently by decanting in the syringes after separation into the three classic levels: Triglycerides from the broken adipose tissue are in the upper part, pure fat is in the middle, and a small amount of blood mixed with modified

Fig. 29.1  Fat is harvested using a thin cannula and a Toomey System Syringe

29  Fat Transplants in Male and Female Genitals Fig. 29.2  (a) The fat is prepared through a very delicate decanting in the syringes. (b) The three classic levels: tryglicerides from the broken adipocytes in the upper level, pure fat in the middle, and small amounts of blood mixed with Klein’s solution in the lower level

a

Klein’s solution is in the lower level (Fig. 29.2) (11, 12). In patients with an excessive deposit of fat in the pubis, it is aspirated at this time. The authors prefer to manipulate the fat in a closed circuit to minimize the risk of contamination or damage to the adipocytes. Insulin added to the fat has no benefit. When the fat has been harvested, the syringe is set with the needle downward, depressing the plunger to remove modified Klein’s solution. The fat is not washed with saline, as is done by other surgeons (13). This allows only the pure fat remaining to be used for the transplant. Standard operating room sterile technique must be used when harvesting and injecting fat to avoid infection. Frozen fat may be used for later injection; however, this is not used because of the possibility of infection and risk of over-manipulation with adipocyte damage (8, 14). Anesthesia in the genital area is 1% lidocaine without epinephrine using a disposable plastic 1-mL syringe with a 30-gauge needle. A minimal amount of this solution (from 0.25 to 0.50 mL) is injected into each of specific points. In the male at 6 and 12 o’clock in the inner face of the foreskin and in the female at the upper pole of both labia majora and at the right side  of the mons pubis. No more anesthetic is necessary.

219

b

Fig. 29.3  Fat is injected into the penis in a retrograde fashion

left hand while placing a type of tourniquet at the base of the same with the right hand to prevent dispersion of the fat (Fig. 29.3). The injection is made in a radial and retrograde form using a total of 60 mL of fat, which is adequate. The two small incisions are closed with 6–0 fast-absorbing plain gut and the penis is kept elevated to reduce inflammation and excessive swelling. A bandage is applied similar to that used after a circumcision. This position is maintained for 24 h after the operation. The patient returns our office on the fourth or the eighth day. There is a surprising absence of pain and only slight swelling. The bruises are either slight or nonexistent (Fig. 29.4).

29.4  Penile Enhancement Two small incisions are performed with a #11 scalpel in the premarked points and the fat is injected using thin cannulas (no larger than 14 gauge) of the same type used for breast or calf transplants. At this moment, the assistant must stretch the penis, taking the glans with the

29.5  Vulvar Enhancement Using a #11 scalpel, three small incisions are made in the previously anesthetized sites. Thin cannulas are used to inject fat. First, the cannula is inserted in a

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Fig. 29.4  One week postoperative after penile enlargement with fat transfer. Note no bruising

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caudal direc­tion up to the lower third of the labium majora and the transplant is performed as the cannula is withdrawn (Fig. 29.5). Since many adipocytes die during surgery, some degree of overcorrection is necessary to com­pensate in the case of women (Fig. 29.6) (8). Once both labia have been injected fat is transplanted into the pubis. An average of 100–120 mL is used. Incisions are closed using 6–0 fast-absorbing plain gut. Pressure bandages are used only on the abdominal donor area, and they are removed the next day. One of the most important points in the injection technique is to place the fat in small segments and in different layers into the subcutaneous tissue to increase adipocyte survival (1, 15, 16). The adipocyte survives through the blood vessels furnished by the adjacent tissues. If placed in large segments, such nutrition by these blood vessels may not occur. Fat is not absorbed when injected in small amounts in the penis. It is possible that its anatomical conformation (rich vascularization with an almost total absence of subcutaneous fat and the presence of the tunica albuginea) accounts for this particular behavior of the injected fat. In women, a decrease of 20–30% has been observed.

29.6  Postoperative Care

Fig. 29.5  Injecting fat in the right labia majora

The patient is ambulatory with occasional minimal pain that can be relieved by using acetaminophen. To decrease the inflammation prednisone two tablets 5-mg each is prescribed to be taken immediately after dinner, breakfast, and dinner next day (six tablets at all). Cold compresses are used four or more times a day in the first 4 days (for swelling and discomfort). Patients are able to resume their normal activities (job, studies, etc.), the very next day after surgery. Sexual activities are permitted after 4 days postoperatively since there is minimal inflammation and lack of pain.

29.7  Complications

Fig. 29.6  Some overcorrection is needed. Note the aspect of the injected right labia

Absorption, infection, and embolism are the most common complications in general in the cases of fat injection. Owing to the manipulation of the fat, some adipocytes do not survive the trauma of the transfer.

29  Fat Transplants in Male and Female Genitals

Because of this and the lack of adequate blood support, some degree of fat absorption takes place. The percentage of absorption can be decreased by manipulating fat very gently and avoiding unnecessary manipulation and desiccation. Fat should always be injected in small segments in different layers (15, 16). When using tumescent anesthesia in the donor area, bleeding is not usually seen. Blood losses are less than 1% of the total aspirated amount (10). Cyst formation and calcifications can occur, but they are generally small and self-limited (8). if a cyst does not disappear quickly, it may be treated with intralesional triamcinolone injections. To decrease the possibility of cyst formation, never inject fat in the penis in large amounts. Transitory deformities (penile distortion) and cysts (16) are better prevented by not exceeding 60 mL of fat per session in the male genitals (6). In any case, it should be possible and preferable to perform another injection some months later. To avoid embolism, never inject fat in a centripetal direction but inject it when the cannula is being with­ drawn. Infection, although not seen by the surgeons, can be a potential major problem. Strict sterile technique is essential.

29.8  Discussion Fat grafting in male and female genitals with the goal of enhancing these organs is a simple procedure. It must be done very carefully to avoid complications and to have satisfied patients. In men, the injection should not exceed 60 mL of fat per session (6). In women, the recommen­ ded amount is 100–120 mL (6). Injection of larger amounts of fat results in more frequent penile distortion, cysts, or even necrosis (16). For getting better proportion, in some cases it may be necessary to combine fat aspiration from the pubis as well as fat injection into the penis. Combining fat transfer with a section of the suspensory ligament of the penis could increase the length of the organ (17). However, techniques that are more complex and invasive may cause more significant complications. These modifications have proved to be related to a larger incidence of bleeding, hematoma, or neural disturbances. In general, when a procedure is simple, safe, and provides good results, it is more readily acceptable to patients. By using injectable bovine collagen

221

with glutaraldehyde, it is possible to avoid IV sedation or local anesthesia (16). However, the increase in diameter will occur only in the foreskin proximal to the glans and the results will be temporary. There is always the risk of immunological reactions, slow resolution of granulomas, sterile abscesses, necrosis, and other allergic reactions. When this occurs in the facial skin, it constitutes a difficult problem but if occurring in the penis, the situation could be even more disastrous (18).

29.9  Conclusions 1. Fat is not reabsorbed when injected into the penis. Persistence of fat in the penis possibly is related to its peculiar anatomical conformation (rich vascularization, almost total absence of subcutaneous fat, and the presence of the tunica albuginea). In women, the percentage of absorption is about 20–30%. 2. Postoperative pain is so slight that many patients have been able to have sexual intercourse 3 or 4 days after the procedure. 3. The penis injected with fat increases not only in diameter but, according to the patient, also in length. This latter increase may be due to the weight of the fat and the subsequent stretching of the tissue similar to what occurs with tissue expanders. 4. When administered properly, autologous fat transplantation in the genitals is an acceptable procedure resulting in highly satisfied patients. This is mostly due to the fact that they are using their own tissue instead of a prosthesis. Rejection or allergy is ruled out if the material used is harvested from the same person (8). 5. Patients are told that this type of surgery is, not only an injection of fat. It represents in reality an injection of self-esteem. It is obvious that sexual satisfaction for the patients and their mates does not depend exclusively on the size of the genital organ. To paraphrase a distinguished Latin American writer: “Love is the music, and sex is the instrument (19).”

References   1. Hernández-Pérez E. Implantes ele grasa autóloga. Lipo implante. In: Camacho F, Dulanto F (eds), Cirugía Derma­ tológica, Madrid: Biblioteca, F. Aula Médica, 1995:563–569.

222   2. Bircoll M. A nine-year experience with autologous fat transplantation. Am J Cosmet Surg 1992;9:55–59.   3. Newman J, Ftaiha Z. The biographical history of fat transplant surgery. Am J Cosmet Surg 1987;4:85–87.   4. Hernández-Pérez E, Marroquin-Burgos R. Fat injection of the penis: A personal technique. Am J Cosmet Surg 1993;10: 135–138.   5. Fournier PF. Fat transfer. In: Parish LC, Lask GP (eds), Aesthetic Dermatology, New York: McGraw-Hill, 1991:267–275.   6. Hernández-Pérez E, Machado A. Fat transplants in male and female genitals. Am J Cosmet Surg 1996;13:109–111.   7. Klein JA, Kassardjian N. Lidocaine toxicity with tumescent liposuction. Dermatol Surg 1997;23(12):1169–1174.   8. Hernández-Pérez E. Practice perspectives: Fat injection in different parts of the body. Dermatol Nurs 1998;10:135–138.   9. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263–267. 10. Hernández-Pérez E, Henriquez A, Gutiérrez J. Clarifying concepts in modern liposuction. Int J Aesth Restor Surg 1994;14:275–280.

E. Hernández-Pérez et al. 11. Jones J, Lyles M. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997; 14:275–280. 12. Johnson G. Autologous fat graft by injection: Ten years experience. Am J Cosmet Surg 1992;4:73–75. 13. Fulton J, Suárez M, Kimball S, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24:857–865. 14. Jackson R. Frozen fat-does it work? Am J Cosmet Surg 1997;14:339–343. 15. Hernández-Pérez E. Bi-level lipoinjection for facial wrinkles. Am J Cosmet Surg 1992;4:73–75. 16. Brandow K, Newman J. Facial multilayared micro lipoaugmentation. Int J Aesth Restor Surg 1996;4:95–110. 17. Reed HM. Augmentation phaloplasty with girth enhancement employing autologous fat transplantation: A preliminary report. Am J Cosmet Surg 1994;11:85–90. 18. Sito G, Sorrentino L. The mushroom technique for penile enhancement. Am J Cosmet Surg 1998;15:165–166. 19. Allende I. El plan infinito. Diana Literaria, México 1992.

History of Breast Augmentation with Autologous Fat

30

Melvin A. Shiffman

30.1  Introduction There has been some controversy about the use of auto­ logous aspirated fat for mammary augmentation. The complaint has been that small calcifications can occur in the breast that is indistinguishable from cancer and may prevent the diagnosis of cancer.

30.2  Historical Contributions Czerny (1) reported the first use of autogenous fat (a lipoma) in breast reconstruction. Lexer (2) described the removal of the glandular breast in a patient with chronic cystic mastitis and reconstruction with fat rotated from the axilla. May (3) reported on a patient with bilateral breast reconstruction using a free fat autograft on one side and a free fascia-fat autograft on the opposite side. Bames (4) utilized fat from the buttocks denuded of epidermis in the breast and found 40% loss of volume because of fat liquefaction. By placing the graft with its dermal side in contact with the breast tissue and the fascial side in contact with the pectoral fascia, there was about 90% graft survival. Reversal of the placement resulted in 60% survival. Peer (5) stated that dermal-fat grafts provide a readily available transplantation material for establishing normal contour in small breasts instead of foreign implants. Schorcher (6) reported autogenous free fat transplan­ tation to treat hypomastia. He noted that the connective

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA, 92780-2302, USA e-mail: [email protected]

tissue elements remained intact with fat shrinkage to 25% of the original size by 6–9 months. He believed that if the graft was in several pieces, it would receive better nourishment for the recipient site.

30.3 Recent History with Liposuctioned Fat Bircoll (7) was the first to inject autologous fat from liposuction to augment the breast. This helped avoid the complications of breast prostheses (8). He used small droplets of fat (1 cc for each deposit), with a maximum of approximately 130 cc (9). Bircoll and Novack (10) described the use of insulin to pretreat the fat in order to increase the survival percentage. Their report concerned one patient who had autologous fat injection into one breast to allow better symmetry with the opposite reconstructed breast (removed for cancer and reconstructed with transverse abdominal rectus flap). Asken (11) reported the use of autologous fat obtained by liposuction to augment the hypoplastic breast. He advised the injection of fat to be performed on withdrawal to avoid a large amount of fat in one location. Johnson (12) reported more than 50 augmentation mammoplasties performed by macroinjection from liposuctioned fat. Krulig (13) reinjected fat into the breast area and noted more than 50% resorption. In a panel discussion at a meeting of the American Society for Aesthetic & Plastic Surgery, Bircoll (14) reported calcifications in three patients following breast augmentation with fat. All were biopsied and showed normal fat. Ousterhout (15) felt that the audience did not agree with the procedure in light of the calcifications and stated, “….. to create calcifications

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_30, © Springer-Verlag Berlin Heidelberg 2010

223

224

in the breast by fat injections could cause considerable dilemma in mammogram diagnosis and possibly a missed malignancy diagnosis if each area of calcification was not biopsied.” There followed a flurry of letters in The Plastic and Reconstructive Surgery Journal. Linder (16) stated that fat necrosis may require removal of some of the breast as calcifications may occur in areas of fat necrosis, inflammatory reaction may produce a tumor-like mass, and “… extreme reservation should be exercised in performing this procedure in the breast.” Ettelson’s (17) impression was that “… preoperative and postoperative results both in the anterior and lateral views are virtually interchangeable as far as I am concerned. I am frankly shocked that the Journal would publish an article with such an unimpressive result.” Hartrampf and Bennett (18) had the impression that the fate of nonvascularized fat in the breast is fat necrosis and this causes thickening and hardening which are clinically indistinguishable from carcinoma. Also, calcifications can occur in areas of fat necrosis. He stated that “… injection of any material into the breast, including autogenous fat, should be condemned.” Baibak (19) complained about Bircoll’s report (14) that there was no documentation of any change in the overall appearance of the patient. Bircoll (20) responded by stating that no patient developed hard lumpy breasts. Calcifications in two patients occurred within 3 months of fat transplantation and the calcifications were in the fat tissues surrounding the breast which is distinguished by comparison with preoperative mammograms. Calcifications that remain stable can be observed rather than removed and the calcifications in areas of micronecrosis are distinguishable from carcinoma. Microcalcifications occur following breast augmentation with implants, open and closed capsulotomy, and breast reduction. As a new technique, the problem of microcalcifications in fat augmentation of the breast should be fully evaluated and understood before discarding the procedure. Bircoll (21,22) reported an estimate of 1.4% microcalcifications following fat augmen­tation of the breast which are periparenchymal and were not multidensity, rod-like, punctuate, or branching spicules. Miller et al. (23) noted calcifications on mammogram in 3 (12.5%) out of 24 patients who had undergone reduction mammoplasty. These post surgical calcifications all had a benign appearance. Brown et al. (24) reported that there were asymmetric densities on mammograms in

M. A. Shiffman

approximately 50% of patients who underwent reduction mammoplasty. Out of 42 patients, a few developed calcifications on mammogram during the first year and over 50% had calcifications after 2 years. The calcifications were coarse and usually occurred in the periareolar and inferior portions of the breast. Only one patient with calcifications required biopsy. They concluded that “knowledge of the expected mammographic alterations and their time course may help to distinguish between postoperative change and carcinoma, and thus eliminate the need for biopsy in some cases.” Mitnick et al. (25) studied with mammograms 152 patients who had reduction mammoplasty. The incidence of ­calcifications was 24.3%. The calcifications were mainly rounded and well formed with occasional lucent ­center. Gradinger (26) declared that “The use of the autologous fat injection for breast augmentation as advocated by Bircoll (14) is deplored because some patients can develop calcifications and esthetic results are marginal.” Grazer (27) continued to denounce the procedure when he stated that “Autologous fat graft­ ing should never be used as a breast augmentation procedure.… Calcifications have been found to be a problem in some patients, masking malignant and prema­lignant changes. Biopsies must be performed in patients with nodules, pain, or calcification … the aesthetic results are marginal if large-volume augmentation is required.” Pitman (28) opined that the “… presence of calcifications in the breasts of injected patients makes the technique unacceptable.” The Society of Plastic and Reconstructive Surgeons (ASPRS) produced a Position Statement on 1 October 1992, which stated that the society (ASPRS) “strongly condemns the use of fat injections for breast enlargement, warning that the procedure may hamper the detection of early breast cancer, or result in a false-positive cancer screening. Furthermore, women who seek the procedure for breast enlargement are sometimes not informed that much of the injected fat will die, causing scar tissue and calcifications … In a worst case scenario, a patient may face painful exploratory surgery or even mastectomy because of an uncertain mammography result.” It is this author’s opinion that medical legally it would be a breach of the standard of care to do a “mastectomy” because of an uncertain mammography result. Stereot­ actic needle biopsy is simple, accurate, and almost painless. “Exploratory surgery” would be ­virtually unnec­essary in the hands of a capable and knowledgeable mammographer and surgeon.

30  History of Breast Augmentation with Autologous Fat

An article appeared in Cosmetic Surgery Times (1998) quoting Robert W. Alexander, M.D. who de­­ scribed satisfactory results with 60–70% fat retention from autologous fat injection for breast augmentation. There was a 3–4% incidence of small fat cysts, or spherical calcifications which were easily differentiated mam­ mographically from malignancy. What followed were letters objecting to the article and procedures. Lynch (President of the American Society of Plastic and Reconstructive Surgery) and Penn (President of the American Society for Aesthetic Plastic Surgery) (29) reiterated the Position Statement of ASPRS (1992). Gorney (30) (Executive Vice President, Marketing Services, The Doctors’ Company) stated that “the instal­ lation of fat grafts in the breast is an extremely poor idea which will lead to highly undesirable consequences … As any sensible surgeon knows, fat grafts to the breast are notoriously unreliable because the vast majority of the material reabsorbs within a matter of weeks to months, and what remains behind is merely the stroma of the cell, which very quickly calcifies and closely ­initiates the appearance of early cancer.” He states that there were four claims (presumably regarding breast fat injection) that were defended by the Doctors’ Company. One was lost, one was tried and won, and two were settled. The Doctors’ Company specifically excludes fat injection to the breast from coverage. Stone (31) stated that he would not incorporate the procedure into his practice because according to him “… injecting auto­ logous fat into the breast” will cause “at some future date mammogram abnormalities” which will “lead to unneeded biopsies” and “my malpractice carrier specifically will not cover the procedure.” The letters regarding the article in Cosmetic Surgery Times were responded to by Schaefer (Editor-in-Chief) (32). She stated that the political scientist John Stuart Mills wrote “If all mankind minus one, were of one opinion, and only one person were of the contrary opinion, mankind would be no more justified in silencing that one person, than he, if he had the power, would be justified in silencing mankind…If the opinion is right, they are deprived of the opportunity of exchanging error for truth: if wrong, they lose what is almost as great a benefit, the clearer perception and livelier impression of truth, produced by its collusion with error.” Breast augmentation with fat has been reported by a number of authors. Da Silveira (33) reported on 31 patients with hypomastia, asymmetry, postgestational involution, and finishing touches to postmammaplasty

225

who had breast augmentation with fat. Edema usually resolved after 3–4 weeks and resorption of fat ends around the third or fourth month. Complications included resorption, steatonecrosis, one case of calcification in the wall of cyst, and one patient with microcalcifications characteristic of benign disease. There is a need for adequate donor areas and the patient may need more than one lipograft. Fischer (34), Fournier (35, 36), Hin (26), and Fulton (37, 38) have reported success with fat transfer to augment the breast.

30.4  Discussion Those same surgeons, who denounce fat augmentation of the breast because of calcifications, performed breast augmentation with silicone gel implants which have up to 70% capsule contracture rate requiring surgical correction. The silicone covered saline implants presently used have approximately 10% incidence of contracture (smooth implants) and 9% incidence of rippling (textured implants), most of which will require surgical intervention. The fibrous capsule around the implant does develop calcifications which are readily distinguishable from malignant calcification both by position and character. Breast reduction surgery is still performed with a small but significant incidence of stippled calcifications from fat necrosis “within the breast parenchyma.” Despite their appearance some months after surgery, these may need to have stereotactic biopsy because they are within the breast. How­ ever, this does not contraindicate breast reduction by any surgeon’s standard. Patients who desire fullness of the breasts, not large breasts, are satisfied with the procedure. To some physician observers, this may appear to be “unimpressive” but they fail to realize that it is the patient who determines whether or not the surgery is adequate. Many patients fear the problems of implants such as scars, asymmetry, postoperative pain, deflation, capsule contracture, rippling, decreased mammography ­sensitivity, the possible need for repeat surgery, and “possi­ble” autoimmune disease. Fat injection into the breast results in very little discomfort. Lumps which appear are the result of oil cysts from too much fat injected into one area. Calcifications, which may occur months after the injections, can be

226

sampled, if the physician and patient desire, by the simple expedient of stereotactic core needle biopsy. Open biopsy is unnecessary if the core shows benign tissue. These calcifications can then be followed by yearly mammograms just as if done with other surgeries causing microcalcifications. Properly trained and experienced mammographers should be able to distinguish benign from malignant calcifications in the breast. The most important fact is that since 1989 most surgeons performing augmentation of the breast with fat are placing the fat outside the breast parenchyma. Up to 300 mL of fat equally divided is placed into three areas; subpectoral space, intrapectoral muscle, and submammary space. The arguments concerning alteration of the breast parenchyma is now moot except for the accidental placement of fat into the breast itself. It has been reported (39) that the use of the non surgical Brava breast suction system can increase space and vascularization in order to increase the survival of fat transferred to the breast for augmentation. In reference to the article by Spear et al. (40) regarding fat injection to correct contour deformities in the reconstructed breast, it is refreshing to see a positive account of fat transfer to the breast area without the con­ troversy that has given fat augmentation of the breast an undeserved bad name. More recently, Coleman and Saboeiro (41) retrospectively studied their patients with fat transfer to the breast area and found no problem diagnosing breast cancer. Coleman and Saboeiro (41) reported success in fat transfer to the breast and concluded that it should be considered as an alternative to breast augmentation and reconstruction procedures. Two of seventeen patients had breast cancer diagnosed by mammography, one 12 months and one 92 months after fat transfer to the breast.

References   1. Czerny A. Plastischer ersatz der brustdruse durch ein lipoma. Chir Kongr Verhandl 1895;2:216.   2. Lexer E. DeGesamte Weiderherstellungs-Chirurgie. Liepzig, J.B. Barth, 1931.   3. May H. Transplantation and regeneration of tissue. Penn­syl­ vania Med J 1941;45:130.   4. Bames HO. Augmentation mammoplasty by lipo-transplant. Plast Reconstr Surg 1953;11:404–412.   5. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18(4):233–250.

M. A. Shiffman   6. Schorcher F. Fettgewebsver pflanzuang bei zu kneiner. Brust Munchen Med Wochenschr 1957;99(14):489.   7. Bircoll MJ. New frontiers in suction lipoectomy. Second Asian Congress of Plastic Surgery, Pattyea, Thailand, 1984; 80(4):647.   8. Bircoll M. Autologous fat tissue augmentation. Am J Cosm Surg 1987;4(2):141–149.   9. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79(2):267–271. 10. Bircoll M, Novack BH. Autologous fat transplantation employing liposuction techniques. Ann Plast Surg 1987; 18(4):327–329. 11. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosm Surg 1987;4(2):111–120. 12. Johnson GW. Body contouring by macroinjection of autogenous fat. Am J Cosm Surg 1987;4(2):103–109. 13. Krulig E.. Lipo-injection. Am J Cosm Surg 1987;4(2): 123–129. 14. Bircoll M. Panel on fat injection. American Society for Aesthetic Plastic Surgery. Los Angeles, March 26, 1987. 15. Ousterhout DK. Breast augmentation by autologous fat injection (Letter). Plast Reconstr Surg 1987;80(6):868. 16. Linder RM. Fat autografting (Letter). Plast Reconstr Surg 1987;80(4):646–647. 17. Ettelson CD. Fat autografting (Letter). Plast Reconstr Surg 1987;80(4):646. 18. Hartrampf CR Jr, Bennett GK. Autologous fat from liposuction for breast augmentation (Letter). Plast Reconstr Surg 1987;80(4):646. 19. Baibak GJ. Liposuction. Plast Reconstr Surg 1987;80:647. 20. Bircoll M. Reply (Letter). Plast Reconstr Surg 1987; 80(4):647. 21. Bircoll M. Autologous fat transplantation to the breast (Letter). Plast Reconstr Surg 1988;82:361–362. 22. Bircoll M. Autologous fat transplantation: An evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosm Surg 1988;5(4): 283–288. 23. Miller CL, Ferg SA, Fox JW IV. Mammographic changes after reduction mammoplasty. Am J Roentgenol 1987;149:35–38. 24. Brown FE, Sargent SK, Cohen SR, Morain WD. Mammo­ graphic changes following reduction mammoplasty. Plast Recontr Surg 1987;80:691–698. 25. Mitnick JS, Roses DF, Harris MN, Colen SR. Calcification of the breast after reduction mammoplasty. Surg Gynecol Obstet 1990;171:409–412. 26. Gradinger GP. Breast augmentation by autologous fat injection (Letter). Plast Reconstr Surg 1987;80(6):868–869. 27. Grazer FM. Special reconstruction and therapeutic procedures. In: Grazer FM (ed), Atlas of Suction Assisted Lipo­ ectomy in Body Contouring. New York, Churchill Livingstone 1992, pp. 319–329. 28. Pitman GH. Odds and ends: Lipomas, flap debulking, lymphedema, fat reinjection, and additional complications. In: Pitman GH (ed), Liposuction & Aesthetic Surgery. St. Louis: Missouri, Quality Medical Publishing, 1993. 29. Lynch DJ, Penn JG. Fat injection to breast compromises safety. ASPRS and ASAPS do not recommend procedure. Cosm Surg Times 1998;2(6):3. 30. Gorney M. Fat injection to breast compromises safety. Commenting on calcifications. Cosm Surg Times 1998; 2(6):3.

30  History of Breast Augmentation with Autologous Fat 31. Stone A. Fat injection to breast compromises safety. Ques­ tioning the procedure. Cosm Surg Times 1998;2(6):3. 32. Schaeffer I. Fat injection to breast compromises safety. Editorial response. Cosm Surg Times 1998;2(6):3. 33. da Silveira Jacques W. Breast augmentation with autologous lipograft. Am J Cosm Surg 1998;15(2):109–115. 34. Fischer G. Autologous fat implantation for breast augmentation. Workshop on Liposuction and Autologous Fat Reimplant. Isola d’Elba, September 1986. 35. Fournier PF. Breast augmentation with fat transfer. In: Fournier PF (ed), Body Sculpting. U.S.A., Samuel Rolf International 1987, pp. 65–70. 36. Fournier PF. The breast fill. In: Fournier PF (ed), Liposculpture: The Syringe Technique. Paris, Arnette 1991, pp. 357–367.

227 37. Fulton JE. Stabilization of fat transfer to the breast with autologous platelet gel. Int J Cosm Surg 1999;7(1):60–65. 38. Fulton JE. Stabilization of fat transfer to the breast with autologous platelet gel. In: Shiffman MA (ed), Autologous Fat Transplantation. New York, Marcel Dekker 2001, pp. 207–218. 39. Schwanke J. New reasons to consider breast augmentation using autologous fat. Cosm Surg Times 2006;9(6):29–29. 40. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg 2005;116(5):1300–1305 41. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg 2007;119(3): 775–785.

Breast Augmentation with Autologous Fat

31

Tetsuo Shu

31.1  Introduction Liposuction was introduced in 1975 by Fischer (1). The fat retrieved from liposuction ultimately began to be used for augmentation of tissues. Since the introduction of tumescent liposuction by Klein (2), there has been less blood loss in liposuction and more fat retrieval. The author has been performing breast augmentation with autologous fat for over 20 years. In 1989 the author stopped injecting the fat into the breast but injected it into the surrounding tissues with great success.

31.2  Technique Intravenous sedation or general anesthesia is used in all patients. The fat retrieved by liposuction should be washed with normal saline and squeezed in cheesecloth to wash out the blood and broken fat cells (Fig. 31.1). Fat should be injected as pure fat without contaminants (Fig. 31.2). The amount of fat injected into each breast depends on the original size of the breast. If the breast is large and ptotic, up to 300 mL of fat is injected into each breast. The fat is injected while withdrawing the 3 mm cannula in linear fashion to prevent pooling of the fat, which may result in cyst formation and necrosis with calcifications. The fat is injected in one plane through radiating tunnels. The layers of injection are the submuscular, muscular, subglandular, and subcutaneous

T. Shu Daikanyama Clinic, 4F, 1-10-2 Ebisu-Minami, Shibuya-ku, Tokyo, Japan 150-0022

planes. The fat areas are then massaged to help ­distribute the fat evenly. Massage prevents cyst formation.

31.3  Case Reports Case 1 (Fig. 31.3): This patient had hypoplastic breasts. Multiple fat transfers to augment the breasts were performed over a period of 4 years. Fat was taken from the multiple sites in the body and transferred to both breasts in four sessions (Table 31.1 and 31.2). The breasts were enlarged slowly over a period of time until the patient was satisfied. Case 2 (Fig. 31.4): This patient had right breast lumpectomy for cancer. Fat was retrieved from multiple areas and there were four sessions of fat transfer to the right breast performed over a four and a half year period (Table 31.3). The fat filled the breast so that the breasts were almost equal. Case 3 (Fig. 31.5): This patient had breast implant removal from prior augmentation after three sessions over 3 years, during which fat was taken from multiple areas and transferred to both breasts (Table 31.4). The result was very full, normal appearing breasts.

31.4  Discussion Fat transfer to the breast is relatively easy. The fat should be washed thoroughly to remove blood products before transfer. Injection of fat should be through tunnels at various levels outside the breast gland. Care should be taken that the fat is not injected into pools and the fat is massaged after injection so that it will not necrose and calcify. The results of fat augmentation of the breast have been excellent with minimal complications.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_31, © Springer-Verlag Berlin Heidelberg 2010

229

230

a

T. Shu

b

d

c

e

g

f

Fig. 31.1  Preparation of aspirated fat. (a) Equipment for fat transfer to augment the breasts. (b) Aspirated fat poured into cheesecloth. (c) Cheesecloth wrapped around fat and squeezed

to remove excess liquid. (d) Excess fluid cleaned from around cheesecloth. (e) Fat is now very thick. (f) Fat removed with a spoon. (g) Fat inserted into syringe

Fig. 31.2  Clean fat in syringes ready for insertion

Fig. 31.3  (a1, a2) Preoperative. (b1, b2) One year postoperative after first fat transfer and before second fat transfer. (c1, c2) Three years postoperative after second fat transfer and before the third fat transfer. (d1, d2) Four years postoperative after third fat transfer and before fourth fat transfer. (e1, e2) Postoperative mammograms showing darkened areas of fat transfer posterior to breast gland and no calcifications

31  Breast Augmentation with Autologous Fat

a1

b1

b2

231

c1

c2

a2

d1

d2

e1

e2

232

T. Shu

Table 31.1  Case 1: Breast augmentation with fat. Sites of fat retrieval and amounts injected into breasts in four sessions 1st Injection 2nd Injection 3rd Injection 4th Injection

1992/3/17 1994/3/29 1995/9/14 1996/3/1

Right site (mL)

Left site (mL)

Liposuction

R: 140 R: 180 R: 50 R: 54

L: 100 L: 120 L: 50 L: 54

Abdomen:450, hip:800 Thighs 1,400 Back,waist:500 Legs:330

Table 31.2  Case 1 measurements before fat transfer and after each fat transfer Before 2nd Surg before 3rd Ope before 4th Ope before

Height

Weight

Breast top

Breast under

Abdomen

Abdomen waist

Hips

160 160 160 160

46.5 47.0 47.0 47.5

75.0 81.4 79.3 79.2

67.0 67.5 68.0 66.6

76.1 73.0

67.5 67.0

88.5 83.0

Fig. 31.4  Breast fat transplantation after breast cancer operation. (a) Preoperative (b) Two years after two injections of fat and before third injection. (c) Four and a half years after three fat injections and before fourth injection. (d) Six and a half years after four fat injections. (e1–e3) Mammograms 1: Pre­ operative. 2: Two years after three fat injections. 3: Six and a half years after four fat injections. (f1–f3) 1: Preoperative skin adherent to ribs. 2: Injection of fat between skin and ribs to detach the adhesions. 3: After fat injections were completed

a

c

b

d

31  Breast Augmentation with Autologous Fat Fig. 31.4  (continued)

233

e1

f1

e2

f2

e3

f3

Table 31.3  Case 2: Right breast augmentation with fat following left breast lumpectomy for cancer. Sites of fat retrieval and amounts injected into breasts in four sessions 1st Injection 2nd Injection 3rd Injection 4th Injection

1997/10/8 1998/1/16 1999/5/17 2002/3/19

Right (mL)

Left (mL)

Liposuction

R: 122 R: 175 R: 75 R: 50

L: 187 L: 233 L: 200 L: 75

Hips, waist, Thighs Abdomen Arms, back

234

T. Shu

a

c

b

d

e

Fig. 31.5  (a) Pre fat transfer with 115 mL breast prostheses. (b) One month postoperative. (c) Six years after three fat injections. (d) Removal of breast prostheses 5 years after fat transfers were

begun. (e) Ten and a half years after fat transfers. (f) Mammography. 1: Five years after three fat transfers. 2: Nine years after fat transfers and removal of breast prostheses

31  Breast Augmentation with Autologous Fat Fig. 31.5  (continued)

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f1a

f1b

f2a

f2b

Table 31.4  Case 3: Breast augmentation with fat transfer and then removal of breast augmentation prostheses. Sites of fat retrieval and amounts injected into breasts in three sessions over 3 years 1st Injection 2nd Injection 3rd Injection

1991/4/5 1993/4/29 1994/8/2 1996/4/3

Right (mL)

Left (mL)

Liposuction

  55 180 145

  55 160 112

Abdomen, silicone bag 150 mL Thighs, legs Abdomen, hips, waist Removal of silicone bag

References 1. Fischer G. Surgical treatment of cellulitis. Third International Congress of International Academy of Cosmetic Surgery. Rome, May 31, 1975. 2. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263–267.

Fat Transfer and Implant Breast Augmentation

32

Katsuya Takasu and Shizu Takasu

32.1  Introduction

32.2  Technique

Since the controversy over the safety of silicone-gelfilled breast implants, inflatable saline-filled implants are popular materials for augmentation mammoplasty in Japan. Saline solution is less viscous; therefore, saline-filled implants somehow provide a firmer and less elastic touch to the overlying breasts when compared with silicone-gel implants. This shortcoming has caused dissatisfaction among patients, especially when saline-filled implants are used for very small breasts. Many of the Japanese patients seen in our clinic are skinny, and their breasts are extremely hypoplastic. The authors have found that saline-filled implants are palpable through their thin chest skin even though they are placed under the pectoral muscles. Fat injection has been utilized for breast augmentation (1, 2). Although some of the results reported have been encouraging, this technique is not free of complications. Clinical trials have shown problems related to unpredictable postoperative resorption, fat necrosis, cal­ cification, and cyst formation (3–5). They have found the rationale behind transplanting a limited amount of fat in an area in contact with well-vascularized tissue (6–8). The major problem lies in injecting enough fat to obtain the desired volume. This is particularly so, when fat transplantation alone is used for patients with small breasts. According to the authors, the combination of the above two procedures might eliminate the problems associated with either of the approach.

The procedure is performed under general anesthesia. Fat is harvested from convenient sites, such as the abdomen, buttock, and thighs, using a suction machine. Tumescent technique is used to fill the donor areas (9). The aspirate is rinsed repeatedly with saline solution to remove the blood component. The collected fat is packed into multiple 20 mL syringes for injection. Through a small stab wound along the inframammary fold, the fat is then injected into the breast using a fine blunt-tip cannula (2.0 mm in diameter). It is important to inject a small amount of fat at each location in order to secure sufficient nutrition for the cells (1, 2, 6–8). The fat is therefore grafted into multiple areas of the entire breast, including the subcutaneous tissue, pectoral fascia and the pectoral muscle. At the completion of the injection, the breast is massaged manually in order to evenly spread out the injected material. A transverse incision is made in the axilla and the dissection is performed under the pectoral muscle. At the beginning of the operation Klein’s solution is infiltrated into the subpectoral space in order to minimize bleeding during the dissection. An inflatable silicone bag implant is then inserted into the submuscular pocket and the implant is filled with saline.

K. Takasu (*) Takasu Clinic, 2-14-27 Akasaka, Kokusai-Shin-Akasaka Building, Higashi-kan 2F, Minato-ku, Tokyo 107-0052, Japan e-mail: [email protected]

32.3  Clinical Case A 23-year-old Japanese female presented with mammary hypoplasia (Fig. 32.1), and she desired considerable enlargement of the breast. Saline-bag implantation was definitely indicated and the size of implant required should be more than 300 mL to achieve the desired

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_32, © Springer-Verlag Berlin Heidelberg 2010

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K. Takasu and S. Takasu

Fig. 32.1  Preoperative view. A 23-year-old Japanese female with mammary hypoplasia. Her abdomen is also thin. Note the fatty buttock and thigh

Fig. 32.2  One-week postoperatively. Note significant fullness of her breasts

volume. However, her small mammary glands and thin subcutaneous tissue did not seem thick enough to conceal the firm touch of saline-filled implants. It was, therefore, suggested that the combined use of fat injection as an adjacent procedure with the inflatable implant might be of benefit to provide a natural look and palpation to her augmented breast. Four hundred milliliters of fat were collected by means of liposuction from her abdomen, buttock, and

bilateral thighs. Two hundred milliliters of aspirate were injected into each breast area. Using the standard transaxillary approach, 250 mL saline-filled implants were inserted under the pectoral muscle. Her postoperative course was uneventful. Immediately after the surgery, her breast enlargement was somewhat overwhelming (Fig. 32.2). The 1-week postoperative CT scan showed significant thickening of the breast tissue overlying the prosthesis which

32  Fat Transfer and Implant Breast Augmentation

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a

b

c

d

Fig. 32.3  (a) Preoperative CT scan. (b) One-week postoperative CT scan shows the thickening of breast tissue due to fat injection and inflammatory reaction. Note the saline-filled implant under the pectoral muscle. (c) Two-month postoperative CT scan. Note

significant volume reduction (about two-thirds) of breast tissue when compared with 1-week postoperative CT scan. (d) Twoyear postoperative CT scan. Note slight thinning of the breast tissue when compared with 2-month postoperative CT scan

was placed under the pectoral major muscle (Fig. 32.3). Over the course of the following 3 weeks, there was observable regression in the fullness of her breast. The breast had lost more than half of the injected volume by that time. Thereafter, the resorption seemed to slow down. The 2-month postoperative CT scan showed no cyst formation in the breast (Fig. 32.3). The breast tissue lost significant volume, about two-thirds of the transplanted fat, when compared with that seen 1 week postoperatively. This volume loss was obvious on the clinical observation (Fig. 32.4). Only a small amount of the injected fat was retained in the subcutaneous tissue and breast tissue. Nonetheless, the remaining fat helped to camouflage the saline-filled implants. The patient was satisfied with her breasts and also pleased with the body contour as a result of liposuction. Both clinical observation and CT scan demonstrated that this benefit lasted for at least 2 years (Figs. 32.3, 32.5).

32.4 Discussion The technique of transplanting autologous fat obtained via liposuction has been generally accepted for soft tissue augmentation. Many reports have shown that much, if not all, of the transplanted fat is retained when small quantities are placed in adequately vascularized areas (4, 6–8). Accordingly, when this method is used for breast augmentation, the injected amount needs to be limited to avoid remarkable resorption related to liquidization, necrosis and cyst formation. However, there has been no definitive answer to the volume limit of how much can be transplanted with success. Bircoll described that this volume limitation appeared to be about 130 mL, while Fulton (2) mentioned that his limit was 300–350 mL. Although the illustrations of the latter report showed attractive improvement on the breast appearance, the X-ray study demonstrated the

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K. Takasu and S. Takasu

Fig. 32.4  Two-months postoperatively. Note significant volume reduction of her breasts when compared with that of 1-week postoperatively

Fig. 32.5  Two-years postoperatively. Further volume decrease, although little, is noticed when compared with that of 2-months postoperatively. Note improvement of lower body contour as well as breast augmentation

development of eggshell calcification around the lipid droplets. This suggests that the amount of fat injected was too much, resulting in liquifaction and/or necrosis of injected fat. The authors transplanted 200 mL of fat, which lost more than two-thirds of the volume during the follow-up period. This resorption was much more than was expected. The amount of injection, 200 mL, was considered too large for the small breast of our patient. The size of the breast is an important issue to determine the injection volume. The smaller the breasts are, the smaller the amount of fat injection should be. Although the volume retention of the transplanted fat was small in our case, the remaining fat provided

sufficient thickness to the breasts and prevented the firm feel of the breasts resulting from saline-filled implants. This method of using fat injection together with saline-filled breast prostheses was found very useful in producing a natural look and soft touch of the breast. Unfortunately, this procedure can not be used for every case. The search for donor site can be a problem because many of the patients seeking augmentation mammoplasty, seen in our clinic, are very thin. The combined method described here is useful for those individuals who benefit from fat injection for breast augmentation as described by Fulton (2). The candidates

32  Fat Transfer and Implant Breast Augmentation

should have a sufficient amount of disharmonious obesity. Fat transplantation alone, as a single procedure, is indicated for a woman who is satisfied with a small to modest size increase; for example, increase by a single bra size or less (1, 2). In contrast, with the presented technique a modest to even large-size augmentation of small breasts can be obtained.

References 1. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79(3):267–271. 2. Fulton JE. Breast contouring by autologous fat transfer. Am J Cosmet Surg 1992;9(3):273–279.

241 3. Ersek RA. Transplantation of purified autologous fat: A  3-year follow-up is disappointing. Plast Reconstr Surg 1991;87(2):219–227. 4. Horl HW, Feller AM, Biemer E. Technique for liposuction fat reimplantation and long-term volume evaluation by magnetic resonance imaging. Ann Plast Surg 1991;26(3): 248–258. 5. Har-Shai Y, Lindenbaum E, Ben-Itzhak O, Hirshowitz B. Large liponecrotic psuedocyst formation following cheek augmentation by fat injection. Aesthetic Plast Surg 1996; 20(5):417–419. 6. Bircoll MA. Nine-year experience with autologous fat transplantation. Am J Cosmet Surg 1992;9:55–59. 7. Niechajev I, Sevcuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 8. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin 1990;8(3):523–537. 9. Klein J. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16(3):248–262.

33

Fat Transfer with Platelet-Rich Plasma for Breast Augmentation1 Robert W. Alexander

33.1  Introduction It is generally acknowledged that tissue augmentation with autologous elements is considered the ideal choice for transplantation and volume augmentation surgery. As is well recognized, the ideal graft tissue should offer the standard features of being readily available, have low antigenicity, minimal donor-site morbidity, predictability and reproducible retention, and should avoid disease transmission. Autologous fat grafting meets all of these fundamental criteria, and therefore represents a very appealing resource for soft tissue volume augmentation. It is well established that autologous tissue grafts survive the harvest and transfer procedures to a healthy recipient site by the principles of induction and conduction (1–7). Autologous fat grafting has rapidly become a very important treatment modality over the past 15 years. Fat tissue survival, although well documented, has often been reported as somewhat unpredictable in its effectiveness or longevity. It was not until the early 1990s that many surgeons recognized the actual mechanism of liposuction surgery and harvest. Since the advent of low pressure, closed syringe system harvest and super smooth harvest and transfer cannulas, fat grafting (large and small volumes) has become one

The author has no financial interest in Harvest Technology, Tulip Medical, or Shippert Medical companies.

1

R. W. Alexander Department of Surgery, University of Washington, Seatle, WA, USA 3500 188th St., S.W. Suite 670, Lynnwood, WA 98037, USA e-mail: [email protected]

among the most frequently utilized therapy in face and body contouring procedures (8–13). Gradual standardization of consistent harvesting, manipulations, and transfer protocols is improving the ability to accurately predict volume enhancements and appreciate the long-term survival of the grafted tissues (14). Many opinions expressed in the surgical community regarding the efficacy of autologous fat grafting seem in conflict with our experiences relating to the amount of graft retained for long-term success (1, 4, 5, 8, 15, 16). Most of those claiming high resorption rates (40–60%) do not account for the fluid volumes needed to transport the harvest and transfer tissues. For example, if the harvested and transferred graft materials are comprised of 30% fluid and 60% cellular elements, the observed reduction in mass volume seen in the first few weeks most likely represents the gradual extraction of the carrier fluids, and is not representative of the failure of graft cellular element survival. In vitro studies demonstrate very high survival rates in tissue culture. It appears that survival following low pressure suction harvest is in the high 90 percentile of intact cells observed (4, 5, 11, 13, 17, 18). There are many factors that appear to exert substantial influence on the success of autologous fat transplantation. Some of these include the patient’s systemic health, genetic predisposition for cellular fat storage from the preferred donor sites (so-called “primary” fat deposit locations), pre- and postgrafting nutrition, basal metabolic rate, use of minimally traumatic harvest and handling techniques, proper preparation of the recipient bed, and relative early graft immobilization in the recipient sites during the initial graft acceptance and healing cascade (9). The value of additives to autologous fat grafts is becoming much better documented and understood. With the ability to favorably influence the body’s wound-healing

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efforts through the use of such additives, recognition of the value, safety, and predictability in autologous fat grafts has greatly increased (1, 10). In addition, perhaps one of the most important advancements in the utilization of adult lipocytes and stimulating mesenchymal stem cell component as fillers has been the utilization of platelet-derived factors added to the harvested graft materials (1). Platelets are living, but terminal cytoplasmic portions of marrow megakaryocytes. They have no nucleus for replication and typically last for 5–9 days in vivo. For many years, their role was considered only to contribute to the hemostatic process, in which they become tacky and adhere together to form a plug. They are now understood to extrude important initiators of the coagulation cascade. In more recent research, it is known that they also actively extrude multiple growth factors that are very important in early wound-healing processes. In response to platelet-to-platelet or platelet-to-connective tissue contact, the platelet cell membrane is “activated” (Fig. 33.1) to release these products from the alpha granules via active extrusion. When these extruded growth factors are released, histones and carbohydrate chains are added to receptor sites, thereby creating their unique chemistries and making them “active” growth factors. It is important to have this basic appreciation of the contribution that plateletderived products make in wound healing, and to extrap­ olate this into autologous fat graft acceptance. Since the advent of a very convenient harvest and preparation system for the isolation of platelet-rich plasma (PRP) (Harvest Technology), the ability to use PRP (also known as APC – autologous platelet concentrate) has become a reality in the outpatient surgical and hospital settings (10). As is scientifically clearly appreciated, wound healing is initiated in a relatively complex environment, typically started and maintained from elements specifically derived from platelets. Besides the initiation of coagulation processes, the platelets undergo a degranulation process that releases a complex group of growth factors and cytokines (peptides) essential for woundhealing mechanisms. The platelet-derived growth factors (PDGF) are characterized as regulatory peptides that have specific tissue site receptors (19–22). These serve to regulate and deregulate cellular activity, enzymes, angiogenic factors, anti-angiogenic factors,

R. W. Alexander

a

b

c

Fig. 33.1  (a) Platelets. (b) Platelet activation. Receptor site and contact activation (platelet-to-platelet and platelet-to-fibrous matrix) to initiate growth factor release and healing cascade mechanisms. (c) Activated platelets

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

induction agents for gene expression, and much more (21, 23–25). Initial studies demonstrating the powerful expression of PDGF have been reported for bone healing (also from a mesenchymal-derived stem cell set) (3). It is now accepted that use of the platelet-derived factors in autologous fat transplantation and wound healing are of equal importance. It is beyond the scope of this chapter to provide a complete explanation of the biology of wound healing, but it is important to express the potential enhancement of known pathways to improve and enhance the survivability of grafted cells for long-term volume success. It is important to have a basic understanding of the scientific relevance of utilization of PRP in autologous fat grafting techniques (26–29). The potential of enhanced viability and clinical success of using transplanted fat in both small and large volume applications explains the importance of such combination to promote natural wound-healing mechanisms. The introduction of such concentrated growth factors during the preparation and transfer phase may greatly potentiate wound healing through normal physiologic mechanisms that control cellular recruitment, migration, and differentiation within the recipient sites. In addition, such additives contribute to the induction and conduction aspects of the undifferentiated mesenchymal stem cell population of both the donor and the recipient and, thereby, may significantly contribute to the overall graft success. The author’s experience suggests that use of PRP and calcium chloride with or without thrombin increases the long-term retention of the transplanted fat cells and increases the rate of revascularization and survival of the transplanted cells (10). This enhancement of the healing rate and graft acceptance is thought to decrease the potential for liponecrosis, lipid cyst formation, and the incidence of spherical microcalcifications within the breast tissues (1).

33.2 General Biology of Wound and Graft Healing with PRP The clinical value of PRP as a promoter of wound healing is very well documented (22, 25–30). PRP is rich in both PDGF and transforming growth factor-b 1 (TGF-b1), which are derived directly from degranulating platelets, and which contain the highest

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concentrations of those elements. These growth ­factors are recognized as key elements in initiation and subsequent progression of the wound-healing cascade. The addition of PDGF has been shown to stimulate the actual damaged cytoplasmic membrane repair and permit return to metabolic activity in the in vitro cultured lipocytes, and to synergistically promote the healing of wounds by its ability to restore the plasma’s function (22, 25) (Lyles, Personal Communication). It is also well established that the key cytokines derived from the platelet degranulation processes are intrinsically involved in maintaining the actual healing process. The cytokines most implicated in this wound-healing process are listed in Table 33.1. Both PDGF and TGF-b1 are concentrated in the alpha granule of the platelet, and are released with platelet cellular activation and degranulation. Each has shown a marked beneficial effect on wound healing (10, 31). Following initial extrusion, such factors become complete growth factors via the process of extrusion of the growth factors meeting with histones and carbohydrate side chains in a wound site and resulting in “active” growth factors. As an example of activation, PDGF has a direct mitogenic influence on the target cells by finding specific cell surface receptors, and indirectly enhancing the proliferative response even in cells lacking detectable PDGF receptors (22, 27). Platelets are the richest known source of PDGF, although it has also been identified within macrophages, fibroblasts, and some endothelial cells (30). Likewise, TGF-b1 concentrates are primarily released from the  alpha granule, but have also been isolated in ­macrophages. Since TGF-b1 is chemotactic for the Table 33.1  List of some of the most common platelet-derived cytokines implicated in wound healing Platelet-derived growth factor PDGF aa, bb, ab Transforming growth factor b1, b2 TGF-b1, TGF-b2 Platelet-derived epidermal PDEGF growth factor Platelet-derived angiogenesis factor PDAF Platelet factor 4 PF-4 P-selectin GMP-140 Interleukin 1 IL-1 Fibroblast growth factor FGF Interferons: alpha, gamma IFN-a, IFN-g Insulin-like growth factor IGF

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recruitment of macrophages and fibroblasts, it is also a potent stimulator of granulation tissue formation. Working synergistically, PDGF initially acts as an attractant for monocytes, macrophages, or both, and then becomes an activator to begin production and secretion of additional PDGF into the wound area. This is known as an autocrine amplification system and is important in sustaining the wound-healing processes (1, 22). In autologous fat cell transfer, placement of harvested cells into created potential space (pre-tunneling) permits recipient site cellular contact with graft cells. This tunneling and placement also produces some degree of platelet-containing blood to be released in the field from native sources. The addition of highly concentrated PRP then enhances the activity of these processes, and offers important acceleration of the early inflammatory activities. This complements the native (recipient) site processes started with mild injury. In graft situations, initial wound oxygen concentration is decreased, resulting in relative hypoxic (partial pressure of oxygen of 5–10 mmHg) and acidotic (pH 4–6) conditions within the graft itself. This area is surrounded by recipient tissues that are normal (partial pressure of oxygen 45–55 mmHg) and have a physiologic pH (7.42). With placement of PRP with the graft materials, activity of the lipocytes, mesenchymal stem cell element (in both donor and recipient tissues), interstitial collagen, and fibroblasts are more rapidly activated to respond. The recipient site provides the needed circulation and cellular element access for structural cells, healing capable cells, and intact capillaries. It is in this junctional area that small capillaries develop terminal clots, and offer exposed endothelial cells for revascularization. It has been suggested that this may explain why small aliquots of graft placed in prepared tunnels to provide surrounding native fat cells and stroma, contribute to enhanced graft survival and success. The establishment of oxygen tension potential between the graft and the surrounding recipient bed tissues is capable of inducing macrophage recruitment and promoting angiogenesis by secreting macrophagederived angiogenesis factor and macrophage-derived growth factor (32–34). The angiogenic effect of macrophages is selectively induced by mild hypoxia and may be potentiated by hyperbaric oxygen therapy. In the presence of normal oxygen tensions, the number of fibroblasts, amount of collagen deposit, as well as the number of capillaries can be increased by increasing the

R. W. Alexander

number of macrophages present. Therefore, it can be concluded that the healing potential of a wound is not only influenced by the presence or absence of chemotactic agents, but also by the number of competent cells. Working synergistically, the recipient site conditions, plus the concentrated factors derived from PRP serve to enhance the healing environment. This very complex environment, simplified for the sake of this discussion, represents the basic model of wound healing in any tissue injury. The endogenous system of repair starts, maintains, and promotes repair related to the needs of the injury and offers an opportunity for surgeons to encourage enhanced tissue regeneration and graft tissue acceptance. Use of concentrated platelet gels, “activated” in PRP by the addition of calcium chloride and thrombin, appears to offer a unique biologic sealant and graft carrier (gel) to the recipient sites. This combination has been used extensively in a variety of disciplines with remarkable clinical success (1, 5–7, 16, 21, 26, 27, 35). In the activated PRP (PRP+) graft, the gel matrix may provide some helpful early graft immobilization, known to be contributory to a variety of autologous grafts.

33.3 Autologous Fat Graft Healing Model Some early investigators suggested that some or all trans­ planted mature adipocytes might de-differentiate into a precursor phenotype, or might maintain characteristics of donor-site adipose tissue. Work by Jones et al. clearly demonstrated in vitro, that low pressure, syringe harvested fat did not regress, but did become metabolically active to begin to store lipid within the cells (31). In addition, considering the fact that autologous fat grafts do best where existing adipose tissues exist, it is considered very likely that additional induction stimuli within the recipient and/or donor-cell populations do exist. This promotes differentiation of precursor elements into new adipocytes, making additional graft cellular tissues within the recipient bed (36–39). Later studies, which involved the placement of PRP into the cell culture, have further demonstrated actual repair of damaged cytoplasmic membranes to an intact state, metabolically active. In addition, it appeared that some induction of pluripotential cells into mature adipocytes was stimulated, and liponeogenesis was

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

initiated in a three-dimensional tissue culture matrix (Lyles, Personal Communication). In the autologous fat graft, it is convenient to characterize three stages of graft acceptance (Fig. 33.2). During the first stage, cellular differentiation and activation of pre-adipocytes begins with the release of PDGF and TGF-b1 during degranulation of platelets. PDGF is believed to both stimulate mitogenesis and differentiation of the preadipocyte. Simultaneously, angio­genesis is stimulated, resulting in capillary budding and ingrowth via induction of endothelial cell mitosis. This initial stage of graft healing is measured in hours and days, with high activity persisting for up to 1 week. The second stage, typified by fibroblast activation, usually lasts for up to 2 weeks. It is suggested that the TGF-b1 is responsible for initial fibroblastic activation, resulting in  increased numbers of fibroblasts, and stimulates

a

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additional differentiation of precursor adipocyte cells. The prolonged presence of TGF-b1 further acts to stimulate adipocyte lipogenesis, while fibroblasts begin to synthesize pro-collagen type 1 in preparation for deposit of the collagen matrix to support the capillary in-growth activities. The activated fibroblasts begin synthesis of fibronectin and hyaluronic acid - known essential elements of the new extracellular matrix. The third stage represents the beginning of wound maturation and typically remains active for up to 1 year. During this time, the TGF-b1 continues to be active, encouraging additional fibroblast activity. PDGF activates the secretion of certain enzymes (i.e., collagenase) to assist in collagen remodeling and wound maturation. The action of these growth factors is clearly synergistic in the promotion of acceptance of autologous fat grafts (22). PDGF participates in the development of the autocrine amplification

c

d

b

Fig. 33.2  (a) Stage 1: Transfer total syringe into blood chamber. (b) Stage 2: Load Smart PReP®II. (c) Stage 3: After processing, use syringe with spacer and withdraw PPP (yellow). (d) Stage 4: After second spin, the platelet-rich plasma (PRP) is isolated (red)

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system. This feedback system both initiates and maintains the healing and integration of the newly transplanted and differentiated cells by capillary in-growth and collagen remodeling within the recipient bed.

33.4  Technique 33.4.1  Isolation of Platelet-Rich Plasma Early experiences with isolation techniques for PRP were difficult due to the equipment size, cost, and need for a perfusionist, making its use inconvenient, expensive, and requiring substantially larger blood volume draw than the current system (1). Since the development of simple, precise equipment in a complete kit format, the costs of isolation and ease of use have greatly improved (10). It is now practical to have the isolation capability within a practice surgical suite, ASC or hospital setting without the need of additional personnel, requiring only 18–48 cc volume of patient blood draw, and at a dramatically less cost basis. We currently use an automated, dual spin process (SmartPrep IITM, Harvest Technologies Inc., Plymouth, MA) (Fig. 33.3). The patient is phlebotomized to obtain a whole blood sample, the volume of which is dependent on the amount of APC needed for a given protocol. In the case of large volume grafting, as in breast or buttock augmentation, we utilize 10–20 ml of PRP following the simple protocol and kits containing everything needed to properly isolate the platelet concentrate. The drawn specimen is placed in the provided sterile container containing citrate phosphate dextrose as an anticoagulant. This container is then placed in the SmartPrep dual spin centrifuge for an automated cycle, resulting in

R. W. Alexander

separation into its three primary components: red blood cells, PRP, and platelet poor plasma (PPP). Owing to the differing densities of the above components, each isolates in its own respective layer following timed centrifugation. The cell separator allows the removal of the least dense top layer of PPP (which offers the ability to form a fibrin glue when mixed with thrombin, which is useful in many open surgical and graft procedures). Following removal of the PPP layer, the remaining specimen is centrifuged at 2,400 rpm, allowing accurate separation of the PRP layer from the denser blood cell layer. The isolated PRP is then introduced into the sterile field for use directly in surgical wound sites or mixed with graft materials in preparation for tissue transfer. In large volume transfers, addition of PRP is in a ratio ranging from 10 cc per 500 cc of harvested graft materials to 20 cc per 500 cc of graft (0.5–1% concentration). Additional studies are underway to try to identify the minimal PRP concentration to graft volume in order to maximize effects (10). Grafts may be transplanted in both a fibrin gel form (i.e., “activated,” after addition of the proper proportions of thrombin and calcium chloride) or in the isolated graft plus PRP form with no additional additives (40– 43). Based on current clinical observations, in fat grafting there seems to be no distinct difference between the two techniques, unlike in bone and cartilage graft applications which are improved by placement of grafts in a gel matrix. The remaining blood cells are discarded rather than returned to the patient. As the volumes now extracted are typically less than 50 cc (some ten times less than previous isolation cell separator devices which required 500–600 cc draw), there is no significant concern about volume loss to the patient.

33.4.2 Harvest of Autologous Fat by Closed Syringe

Fig. 33.3  Tulip closed syringe system for minimally traumatic harvesting of autologous fat and matrix. Coated external cannulas with internal polish via extrusion process to maximize smoothness and minimize trauma

Most experienced fat transfer surgeons have adopted use of low pressure, syringe harvesting of autologous fat graft materials. Selection of donor site for harvest is considered an important issue. It appears that autologous fat grafts display donor-site memory (i.e., it may retain the metabolic and storage characteristics of adipocytes common to the sites selected for harvest). This suggests that genetic influence varying with the hereditary distribution

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

commonly reported with related individuals may be of great significance (1, 9, 10, 44). This has significant clinical importance in the determination of the ideal donorsite areas, making such selection not on the basis of the surgeon’s convenience or preference, but on the basis of demonstrated fat storage preference and fat metabolic activity levels in each individual patient. These so-called “problem” areas are recognized as metabolically resistant locations (i.e., to exercise and diet programs), and are commonly referred to as “primary deposit sites.” The areas that are influenced by diet and exercise are known as “secondary deposit sites.” Harvest is carried out utilizing tumescent fluid infiltration of the selected donor sites, composed of sterile saline with 0.05% xylocaine with 1:1,000,000 epinephrine. It is common to infiltrate in a ratio of 1:1 up to 2:1 (infiltrate:extraction volumes) via a multiport infiltrator to evenly distribute the fluids throughout the donor-site tissues which provides the liquid vehicle to gently remove the graft tissues. Currently, use of superpolished (internal via extrusion techniques, external by coating techniques, Tulip Cell Friendly™ system) is favored (Fig. 33.4). For large volume transfer, we attempt to minimize graft harvest trauma, by utilization of 2.1–3.7 mm external diameter cannulas, and displace air from the system by filling the cannula with saline or ringers lactate solution prior to application of negative pressure. During the actual graft harvest, low pressure is applied by limiting the plunger movement to one-half or less of the syringe being used. In large volume cases, we favor use of the Tulip Cell Friendly System patented for use with 60-ml Toomey syringes and the superpolished, coated titanium cannula and the bi-beveled cobra tip (9, 10). Recent advances in harvesting large volume is seen in the use of the TissueTrans™ system (Fig. 33.4) to harvest, rinse, and permit addition of PRP in 60-ml Toomey syringes (14). a

b

Fig. 33.4  Tissue3-Trans System (Shippert Medical) for large column harvesting, rinsing, and PRP insertion of autologous fat

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The actual ideal diameter of cannulas for harvest is not certain because of the evolving belief that transfer of some stromal matrix (which actually contains the majority of undifferentiated precursor cells) may, in fact, be contributory to long-term graft success. Use of larger harvesting cannulas may be more effective in large volume scenario from a minimal pressure extraction. Regardless, use of larger harvest cannulas are considered to be potentially more efficient in harvest speed, substantially reducing the time for harvesting viable cellular and stromal (containing adult stem cell) materials (average operating times of 1–2 h maximum). After rinsing the harvested graft material to effectively reduce the intracellular lidocaine concentration (45) and permit removal of extracellular lipid materials and debris, the PRP is added to the autologous graft materials in an approximate ratio of 0.5–1% of the total graft prepared for large volume transplantation. Very low speed centrifugation has been used to further concentrate the graft materials from infranatant fluids. In the event that the thrombin-calcium chloride additive is introduced into the graft materials, the condensation of the graft is found to be equally effective to concentrate it without use of any additional centrifugation. Fol­ lowing gentle agitation to thoroughly mix the graft and PRP, it is left for a 5–10 min period to permit release of platelet concentrate component elements. Following this interval to biologically “activate” the graft, it is ready for placement in the recipient sites (1).

33.4.3 Autologous Fat Graft Breast Augmentation with PRP In preparation for transfer augmentation of the breasts, the patient is marked in an upright position in a fashion similar to that for alloplastic augmentation, but with the breasts also marked in quadrants centered on the nippleareolar complex (Fig. 33.5). The line intersecting the inframammary crease and the vertical quadrant line represents the primary 3 mm access point for pre-­ tunneling and graft placement in layers (Fig. 33.6). With the glandular breast tissues elevated, pretunneling is carried out using a 3 mm bibeveled ­cobra-style cannula along the deeper aspects of native fat on the Pectoralis Major Muscle fascia surface, thence layering more superfically, towards the breast glandular elements in preparation for subsequent grafting. There has been

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a

a Pectoral Musle

Glandular-Ductile Tissues

Nipple Areola Complex

Retroglandular Fat (Layered Tunnels)

b Fat Graft Layered

Chest Wall

b

Fig. 33.5  Marking of patient. (a) 38-year-old female marked in upright position. (b) One year postoperatively after fat grafting with PRP (150 ml bilateral)

some suggestion that intramuscular or submuscular grafting may be advantageous, but this has not been well ­documented (40). Pre-tunneling is considered very important to provide loosened tunnels of “native” fat tissues, initiate recipient site healing efforts, and provide a resident cellular and precursor cell matrix to receive the graft materials. Stacking of layers of graft is recommended to provide the desired increase in volume in an evenly

Tunnels for graft placement

(3mm opening)

Inframammary crease

Fig. 33.6  (a) Separation into quadrants for breast augmentation with autologous fat. Single access point is located within the inframammary crease intersection with vertical marking centered through nipple-areolar complex. (b) Placement of fat in autologous fat graft augmentation

distributed and effective manner. As in small volume experiences with autologous fat, it is clear that grafted fat does best in areas where existing fat is found and where graft can be surrounded by these native elements

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

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a

b

Fig. 33.7  Tendercups™ used to immobilize autologous fat grafts. (a) TenderFoam™ on abdomen postharvest and Tendercups™ posttransfer. (b) Black is dense, closed cell foam cup former lined with pink TenderFoam™ layer next to skin surface

(10, 46). Tendercups™ is used to immobilize autologous fat grafts (Fig. 33.7). In the clinical trial period of 1992–1996, volumes of graft were electively limited to 150 ml (±10%) and evenly distributed within the four quadrants of breast. Since that time, volumes of up to 300 ml per breast have been transferred effectively, with placement of more volume within the upper hemispheres where significant volume losses are commonly found (47). It is considered very important to understand that the amount of graft volume that can be placed is in direct correlation with the existing native fat volumes. That is, in patients with greater amounts of native breast fat, larger volumes may be transplanted and well vascularized during the healing process (10). Very thin patients or patients with essentially no palpable retroglandular fat deposits may not be ideal candidates for the fat graft augmentation of the breasts. In those with very limited recipient site fat tissues, it is common to transfer lower volumes (such as 150 ml or less to each side), and plan on a secondary transfer in 4–6 months. With the initial stage increasing the volume of adipose tissues, the breasts may effectively accommodate larger graft volume placement in the subsequent treatment. In our experience, out of approximately 240 fat graft augmentations since the

clinical trial experience, 28% opted to have a second transfer for this reason, or simply to further augment the breasts. The average clinical volume increase at 1 year is estimated at one cup size, with some achieving larger enhancements. Placement options to accurately deal with small asymmetries, depressions, alloplastic implant rippling, and to help restore the upper hemisphere fullness needed in many augmentation patients are available via this technique (47, 48). Retention of grafted tissues taken from the hereditary (genetic) sites is considered very high. These observations, coupled with in vitro studies, confirm that cell viability may be well within the 90th percentile. Research on the ability to provide a quantitative analysis based on biochemical characteristic differential is underway at this time. Further, longevity of such volume increases followed over the past 15 years confirms that volume retention is a long-term effect considering the anticipated loss of subdermal fat deposits in the face and breast areas associated with normal aging processes (1,  10). It is very important to understand that many reports with respect to the “take” rate are often misinterpreted. That the authors do not account for the fact that at least 30–40% of the transferred volumes do not represent cellular tissues, but rather the carrier fluids introduced with the

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graft cell placement at the time of transfer. It should not be surprising to see initial volume reductions following graft surgery resulting from the gradual removal of these carrier fluids during the healing and graft acceptance process. Experience in breast augmentation via autologous fat grafting suggests that volumes achieved at 4–6 weeks represent the graft placed, with most of the edema and transfer fluids moving away from the graft sites (1, 47–49). The timing of secondary transfers is typically 4–6 months to permit the wound-healing processes and inflammatory stabilization. It is suggested that early regraft intervention while active inflammatory processes are in progress is detrimental to graft success. This is consistent with the suggestions that rinsing harvested graft materials to remove the red blood cell components (which stimulate inflammatory processes) is nec­ essary (45). In addition, this concept is consistent with the findings reported by Clark (50) in studies of retention of fat in granulation tissue beds. Conclusions of those studies were that lipocytes did not flourish in the acidic environment of active inflammatory activities in granulating tissues until neovascularization and extravasation of red blood cells were complete.

a

Fig. 33.8  (a) Preoperative 30-year-old patient. (b) Three years postoperative single stage grafting of 160 ml bilateral grafts without PRP

33.5  Results and Complications Fifteen years of experience confirms that breast augmentation utilizing autologous fat grafting can be safely, predictably, and effectively accomplished. Use of additives, such as PRP, appears to further enhance the success and rate of graft acceptance in both small and large volume applications. PRP was proven to provide such improvements, and can be inexpensively isolated and applied to multiple surgical applications, including breast augmentation by fat grafting (Figs. 33.8 and 33.9). There appears to be minimal morbidity associated with transplantation of autologous fat in the retroglandular breast, and those described appear to be similar or less severe than those associated with alloplastic choices. With the limited size of the access points (<3 mm), the gentle blunt tunneling in the recipient bed, and the autologous nature of grafts appear favorable in breast augmentation of volume by this modality. It is noted that the limitations and complications most encountered with this group of procedures relate to the harvesting, preparation, and delivery of the

b

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation Fig. 33.9  (a) Preoperative patient. (b) Postoperative following fat transfer without PRP. (c) Preoperative patient. (d) Postoperatively following fat transfer with PRP

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a

b

c

d

autologous grafts to the prepared recipient bed. One of the ongoing difficulties in the interpretation of many reports relates directly to limited or no standardization of techniques for each step in the process. This being the case, accurate comparisons or the ability to duplicate results of the studies, to draw valid scientific opinions, is essentially impossible. Recently, the American

Society of Liposuction Surgery has prepared a preliminary standardization of protocols which will hopefully improve the ability of surgeons to interpret and compare reports in scientific sessions and publications. There is no single “correct” way to perform the harvest, preparation, or transfer, but the ability to observe consistency of results and long-term efficacy may be

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improved by better understanding the nuances that enhance patient results (14). The basic risks associated with conventional liposuction harvest techniques, albeit relatively infrequent, is even less encountered based on the limited volumes typically extracted for fat transfer. The morbidity of this procedure seems to be directly proportional to the instrumentation, technique and aggressiveness of the harvesting procedure. As a secondary benefit, donor areas often achieve a desired benefit associated with unwanted, exercise-diet resistant deposit reduction and improved contouring (10, 50). Autologous fat grafting has advantages and limitations when compared with alloplastic augmentation. There are no implant related difficulties such as neurological nipple-areola injury, deflation, leakage, rippling or visible margins of implants, limited capsule expected longevity, or capsular contraction (10, 48–50). Limitations observed in fat graft augmentation of the breast area, make patient selection extremely important. Since there is no limiting capsule filled with volume material, the resultant volume increases realized may be somewhat limited. In other words, for patients whose primary concern is size increase, it is often better to recommend implants to achieve their goals. With structural augmentation via fat grafting, the tissues are more diffusely infiltrated in stacked tunnels which are feathered along the margins. This permits the opportunity to provide specific area support and volumes in the areas of the inframammary crease, sternal (cleavage) areas, and upper hemispheres where many patients demonstrate loss of fullness such as following pregnancy and aging. The candidates selecting the fat graft alternative tend to be moderately older, in the 26–55year age group. In this mature population, often restoration of fullness and support exceeds the desire for large volume increases. There may be a modest difference in the realized graft enlargement based on vascular patterns which have changed with pregnancy and hormonal cycle changes. This variable is the subject of additional study, including retrospective analysis of volume increases and patient satisfaction analysis (49). Reports of additional unanticipated disproportional enlargement have been recorded up to 10 years after grafting in patients having substantial weight gains in that period. This is interpreted as consistent with the genetic predisposition of grafted cells to store lipid. Structural grafting may also permit better im­ plant  margin masking, and can be used in select

R. W. Alexander

postlumpectomy or minor asymmetric areas. In the very thin patient, with minimal retroglandular native volumes, addition of such volume via grafting is often completed prior to actual alloplastic implant placement, knowing that implant margins may be difficult to hide. It is believed that recipient site characteristics (such as thickness, density and vascularization of recipient bed, etc.) may contribute to limitations of graft volumes that are readily accepted in the site. As mentioned, it has been well documented that autologous fat grafts do better in sites rich in existing “native” fat cellular and stromal elements. Whether this is involved in cellular survival or is a function of induction effects on undifferentiated stem cells (pre-adipocytes and ­mesenchymal types), or simply the presence of favorable infrastructure and environment, remains unclear at this time. Early tissue culture evidence suggests that on stimulation, harvested cells experience a more rapid return to active metabolic state when directly enhanced with addition of APCs (APC-PRP). This has been demonstrated in examples of cytoplasmic closure and repair following suction harvest, with return to fat metabolic activity in vitro (Lyles, Personal Communication). Recipient site morbidities are similar to those cited with regard to small volume transfers. There is a possibility for development of palpable cystic or nodular accumulations in the recipient site following transplantation (33, 34). This is postulated to represent small areas of extracellular lipid accumulation or steatonecrosis with failure of cellular acceptance (44, 50–58). It is important to note that the clinical frequency of such changes have substantially decreased since the advent of utilization of platelet concentrates. It is believed that the presence of palpable nodules or cystic accumulations may be a direct function of delayed healing or poor circulation within the grafted recipient site (10). Cytosteatonecrosis, resulting in a low grade inflamma­ tory response, may encourage formation of microcysts and spherical calcifications, as has been doc­umented, because of morbidities associated with traditional autologous fat grafting. Such findings, an early expressed concern of many breast surgeons, have become relatively easily differentiated via mammography and ultrasound studies. Current studies using magnetic resonance imaging (MRI) review to gain greater detail of any suspicious areas, much like the recommendations in current silicone implant evaluations, are ongoing.

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

Patients are recommended to have preoperative mammography to serve as a baseline prior to breast augmentation by either alloplastic or autologous means. Following autologous fat graft augmentation, we recommend a follow up study to reset the baseline. After several hundred experiences, it appears that changes, if any, are typically visible within 6–18 months. On four occasions, the findings did not appear for more than 24 months. Imaging specialists report comfort in differentiation of the spherical-type cysts and/or microcalcifications from those potentially harmful to the patient (55). In the clinical trial, the radiologists were blinded as to any procedure, and in many instances their only findings were reported as “greater retroglandular fat matrix of unknown origin” as the only changes noted (49). The occurrence of the above described morbidity can be related to graft trauma at the time of placement, delayed revascularization, or increased inflammatory response within the recipient bed. It has been postulated that the addition of PRP may enhance the healing cascade rates and specifically stimulate greater revascularization processes (10, 47, 49). Recent approval from the FDA for utilization of PRP with bone marrow aspirate confirms the efficacy and safety associated with PRP and mesenchymal stem cell tissues. As a source of mesenchymal stem cells, fat tissue has been well documented to provide higher numbers of such cells than is present in bone tissues (36). The importance of stem cell induction-differentiation in both bone and fat grafting is the current subject of extensive investigations.

33.6  Discussion The scientific literature contains numerous studies to date which have sought to elucidate a biochemical additive or agent which can improve or speed up the acceptance and outcome of autologous fat grafts. Numerous additives such as heparin, calcium, thyroid hormone, bezafibrate, vitamin E, albumin, and insulin have been studied with little or no evidence supporting greater graft acceptance (1, 10, 59–70). Suggestions that use of osmotic gradients (e.g., albumin) may stabilize adipocyte cellular membranes need to be further explored. It is possible that a portion of the effects of PRP additives may also relate to the osmotic characteristic in addition to the wound-healing factors.

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Growth factors are the biologically active signal peptides released from local tissue or blood products (particularly the platelet fraction) that play a critical role in influencing the initiation and progression of the normal wound-healing process. Such factors coordinate the processes of epithelialization, angiogenesis, collagen-matrix formation; the key steps in the woundhealing sequence. Growth factors function in ­paracrine, endocrine and autocrine manners in order to guide the dynamic stages of wound healing. No single growth factor appears to maintain a total physiologic task, but instead these peptides work in a coordinated fashion to orchestrate the normal wound-healing processes. A substantial volume of basic research has displayed the efficacy of these bioactive peptides with regard to healing in both soft and osseous tissues. Steed et al. (71), in a randomized, prospective, double blind, placebo controlled study of 118 patients with chronic, full thickness lower extremity diabetic neurotrophic ulcers of at least 8 weeks duration, displayed a statistically significant difference in both numbers of patients healed and healing rates, after daily application of topical recombi­ nant growth factors. Forty eight percent of patients ran­ domized to the growth factor application group achieved complete wound healing, compared to only 25% wound closure in the control group. Knighton et al. (72) displayed a 93% re-epithelialization in 41 patients displaying a total of 71 chronic wounds after receiving daily treatments with APC (PRP). In a second study by Knigh­ton (73), they confirmed the first study, in complete resolution of wounds in 17 of 21 chronic lower extremity ulcerations, treated over an 8 week course of twice daily PRP/APC application. Of those patients in the placebo group, only 2 of 13 displayed the same results. Upon crossover treatment of the control group with APC (PRP), all previously unresponsive wounds displayed re-epithelialization. Extensive reports in other ­mesenchymal-derived tissues have documented enhanced healing in bone and cartilage models in vivo. Powell et al. (74) reported trends suggesting enhancement of recovery with decreases in postoperative edema and ecchymoses in a pilot, randomized, prospective, controlled clinical trial involving patients undergoing standard deep place facelifting. The effect of growth factors on enhancement on neovascularization was reported by Khouri et al. (75). This study demonstrated that after the application of basic fibroblast growth factor to ischemic flaps, a rat model displayed greater flap survival rates, as well as a greater increase in the

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n­ umber of new blood vessels upon histologic examination. PRP, as a clinical enhancement to native woundhealing capabilities, contains supraphysiologic concentrations of growth factors. Reports extrapolating the basic wound-healing model with respect to transplantation of autologous fat show improved efficacy of such small and large volume grafts in the clinical setting. In those, it is postulated that the effects of PRP, with regard to enhancement of the normal wound-healing processes, can safely and effectively be utilized as an additive in autologous fat grafting. Addition of PRP to grafts appears to actively promote increased graft volume retention and return to metabolic activity. Based on those clinical observations, it is reported that addition of PRP (and the attendant addition of high concentrations of growth factors and cytokines) increased the retention of the transplanted fat cells, increased the rate of revascularization of the grafts, and aided the differentiation of preadipocyte precursor cells into mature adipocytes to further enhance the retained graft volumes (1, 10, 17, 39). Use of mesenchymal stem cells derived from fat tissue is the current subject of study, as they appear to be able to undergo induction-differentiation into a variety of tissues of similar origin, and are more prevalent and easier to obtain than bone marrow cells (36–39). In the case of autologous fat transplantation, the recipient bed represents a basic model of soft tissue injury. There appears to be clinical enhancement of wound repair within that site following introduction of grafts with the PRP additive, favoring maintenance of graft vol­umes and acceptance. Autologous fat cells are injected into a created potential space which is subjected to mild tissue injury as a result of pre-tunneling in the recipient locations. Following grafting, these created spaces consist of transplanted cellular elements, clotted blood containing platelets, exposed endothelial cells, interstitial collagen, fibroblasts and undifferentiated stem cell elements. Use of activated PRP gel or plain PRP-added grafts appear to actively initiate the hemostatic phase of wound healing, which is expected to last for the first few minutes following injury. With the initial tissue injury, the damaged recipient bed cells (native) release their own growth factors (notably PDGF and TGF). Concurrently, activation of the clotting cascade results in the transformation of fibrinogen to fibrin, a potent stimulus for the further release of growth factors from the alpha granules within the aggregated platelets. These factors then

R. W. Alexander

activate their target cells (PMNs, macrophages, lymphocytes, fibroblasts, endothelial cells, epithelial cells, etc.) to proliferate and migrate to the wound site and carry out important functions in the acceptance of grafts and site healing. Knowledge of the inflammatory stage of wound healing (3–5 days after initial injury) is important. It is during these times that success or failure of free grafting may be determined. In this stage, activation of inflammatory cells such as macrophages secreting growth factors, induction of fibroblast proliferation, early collagen synthesis, endothelial cell replication and mobilization, and epidermal cell mobility and proliferation must be appreciated. Next, the proliferative phase (days 3–12 following injury) of the process continues the graft acceptance processes. During this phase, fibroblasts are activated to lay down a new extracellular matrix. Angiogenic growth factors are simultaneously released by injured cells, platelets, macrophages, and extracellular matrix aimed at inducing early vascularization. The remodeling phase (approximately 2 weeks after injury) is a gradual process, lasting for up to 1 year, and is considered to be less critical to the success of individual grafts. During this time, a balance is achieved between synthesis of the new matrix and degradation by proteases, and it provides a permanent infrastructure for long-term graft volume maintenance. Type III collagen is gradually replaced by Type I collagen. The final result of the remodeling phase is formation of the supportive fibrous matrix. Thus, the conclusion drawn regarding addition of concentrated platelet-derived factors to a wound bed is that it will markedly augment and improve the healing process. This enhancement of healing rate and graft survival may result in more favorable and reli­able results with regard to the success of transplantation of autologous fat in small and large volume appli­cations. The importance of growth factors in initiating the differentiation of adipose precursor cells into mature adipocytes is currently under extensive study. In vitro studies have shown that such factors do, in fact, stimulate the proliferation and differentiation of precursor adipose cell cultures (31, 36–39). This bioactivation phenomenon has been studied in a number of clinical trials with success. Yuksel et al. (60) demonstrated quantitative increases in weight maintenance and adipocyte area percentage means in the rat model following addition of insulin-like growth factor 1

33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation

and basic fibroblast growth factor delivered by PLGA/ PEG microspheres in conjunction with autologous fat grafts. Small volume of fat graft survival after growth factor application in the facial region has been studied by Eppley et al. (30). Ninety days postgrafting, those treated with basic fibroblast growth factor soaked dextran beads exhibited greater graft weight maintenance. In addition, the experimental group grafts histologically displayed greater numbers of intact cells as compared to the control graft group. Eppley et al. (76) in a later study, observed near complete graft weight maintenance, larger adipocyte volume, increased number of intact cells, and the presence of numerous smaller adipocyte-like cells 1 year after grafting as compared to the controls. These small adipocytes may represent a group of newly differentiated cells, slowly beginning to return to the metabolic activity of a mature adipocyte. In some autologous fat grafting cases, delayed volume increases have been observed, particularly in cases of large volume transfer. This may suggest a differentiation of precursor cells to adipocyte form, and the delay in restoration of metabolic activities of cytoplasmic lipid storage. Suggestions that growth factors enhance graft volumes, as well as increase the actual number of adipocytes with grafted tissues are very significant. With these observations, it is possible that those mature adipocytes lost in the harvest and transplantation process may be replaced by newly inducted-differentiated cells allowing the overall graft volume to be retained.

33.7  Conclusions The conclusion drawn from scientific and experiential pathways is that autologous fat grafting offers a viable and safe alternative means of breast augmentation in select patients (49, 77). Long lasting, natural contouring, and volume increases are attainable. Since the advent of the closed syringe system for lipocontouring and harvesting for grafts, its predictability and safety is gaining recognition. Many of the early contributions to the literature have made the use of autologous fat grafting feasible and a useful modality in volume augmentation to the breasts (78). The use of additives to bioactivate the grafts and recipient bed appears to substantially improve the augmentation achieved and reduce the incidence of lipid cysts, cellular loss, and microcalcifications. The exact

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incidence of microcalcifications is not established, but in the author’s personal experience, the incidence was found to be 12% in the non-PRP treated grafts, vs. 8% in the PRP treated graft patients (Fig. 33.9). This trend suggests improvement in the acceptance of low pressure, syringe harvested free fat grafts. The literature is now beginning to provide more reporting of such findings, and the actual incidence of lipid cysts and characteristic microcalcifications in a large sample should be forthcoming. Fat graft augmentation may be of value as a simple aesthetic enlargement, or for correction of some asymmetries and breast deformities in a reconstructive application. Patient satisfaction is very high, especially in those in the older median age group and those with major aversion to use of artificial implants of any kind (10). Patient selection and communication remain the most important determinants in successful augmentation with grafts. Establishing patient expectations remains the crucial point in the selection of grafting techniques. Use of additives such as PRP appears to have improved the efficacy, speed of recovery, and safety of the graft alternative. As mainstream practitioners begin to report their findings about these techniques, much needed reproducibility of results and qualitative-quantitative analysis of the augmentation volume will be available. ­Standar­dization of techniques is needed to permit practitioners to more effectively appreciate the results and to experience satisfaction with structural fat grafting in both small and large volume applications. The importance of grafting of autologous fat may be further enhanced with increased understanding of the stem cell implications associated with the tissue. Addi­ tional research relating to the induction-differentiation of transplanted cellular elements is underway at this time. Such information may provide much greater under­ standing of our clinical experience and explanation of our success for long-term maintenance of results. With the rush to explore the possibilities of use of precursor cells, there may be many more clinical applications for the use of mesenchymally-derived, adult stem cell tissues in many areas of medicine and surgery.

References   1. Alexander RW, Abuzeni PZ. Enhancement of autologous fat transplantation with platelet rich plasma. Am J Cosm Surg 2001;18:59–70.

258   2. Whitman DH. Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofacial Surg 1997;55(11):1294–1299.   3. Marx RE. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Path Oral Radiol Endod 1998;85(6):638–646.   4. Fagrell D, Sverker E, Kniola B. Fat cylinder transplantation. An experimental comparative study of three different kinds of transplants. Plast Reconstr Surg 1996;98(1):90–96.   5. Niechajev I, Sevcuk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506.   6. Billings E, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381.   7. Nguyen A, Pasyk KA, Bouvier TN. Comparative study of survival of autologous tissue taken and transplanted by different techniques. Plast Recon Surg 1990;85(3):378–386.   8. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865.   9. Alexander RW. Liposculpture in the superficial plane: closed syringe system for improvement in fat removal and free fat transfer. Am J Cosm Surg 1994;11:127–134. 10. Alexander RW, Sadati K, Corrado A. Platelet-rich plasma (PRP) utilized to promote greater graft volume retention in autologous fat grafting. Am J Cosm Surg 2006;23(4):203–221. 11. Obaji S. Selecting for fat transfer success. Cosm Surg Times 2006;9(4):26. 12. Bircoll M. A nine-year experience with autologous fat transplantation. Am J Cosm Surg 1992;9(1):55–61. 13. Coleman SR. Structural Fat Grafting. Quality Medical Pub­ lishing, St. Louis, MO, 2004, pp 30–175. 14. Shippert R. Autologous fat transfer: eliminating the centrifuge, decreasing lipocyte trauma, and establishing standardization for scientific study. Am J Cosm Surg 2006;23(1):21–27. 15. Ersek RA. Transplantation of purified autologous fat; a three year follow-up is disappointing. Plast Recon Surg 1991:87(2): 219–227. 16. Pinski KS, Roenigk HH. Autologous fat transplantation longterm followup. J Dermatol Surg Oncol 1992;18(3):179–184 17. Lyles MB. Adipocytes hearty: certain storage conditions favor pre-adipocyte survival. Cosm Surg Times 2003;6: 10–11. 18. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S. 19. Forgue-Lafitte ME, Van RL, De Gasquet P, Rosselin G. The presence of epidermal growth factor receptors in cultured human adipocyte precursors. Scand J Clin Lab Invest 1982; 42(8):627–631. 20. Lau D, Roncari D, Yip D, Kindler S, Nilsern S. Purification of a pituitary polypeptide that stimulates the replication of adipocyte precursors in culture. FEBS Lett 1983; 153: 395–398. 21. Zapf J, Schoenle E, Froesch R. Insulin-like growth factor I and II: some biological actions and receptor binding characteristics of two purified constituents of nonsuppressible insulin-like activity of human serum. Eur J Biochem 1978; 87(5):285–296. 22. Reeder GD, Hood A, Hill A. Perioperative autologous sequestration I: physiology, phenomena, and art. Proceedings of the American Academy of Cardiovascular Perfusion, San Antonio, TX, 1993.

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33  Fat Transfer with Platelet-Rich Plasma for Breast Augmentation routine method to improve wound healing and regeneration. Transfus Med 2000;10:325–329. 43. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 2001;107(1):229–237. 44. Coleman SR. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 2007;119(3):775–787. 45. Alexander RW, Maring T, Aghabo T. Autologous fat grafting: a study of residual intracellular adipocyte lidocaine concentrations after serial rinsing with normal saline. Am J Cosm Surg 1999;16:123–126. 46. Ersek RA, Chang P, Salisbury M. A lipo layering of autologous fat: an improved technique with promising results. Plast Reconstr Surg 1998;101(3):820–826. 47. Alexander RW. Breast augmentation by injection of autologous fat. Proceedings of American Society of Cosmetic Breast Surgery, Newport Beach, CA, 1996. 48. Alexander RW. Use of fat transfer for facial and breast augmentation. Proceedings of World Congress on Liposuction Surgery, San Francisco, CA, 1996. 49. Alexander RW. Use of fat grafts for augmentation mammoplasty. Summary of clinical information with radiographic documentation. Proceedings of American Society of Cosmetic Breast Surgery, Newport Beach CA, 1998. 50. Clark ER, Clar EL. Microscopic studies of new formation of fat in living adult rabbits. Am J Anat 1940;67:255–281 51. Fulton JE. Breast contouring by autologous fat transfer. Am J Cosm Surg 1992;9:273–279. 52. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79(2):267–271. 53. Bircoll M. Autologous fat transplantation: an evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosm Surg 1998;5:283–288. 54. Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. The mammographic spectrum of fat necrosis of the breast. Radio­ graphics 1995;15(6):1347–1356. 55. Johnson GW. Benign breast calcifications. Am J Cosm Surg 1988;5:177–180. 56. Pulagam SR, Poulton T, Mamounas EP. Long-term clinical and radiologic results with autologous fat transplantation for breast augmentation. Breast J 2006;6(1):63–67. 57. Fine RE, Staren ED. Updates in breast ultrasound. Surg Clin North Am 2004;84(4):1001–1006. 58. Chala LF, de Barros N, de Camargo Moraes, P, Endo E, Kim SJ, Pinceraato KM, Carvalho FM, Cerri GG. Fat necrosis of the breast: mammographic, sonographic, computed tomography, and magnetic resonance imaging findings. Curr Probl Diagn Radiol 2004;33(3):106–126. 59. Kneeshaw PJ, Lowry M, Manton D, Hubbard A, Drew PJ, Turnbull LW. Differentiation of benign from malignant breast disease associated with screening detected microcalcifications using dynamic contract enhanced magnetic resonance imaging. Breast 2006;15(1):29–38. 60. Yuksel E, Weinfeld AB, Cleek R, Wamsley S, Jensen J, Boutros S, Waugh JM, Shenaq SM, Spira M. Increased free fat-graft survival with the long-term local delivery of insulin, insulin-like growth factor-1, and basic fibroblast growth fac-

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tor by PLGA/PEG microspheres. Plast Reconstr Surg 2000; 105(5):1712–1720. 61. Wabitsch M, Hauner H, Heinze E, Teller WM. The role of growth hormone/insulin-like growth factors in adipocyte differentiation. Metabolism 1995;44(10 Suppl 4):45–49. 62. Boney CM, Moats-Staats BM, StilesAD, D’ErcoleAJ. Expression of insulin-like growth factor-1 (IGF-1) and IGFbinding proteins during adipogenesis. Endocrinology 1994; 135(5):1863–1868. 63. Alexander RW. Platelet rich plasma offers vast fat graft benefits. Cosm Surg Times 2004;7(3):18–20. 64. Menschik Z. Vitamin E and adipose tissue. Edinb Med J1944;51:486–489. 65. Sidman RL. The direct effect of insulin on organ cultures of brown fat. Anat Rec 1956;124(4):723–739. 66. Reynold AE. Marble A, Fawcett DW. Action of insulin on deposition of glycogen and storage of fat in adipose tissue. Endocrinology 1950;46:55–66. 67. Krawisz BR, Scott RE. Coupling of proadipocyte growth arrest and differentiation. I. Induction by heparinized medium containing human plasma. J Cell Biol 1982;94(2): 394–399. 68. Flores-Delgado G, Marsch-Moreno M, Kuri-Harcuch W. Thyroid hormone stimulates adipocyte differentiation of 3T3 cells. Mol Cell Biochem 1987;76(1):35–43. 69. Brandes R, Hertz R, Arad R, Nashtat S, Weil S, Bar-Tana J. Adipocyte conversion of cultured 3T3-L1 pre-adipocytes by benzafibrate. Life Sci 1987;40(10):935–941. 70. Ullmann Y, Hyanms M, Ramon Y, Beach D, Peled IJ, Lindenbaum ES. Enhancing survival of aspirated human fat injected into nude mice. Plast Reconstr Surg 1998;101 (7):1940–1944. 71. Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. J Vasc Surg 1995;21(1):79–81. 72. Knighton DR, Ciresi K, Fiegel V, Schumerth S, Butler E, Cerra F. The use of topically applied platelet growth factors in chronic non-healing wounds. Wounds 1998;1:71–78. 73. Knighton DR, Ciresi K, Fiegel VD, Schumerth S, Butler E, Cerra F. Stimulation of repair in chronic, non-healing cutaneous ulcers using platelet-derived wound healing formula. Surg Gynecol Obstet 1990;170(1):56–60. 74. Powell DM, Chang E, Farrior EH. Recovery from deepplane rhytidectomy following unilateral wound treatment with autologous platelet gel. Arch Plast Surg 2001;3(4): 245–250. 75. Khouri RK, Brown DM, Leal-Khouri SM, Tark KC, Shaw WW. The effect of basic fibroblast growth factor on the neovascularization process: skin flap survival and staged flap transfers. Br J Plast Surg 1991;44(8):585–588. 76. Eppley BL, Sidner RA, Platis JM, Sadove MA. Bioactivation of free-fat transfer: a potentially new approach to improving fat survival. Plast Reconstr Surg 1992;90(6):1022–1030. 77. Alexander RW. Results are satisfying using autologous fat: breast augmentation with autologous fat transfer. Cosm Surg Times 1998;2(4):4. 78. Fournier PF. The breast fill. In Fournier PF (ed), Liposculpture: The Syringe Technique. Arnette-Blackwell, Paris, 1991, pp. 357–367.

34

Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue Kotaro Yoshimura, Katsujiro Sato, and Daisuke Matsumoto

34.1  Introduction Autologous fat transplantation is a promising cosmetic treatment for facial rejuvenation and soft-tissue augmentation because of the lack of an incision scar and complications associated with foreign materials. However, certain problems remain, including unpredictable outcomes and a low rate of graft survival due to partial necrosis. Autologous fat transplantation has been used for breast augmentation by only a limited number of plastic surgeons (1). This procedure is controversial because of the lack of consensus on whether it is safe and appropriate due to associated micro­ calcifications that might cause confusion during the ­evaluation of mammograms. Recently, autologous fat injection has been re-evaluated as a potential alternative to artificial implants for breast augmentation (1–7). This re-evaluation may reflect recent advances in autologous fat transfer and the radiological detection of breast cancer. A novel approach to autologous fat grafting called cell-assisted lipotransfer (CAL) is the current preferred method by the authors for transplantation of aspirated fat tissue and adipose progenitor cells or adiposederived stem/stromal cells (ASCs), which consists of the grafting of progenitor-enriched fat tissue (Fig. 34.1) (8). The therapeutic strategy is based on the observation that aspirated fat is vessel-poor and adipose progenitor cell-poor as compared to intact whole fat (9).

K. Yoshimura () Department of Plastic Surgery, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan e-mail: [email protected]

Cell-Assisted Lipotransfer (CAL) Aspirated fat (ASC-poor fat)

Freshly isolated SVFs

CAL fat (ASC-enriched fat)

Excised fat tissue

Fig. 34.1  Scheme of cell-assisted lipotransfer (CAL). Relatively adipose-derived stromal/stem cells (ASC)-poor aspirated fat tissue is converted to ASC-rich fat tissue by supplementation with ASCs isolated from the other half of the aspirated fat sample. The ASCs are attached to the aspirated fat, which is used as a scaffold in this strategy (8, 19)

34.2 Adipose Tissue-Specific Progenitors with Multipotency It has been shown that fibroblast-like stromal cells obtained from liposuction aspirates can differentiate into various cell lineages (10, 11) such as adipogenic, osteogenic, chondrogenic, myogenic, cardiomyogenic, and neurogenic. Thus, the adipose tissue-specific progenitor cells are now called “Adipose-derived stem/ pogenitor cells (ASCs)” and are expected to become valuable tools in a wide range of cell-based therapies (12) (Fig. 34.2). Adipose tissue is known to be rich in microvasculature (10), and ASCs were shown to have angiogenic characteristics and to experimentally differentiate into vascular endothelial cells (9,  14,  15).

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_34, © Springer-Verlag Berlin Heidelberg 2010

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Adipose tissue

Lipoaspirates Adipocyte

20-30%?

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Endothelial cell, Pericyte, etc.

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Col I,III,IV,V,VI laminin,fibronectin,,

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ASCs Vasculature

Bone Cartilage Nerve

Fat Tendon

Muscles (cardiac, skeletal)

Liver

Fig. 34.2  The stromal vascular fraction (SVF) can be obtained from adipose and fluid portions of liposuction aspirates through collagenase digestion. SVF contains 10–35% ASCs, some of which are multipotent and have been shown to differentiate into several lineages in vitro. SVF also contains blood-derived cells such as leukocytes

Human ASCs are distinct from other mesenchymal progenitors in their surface marker expression profile; notably, only ASCs express stem cell-associated marker CD34 in higher percentages than do bone marrow-derived mesenchymal stem cells and dermal fibroblasts (11). ASCs are currently used in clinical trials of treatments for bone defect (autologous fresh ASCs) (16), rectovaginal fistula (autologous cultured ASCs) (17), graft vs. host disease (nonautologous ASCs) (18), and softtissue augmentation by CAL (autologous fresh ASCs) (5–7, 19). If ASCs are harvested from a large volume (e.g., 500 mL) of liposuction aspirates, ASCs can be used without cell expansion because a sufficient number can be obtained from such a volume. Furthermore, the use of minimally manipulated fresh cells might lead to higher safety and efficacy in actual treatments.

34.3 Biological and Therapeutic Concepts of Cell-Assisted Lipotransfer 1. Cell components of adipose tissue Adipose tissue consists predominantly of adipocytes, ASCs, endothelial cells, pericytes, fibroblasts, and extracellular matrix (ECM). Adipocytes constitute more

<130 µm

Fig. 34.3  Scheme of adipose tissue components. Adipocytes constitute more than 90% of tissue volume but only 50–60% of the total cell number. ASCs, endothelial cells, fibroblasts, and other cells constitute the remainder. Extracellular matrix (ECM) of the adipose tissue contains various collagens, laminin, fibrinogen, and other ECM substances

than 90% of tissue volume but they are much larger in size than the other cells, and the number of adipocytes is estimated to be only less than 50% about of the total cell number (20, 21) (Fig. 34.3). ASCs are adipose tissue-specific progenitor cells that contribute to adipose tissue turnover (adipose tissue is considered to turnover every several to 10 years (22, 23)) and provide cells for the next generation. Based on recent studies, ASCs are considered to be bipotent progenitors, being sources of both adipogenic and angiogenic lineages (15). 2. Aspirated fat tissue vs. intact fat tissue In general, we can use only aspirated fat tissue as lipoinjection material. Aspirated fat is a fragile part of  the adipose tissue taken under negative pressure. Indeed, a fibrous honeycomb structure is left in the donor tissue after liposuction. Our research has revealed that aspirated fat contains only half the number of ASCs as intact whole fat (9, 21) (Fig. 34.4). The two main reasons for this relative deficiency of ASCs are the following. (a) A major portion of ASCs is located around large vessels (within tunica adventitia) and is left at the donor site. (b) A part of ASCs is released into the fluid portion of liposuction aspirates (11). Our histo­ logical studies have indicated that ASCs are located not only between adipocytes but also around vessels. Large vessels are located in the fibrous part of the tissue contained by intact whole fat but much less by aspirated fat. Thus, aspirated fat tissue is regarded as progenitorpoor fat tissue as compared to intact fat tissue.

34  Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue aspirated fat

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excised fat

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Honeycomb structure after liposuction

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100%

ASCs from aspirated fat/ ASCs from excised fat

Large vasculatures 1.0 0.8 0.6 0.4 0.2 0.0

#1

#2

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Ave.

Fig. 34.4  Comparison of human aspirated fat and excised whole fat obtained from a single site of a single patient. Histology of aspirated fat and excised fat (top) (hematoxylin and eosin-stained microphotographs and scanning electron micrographs; red scale bar = 200 mm, white scale bar = 40 mm). The basic structure of adipose tissue was preserved in the aspirated fat, while significantly fewer vascular vessels, especially those of large size, were detected in aspirated fat than in excised fat. It is well known that the honeycomb structures of vascular

and neural perforator networks are left intact in aspirated sites following liposuction procedures (bottom). Adipose-derived stromal/stem cell (ASC) yield from aspirated fat and excised fat. Both tissues were processed for isolation of SVFs, which were then cultured for 1 week. Ratios of ASC yields from aspirated fat to ASC yields from excised fat of the same volume were calculated; data  from three patients (#1–4) and their average value are shown. The ASC yield from aspirated fat was significantly less (56 ± 12%) than the yield from excised fat (9, 21)

3. Stromal vascular fraction

SVF is used to supplement fat graft tissue without any manipulations such as cell sorting or culture.

Through collagenase digestion, a heterogeneous cell mixture can be extracted from adipose tissue as a cell pellet. This cell fraction is called the “stromal vascular fraction” (SVF) (Fig. 34.2) because it contains mostly stromal cells, vascular endothelial cells, and mural cells, but not adipocytes. In the clinical setting, the SVF contains a substantial amount of blood-derived cells such as leucocytes and erythrocytes as well as adipose-derived cells such as ASCs and vascular endothelial cells. Our pilot study (20) revealed that nucleated cells contained in SVF are composed of 37% white blood cells, 35% ASCs, and 15% endothelial cells and other cells, though the percentage of blood-derived cells strongly depends on individual hemorrhage volumes. In CAL, freshly isolated autologous

4. Progenitor to adipocyte ratio In general, tissue grafting is performed using graft tissue with an intact organ-specific ratio of progenitor cells to differentiated adult cells. For example, in splitor full-thickness skin grafting, the graft skin has the same number of basal keratinocytes and other keratinocytes as intact skin. The ratio of basal keratinocyte number to other differentiated cell number is the progenitor to mature cell ratio for the epidermis. In adipose tissue, aspirated fat has a significantly lower progenitor to mature cell ratio and this low ASC to adipocyte ratio might be the main reason for ­long-term

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Improve “ASC/Adipocyte ratio” oil

water Before

After

Centrifugation

Before

1200 g

Fig. 34.5  Effects of centrifugation on aspirated adipose tissue. The adipose portion was concentrated to 71.0% of the original volume after centrifugation for 3 min at 1,200 × g. The volume of the adipose portion significantly reduced and the volume of the fluid and oil portions significantly increased. However, the number of ASCs contained in the adipose portion did not significantly change by the centrifugation. Thus, centrifugation at 1,200 × g led to condensation of cell numbers per volume of adipocytes and ASCs by 25 and 43%, respectively, and improved the ASC to adipocyte ratio by 14% (26)

atrophy of transplanted adipose tissue. There are at least three experimental studies (9, 24, 25) demonstrating that supplementing adipose progenitor cells enhances the volume or weight of survived adipose tissue. The authors have found that centrifugation of the aspirated fat influences engraftment efficiency substantially, because centrifugation at 1,200 × g decreases the fat volume by 30%, damaging 12% of the adipocytes and 0% of the ASCs (26) (Fig. 34.5). This leads to condensation of cell numbers per volume of adipocytes and ASCs by 25 and 43%, respectively, and improves the ASC to adipocyte ratio by 14%. Thus, even centrifugation alone is likely to lead to better aspirated fat engraftment.

34.4 Concept of Cell-Assisted Lipotransfer Enrichment of adipose progenitor cells can be supplemented with the SVF. Supplementation with SVF im­­ proves the progenitor to adipocyte ratio − progenitor-poor

aspirated fat tissue is converted to progenitor-rich fat tissue. It was hypothesized that this progenitor-enriched fat tissue would not only survive better but would also preserve its volume with minimal atrophy. In CAL, freshly isolated SVF, which contains ASCs, is added to progenitor-poor aspirated fat tissue; the cells are attached to the aspirated fat before transplantation, with the fat acting as a living bioscaffold (Fig. 34.1). After transplantation, the ASC-supplemented adipose tissue encounters ischemia and subsequent reperfusion, the high pressure of edema, and inflammatory changes in the host tissue. The microenvironments, injury-associated growth factors, and inflammation-associated cytokines and chemokines influence ASC behavior during the acute phase of tissue repair, as discussed in the next section.

34.5 Possible Roles of Adipose-Derived Stem/Stromal Cells in Cell-Assisted Lipotransfer There are four possible roles for ASCs in CAL, which have partly been confirmed in preclinical studies (9, 24, 25). First, ASCs differentiate into adipocytes and contribute to the regeneration of adipose tissue. Second, ASCs differentiate into endothelial cells and possibly vascular mural cells (9, 14, 15), thereby promoting angiogenesis and graft survival. Third, ASCs release angiogenic growth factors such as hepatocyte growth factor in response to injury, hypoxia, and other conditions (27, 28), and these factors influence the surrounding host tissue. Finally, and possibly most importantly, some ASCs survive as original ASCs (9). In the adipose, ASCs reside between adipocytes or in the ECM, especially around vessels, and contribute to the turnover of adipose tissue, which is known to be very slow (2 years or more) (22, 23). However, surviving adipose grafts probably turn over during the first 2–3 months after transplantation because they experience temporary ischemia followed by reperfusion injury (8). This turnover, i.e., the replacement process of the adipose tissue, is conducted by tissue-specific progenitor cells, which are ASCs. The relative deficiency of ASCs in aspirated fat could affect the replacement process and lead to postoperative atrophy of grafted fat, which commonly occurs during the first 6 months following lipoinjection.

34  Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue

34.6  Technique Surgical procedures Donor sites are determined according to patient’s preference and body mass index (BMI). If the patient’s BMI is greater than 25, then 1,500 mL of aspirated fat can usually be harvested from either the abdomen and flanks, or posterior, medial, and lateral thighs. If BMI is less than 20, fat should be harvested from both abdomen and thighs. After the liposuction site is infiltrated with saline solution containing diluted epinephrine (0.001%) under general anesthesia, the adipose tissue is suctioned using a cannula with 2.5 mm inner diameter and a conventional liposuction machine. About a half of the collected liposuction aspirate (500–800 mL of aspirated fat) is used to harvest the SVF. The SVF is isolated from both the adipose portion and the fluid portion of liposuction aspirates, as described below (11), and the cell processing procedure takes about 80 min. During the processing period, the remaining half of lipoaspirate is harvested and prepared as a graft material. The aspirate is centrifuged at 700 × g for 3 min, and the floating adipose portion is placed in a metal jar (1,000 mL) placed in an ice water bath. For the injection syringe, the authors use a 10-mL LeVeen inflator (Boston Scientific Corp., MA) or the authors’ original syringe (20 mL) because they are both screw-type syringes (with a threaded plunger) with threaded connections that fit both the connecting tube and the needle, providing precise control during injection (Fig. 34.6). Two syringes are used in order to reduce the time of the procedure. While one syringe is being used for an injection the other is filled with the graft material in preparation for the next injection. A 16- or 18-gauge needle (150 mm long) is used for lipoinjection and inserted subcutaneously at one of the four points indicated in Fig. 34.7. Care is taken to insert the needle horizontally (parallel to the body) in order to avoid damaging the pleura and causing a pneumothorax. The needle is inserted in several layers and directions and is continuously and gradually retracted as the plunger is advanced (Fig. 34.7), thereby ensuring diffuse distribution of the graft material. The grafts are placed into the fatty layers on, around, and under the mammary glands (but not intentionally into the mammary glands), as well as into the pectoralis muscles. After training, the operator can easily recognize the difference between mammary gland or pectoralis fascia, which are harder tissues, and the fat or muscle

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tissue. After the surgery, the breasts are maintained in the proper position using a brassier; massage of the breasts is prohibited during the first 3 months. For patients with artificial breast implants, CAL can be performed immediately following implant removal (6, 7). During the cell isolation period, the breast implants are removed through a periareolar incision made at the caudal third of the areola margin. Lipoinjection is initiated at the deepest layer under the implant capsule and completed with injection into the most superficial subcutaneous layer. Again, in the deepest layer, it is important to insert and place the needle horizontally (parallel to the body) in order to avoid damaging the pleura. The operator can insert a finger into the implant capsule and place

Fig. 34.6  Injection devices. A high-pressure injection can be performed with a disposable syringe with a threaded plunger. A 150-mm long 16- or 18-gauge needle is connected to the syringe with a connecting tube threaded at both ends. The injection needle is rigidly manipulated by an operator, while an assistant rotates the plunger according to the operator’s instruction

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a Lateral

Medial

b

Fig. 34.7  Injection method. (a) The needle is inserted from either one of two points on the areola margin or one of two points at the infra-mammary fold in various directions and planes to achieve a diffuse distribution. (b) A small amount of fat tissue is injected in small aliquots or a thin string with a long needle on a syringe with a threaded plunger while the needle is continuously withdrawn (5)

it at the bottom of the capsule to recognize the location of the injection needle. The needle is inserted from the lateral margin of the breast and from a point on the inflamammary fold. Lipoinjection between the capsule and the skin is done from the same two points and from the periareolar incision. This technique helps to ensure a diffuse distribution of the graft material; no injections are made into the mammary glands or into the capsular cavity. Finally, the capsular cavity is washed with saline and the periareolar incision is closed.

34.7 Cell Processing (Stromal Vascular Fraction Isolation Procedure) Processed lipoaspirate cells (PLA) cells and liposuction aspirate fluid (LAF) cells are separated from the fatty and fluid portions of liposuction aspirates,

respectively. For PLA cells, the suctioned fat is digested with 0.075% collagenase in phosphate buffered saline for 30 min on a shaker at 37°C after centrifugation. Mature adipocytes and connective tissues are separated from cell pellets by centrifugation (800 × g, 10 min); the pellets are then resuspended in erythrocyte lysis buffer (155 mM NH4Cl, 10 mM, KHCO3, 0.1 mM EDTA) and incubated for 5 min at room temperature. The pellets are resuspended and passed through a 100mm mesh filter (Millipore, Billerica, MA). To eliminate any remaining collagenase, the cells pellets are washed at least three times in Dulbecco’s Modified Eagle’s Medium (DMEM) by repeated suspension and centrifugation. For LAF cells, the suctioned fluid is centrifuged (400 × g, 10 min) and the pellets resuspended in erythrocyte lysis buffer. After 5 min at room temperature, lysates are passed through a 100-mm mesh filter. Again, the cell pellets are washed at least three times in DMEM and passed through a 100-mm mesh filter. The entire procedure should be performed by welltrained physicians or technicians in an aseptic room (preferably at a level of good manufacturing practice) according to a designated standard operating procedure. Isolated cells should be strictly evaluated regarding quantity and quality. Cell counts for erythrocytes and nucleated cells are performed using a cell counter used for standard blood testing. The whole process of cell isolation takes about 70–80 min. We also recommend that a fraction of the isolated SVF be seeded and cultured to verify cell viability, and another fraction be frozen and stored in a deep freezer or liquid nitrogen for future cell tracing.

34.8 Results of Clinical Trials (2003–2009) CAL was performed on 307 patients at various anatomical sites, including 269 breast procedures; 40 patients had breast reconstruction after mastectomy, 48 facial procedures, three procedures in the hand, and three in the hip. CAL was performed at two different sites in 17 patients. In 269 breast cases, 52 patients underwent CAL immediately after removal of breast implants. All patients were women with a BMI of 19.6 ± 2.1 (mean ± standard deviation) and the patient’s ages varied from 13 to 73 years (34.9 ± 11.2). The

34  Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue Quantitative analysis of volume change

A standard plane is defined by plotting 3 points. The volume of breast that extends beyond the plane is calculated.

Fig. 34.8  Three-dimensional system for measuring breast volume. Using this system, breast volume can be measured while the patient is in a sitting position

mean volume of injected fat was 268.6 ± 48.2 mL on the left side and 273.1 ± 40.4 mL on the right.

34.9 Preoperative and Postoperative Evaluations In order to evaluate outcomes, physical measurements (maximum and bottom breast circumferences, etc.) were taken, and mammography, magnetic resonance imaging (MRI), echography, photography, and videography performed. A three-dimensional (3D) measurement system was adopted, which enables volumetric evaluation of the breast mound in a standing position. Perpendicular striped lights are projected onto the breasts and photographed using a stereo-type digital camera (Fig. 34.8). The digital images are then analyzed using customized software. The volume and projection of each breast are calculated above a standard plane designated by three fixed points (the shoulder, suprasternal notch, and xiphoid process), which do not usually shift after breast augmentation.

34.10  Outcomes The procedure takes about 3.5–4 h including SVF isolation. The injection process requires 35–60 min for both breasts. Subcutaneous bleeding and edema are typical on some parts of the breasts, but this usually resolves within 1–2 weeks.

[ml] 500 450 400 350 300 250 200 150 100 50 0 0

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Sequential volume changes in breast augmentation cases (preliminary data: 28 patients)

Injection volume =277±39 [ml]

40-90%

30

60

90

120 150 [days]

180 210

240 270

Fig. 34.9  Sequential volume changes after cell-assisted lipotransfer measured using the three-dimensional system (preliminary results for 28 patients). Augmented volume among patients varied between 100 and 250 mL at 6 months, corresponding to 40–90% survival of transplanted adipose tissue

Transplanted adipose tissue was gradually absorbed during the first two postoperative months, particularly during the first month, and the breast volume changed minimally thereafter, although skin tension sometimes decreased after 2 months. The 3D measurements taken at 6 months follow-up showed that the surviving fat volume was 100–250 mL, meaning that the graft take ranged from 40 to 90% (Fig. 34.9). Compared to breasts augmented with implants of the same size, those augmented with CAL were lower but had a more natural contour and softness without any palpable nodules at 6 months follow-up. Patients were satisfied with the outcome despite the limited size increase possible with autologous tissue transfer. Computed tomography (CT) scans and MRI showed that transplanted fat tissue survived and formed a significant thickness of the fatty layer not only subcutaneously on and around the mammary glands but also between the mammary glands and the pectoralis muscles. Regarding CAL-mediated breast augmentation immediately after implant removal, most cases showed natural softness of the breasts without any palpable nodules at 6 months follow-up, and the patients were satisfied with the texture, softness, contour, symmetry, and the absence of foreign material. These satisfactory outcomes are similar to those observed in other soft-tissue augmentation cases, such  as in patients with hemifacial lipoatrophy (19) (Figs. 34.10–34.13).

268 Fig. 34.10  Breast augmentation. (a1–a2) Preoperative 30-year-old woman. (b1–b2) Twenty-four months after breast augmentation with CAL (310 mL in each breast). Her breasts were augmented dramatically with an 8.0 cm increase in breast circumference at 24 months. The breast mounds were soft with no subcutaneous indurations. An original infra-mammary fold on the left breast is slightly visible, but injection scars are not visible (5)

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a1

a2

b1

b2

a

b

Fig. 34.11  Breast augmentation. (a) Preoperative 36-year-old woman whose body mass index was 17.3. (b) Twelve-months postoperative after breast augmentation with CAL (245 mL in each breast). The breast mounds were soft with no subcutaneous indurations or visible scars at 12 months

34.11  Discussion 34.11.1 Refinement of Autologous Fat Graft Techniques It is well accepted that adipose tissue should be grafted in small aliquots, preferably within an area 3 mm in diameter (29). Because it requires a substantial length of time to perform ideal diffuse distribution of suctioned fat into the breast (1), a disposable syringe with a threaded plunger and connections and a very long

needle (150 mm) are used. These devices are critical for performing large-volume lipoinjection safely and precisely in the shortest time possible. We use a relatively large suction cannula (2.5–3.5 mm inner diameter), centrifuge the aspirated fat, and keep it cooled until transplantation. In our experience, outcomes (increase in breast size) are superior when centrifuged vs. noncentrifuged fat is used, although we are yet to perform a quantitative and statistical analysis of this observation. The reason that centrifuged fat produces better outcomes could be that the ASC to adipocyte ratio is improved following centrifugation (26). In addition,

34  Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue

a

Fig. 34.12  Breast augmentation immediately after implant removal. (a) Preoperative 33-year-old woman who had 210 mL saline implants and capsular contractures with upward displacement of the left implant. (b) Twelve-months postoperative after implant removal and simultaneous CAL (260 mL in each breast). The breasts were symmetric and had a natural appearance

a

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b

(bottom). MRI revealed that transplanted adipose tissues had survived and formed thick layers around and under the mammary gland. Mammograms showed no calcifications or other abnormal signs in either breast. Augmented breast mounds maintained sufficient breast volume even after implant removal and were naturally soft without any subcutaneous indurations

b

Fig. 34.13  Breast augmentation immediately after implant removal. (a) Preoperative 25-year-old woman who had 165 mL hydrogel implants (ruptured) with capsular contractures and displacement of the right implant. (b) Twelve-months postoperatively following implant removal and simultaneous CAL

(260 mL in each breast). The breasts were symmetrical, had a natural appearance, and mammography revealed no abnormalities. Augmented breast mounds were soft without injection scars or subcutaneous indurations

centrifugation may be of particular benefit in this procedure because centrifugation decreases the water content in the graft material. Higher water content could disturb the ASCs to adhere to the adipose tissue, leading to unexpected behaviors of ASCs, as discussed below. After transplantation, ASCs probably interact with other cells contained in SVF such as vascular endothelial cells. Therefore, in this treatment, supplementation with the SVF might be superior to supplementation with ASCs alone. Further studies are needed to elucidate the synergistic effects of ASCs with other cells contained in the graft.

34.12  Indications There are several patient factors that may affect the clinical outcome of CAL, such as skin redundancy of the breasts, age, BMI, personal quality or character of fat, scars and adhesions, breast implant and its capsule, systemic disease such as autoimmune disease, and oral corticosteroid use. Lean patients have a disadvantage because it is not easy to obtain 1,500 mL of fat from these patients. Some lean young patients with no history of pregnancy have flat chests and high skin tension, and therefore they cannot accept a large-volume fat graft due to skin shortage. Some patients have oily aspirates and others have

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fibrous aspirates. Patients who have undergone mastectomy have scarring and adhesions to the underlying fascia and some have a history of radiation therapy. Good candidates for CAL are those who have sufficient fat at the donor sites and sufficient skin redundancy on breasts with healthy skin vasculatity and no scars. In the authors’ experience, age does not appear to affect the clinical result. Patients with breast implants, who are already familiar with drawbacks of implants and have sufficient breast skin expanded by implants, are considered good candidates for CAL even though they have implant capsules in place (7). Similarly, the breast skin of women with a history of pregnancy and breast-feeding would have expanded owing to enlargement of the mammary glands, and their breasts can more easily accept a larger injection volume than those with no history of pregnancy.

34.13  Complications Cyst formation (5–15 mm diameter) was detected by MRI in two patients and by echogram in six patients. Tiny cyst formation (smaller than 5 mm), detected only by echogram, might happen more frequently, but no treatment is needed as long as the cyst diameter is less than 10 mm. Small calcifications were detected by mammogram in two patients at 24 months follow-up, but the calcifications were easily distinguished from those associated with breast cancer. Postoperative donor site problems, such as irregularity or seroma, could be more commonly associated with CAL than with conventional treatment because of the large volumes removed during liposuction. In two patients in whom an SVF cell suspension was injected into each breast mound (30 mL per side) immediately after conventional lipoinjection, the breast mounds were somewhat hard to the touch at 3 months; CT scan detected unexpected fibrosis in the subcutaneous fat layers of the breast mounds and on the sternum (30). Therefore, ASCs should be adhered to cells, tissue, ECM, or some type of biological scaffold prior to administration in order to avoid their unexpected differentiation, migration, or other behavior.

K. Yoshimura et al.

34.14  Conclusions Transplanting ASC-enriched fat tissue has provided satisfactory outcomes without any major complications. Our experiences with the CAL technique suggest that ASC supplementation is a safe and effective means of breast augmentation. Controlled studies with longer follow-up are necessary to establish the value of this technique. Continued improvements to this technique could make autologous tissue transfer the first choice for breast augmentation in the future.

References   1. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg 2007;119(3):775–785.   2. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg 2005;116(5):1300–1305.   3. Yoshimura K, Matsumoto D, Gonda K. A clinical trial of soft tissue augmentation by lipoinjection with adiposederived stromal cells (ASCs). Proceedings of the 3rd annual meeting of International Fat Applied Technology Society (IFATS), Charlotteville, Virginia 2005, pp. 9–10.   4. Spear SL, Newman MK. Discussion: Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg 2007;119(3):786–787.   5. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer (CAL) for cosmetic breast augmentation -supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg 2008;32(1):48–55.   6. Yoshimura K, Asano Y, Aoi N, Kurita M, Oshima Y, Sato K, Inoue K, Suga H, Eto H, Kato H, Hirohi T, Harii K. Progenitor-enriched adipose tissue transplantation as rescue for breast implant complications, Breast J, in press.   7. Yoshimura K, Asano Y. Fat injection to the breasts: cosmetic augmentation, implant replacement, inborn deformity, and reconstruction after mastectomy. In Aesthetic and Recon­ structive Surgery of the Breast (Eds) Hall-Findlay EJ, Evans GRD., Elsevier Ltd, London, in press.   8. Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells: roles in adipose tissue remodeling and potential use for soft tissue augmentation. Regen Med 2009; 4:265–273.   9. Matsumoto D, Sato K, Gonda K, Takaki Y, Shigeura T, Sato T, Aiba-Kojima E, Iizuka F, Inoue K, Suga H, Yoshimura  K. Cell-assisted lipotransfer: Supportive use of human adiposederived cells for soft tissue augmentation with lipoinjection. Tissue Eng 2006;12(12):3375–3382. 10. Zuk PA, Zhu M, Ashjian P, De Ugarte DA, Huang JI, Mizuno H, Alfonso ZC, Fraser JK, Benhaim P, Hedrick MH. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell 2002;13(12):4279–4295.

34  Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue 11. Yoshimura K, Shigeura T, Matsumoto D, Sato T, Takaki Y, Aiba-Kojima E, Sato K, Inoue K, Nagase T, Koshima I, Gonda K. Characterization of freshly isolated and cultured cells derived from the fatty and fluid portions of liposuction aspirates. J Cell Physiol 2006;208(1):64–76. 12. Gimble JM, Katz AJ, Bunnell BA. Adipose-derived stem cells for regenerative medicine. Circ Res 2007;100(9):1249–1260. 13. van Harmelen V, Skurk T, Hauner H. Primary culture and differentiation of human adipocyte precursor cells. Methods Mol Med 2005;107:125–135. 14. Miranville A, Heeschen C, Sengenes C, Curat CA, Busse R, Bouloumie A. Improvement of postnatal neovascularization by human adipose tissue-derived stem cells. Circulation 2004;110(3):349–355. 15. Planat-Benard V, Silvestre JS, Cousin B, Andre M, Nibbelink M, Tamarat R, Clergue M, Manneville C, SaillanBarreau C, Duriez M, Tedgui A, Levy B, Penicaud L, Casteilla L. Plasticity of human adipose lineage cells toward endothelial cells: Physiological and therapeutic perspectives. Circulation 2004;109(5):656–663. 16. Lendeckel S, Jodicke A, Christophis P, Heidinger K, Wolff J, Fraser JK, Hedrick MH, Berthold L, Howaldt HP. Autologous stem cells (adipose) and fibrin glue used to treat widespread traumatic calvarial defects: Case report. J Craniomaxillofac Surg 2004;32(6):370–373. 17. Garcia-Olmo D, Garcia-Arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes JA. A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum 2005; 48(7):1416–1423. 18. Fang B, Song Y, Lin Q, Zhang Y, Cao Y, Zhao RC, Ma Y. Human adipose tissue-derived mesenchymal stromal cells as salvage therapy for treatment of severe refractory acute graft-vs.-host disease in two children. Pediatr Transplant 2007;11(7):814–817. 19. Yoshimura K, Sato K, Aoi N, Kurita M, Inoue K, Suga H, Eto H, Kato H, Hirohi T, Harii K. Cell-assisted lipotransfer for facial lipoatrophy: Efficacy of clinical use of adiposederived stem cells. Dermatol Surg 2008;34(5):1178–1185. 20. Suga H, Matsumoto D, Inoue K, Shigeura T, Eto H, Aoi N, Kato H, Abe H, Yoshimura K. Numerical measurement of viable and nonviable adipocytes and other cellular components in aspirated fat tissue. Plast Reconstr Surg 2008;122(1):103–114.

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21. Eto H, Suga H, Matsumoto D, Shigeura T, Inoue K, Aoi N, Kato H, Araki J, Yoshimura K. Characterization of adipose tissue structure and cellular components: Differences between aspirated adipose tissue and excised adipose tissue. Plast Reconstr Surg, in press. 22. Strawford A, Antelo F, Christiansen M, Hellerstein MK. Adipose tissue triglyceride turnover, de novo lipogenesis, and cell proliferation in humans measured with 2H2O. Am J Physiol Endocrinol Metab 2004;286(4):E577–E588. 23. Spalding KL, Arner E, Westermark PO, et al.: Dynamics of fat cell turnover in humans. Nature 2008;453(7196):783–787. 24. Masuda T, Furue M, Matsuda T. Novel strategy for soft tissue augmentation based on transplantation of fragmented omentum and preadipocytes. Tissue Eng 2004;10(11–12): 1672–1683. 25. Moseley TA, Zhu M, Hedrick MH. Adipose-derived stem and progenitor cells as fillers in plastic and reconstructive  surgery. Plast Reconstr Surg 2006;118(3 Suppl): 121S–128S. 26. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, Yoshimura K. Influences of centrifugation on cells and tissues in liposuction aspirates: Optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg 2008;121(3):1033–1041. 27. Rehman J, Traktuev D, Li J, Merfeld-Clauss S, TemmGrove  CJ, Bovenkerk JE, Pell CL, Johnstone BH, Considine RV, March KL. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation 2004;109(10):1292–1298. 28. Suga H, Eto H, Shigeura T, Inoue K, Aoi N, Kato H, Nishimura S, Manabe I, Gonda K, Yoshimura K. IFATS collection: FGF-2-induced HGF secretion by adipose-derived stromal cells inhibits post-injury fibrogenesis through a JNK-dependent mechanism. Stem Cells 2009;27:238-249. 29. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 30. Yoshimura K, Sato K, Aoi N, Kurita M, Suga H, Inoue K, Eto H, Hirohi T, Harii K. Ectopic fibrogenesis induced by transplantation of adipose-derived progenitor cell suspension immediately after lipoinjection. Transplantation 2008; 85(12):1868–1869.

Fat Transfer to the Hand for Rejuvenation

35

Pierre F. Fournier

35.1  Introduction It is as important to think of rejuvenating and embellishing the hands, as it is to think of rejuvenating and embellishing the face. However, very few techniques have been developed for this and few patients at this time request esthetic improvement for their hands. Probably people do not know that such an improvement is possible, because as soon as they are informed that certain procedures are available, they become very enthusiastic and ask to have them done. Following facial or face and neck rejuvenation, it should be normal practice to prescribe similar treatment for the hands. After all, why have hands that look 10 years older than one’s face? Hands, like the face, often look much older and worn than the rest of the body which is protected from the sun and wind for most of the year. A woman’s hands may be damaged by housework because they are not always protected by gloves and by exposure to the more or less corrosive external agents. Face makeup can camouflage aging, but hands have no such artifice. Hands are like face – some stay young for a long time and their shape and color do not change. There are full hands just as there are full faces, and there are thin hands just as there are thin faces that have aged inside and out. Most often, as in any aging process, the hands shrink, the veins appear more bulging and more colored than in youth, and the complexion darkens. Hyperkeratoses appear, multiply, and spread. The back of the hand and the fingers age but not the palm or the palm side of the fingers. P. F. Fournier 55 Boulevard de Strasbourg, 75010 Paris, France e-mail: [email protected]

The degeneration, apart from keratoses and wilted complexion, is due to atrophy and involution of the other components of the hand, mainly the bones and intrinsic muscles, as well as alteration of skin texture. The skin crumbles, wears, and becomes darker just like in the aging of the face. Tissue involution takes place.

35.2  Hand Rejuvenation 35.2.1  Hand Lift A hand lift that consists of a greater or lesser undermining of the hand and intradermal suture on the ulnar side of the hand has been proposed. Another technique proposes skin undermining at the wrist level on the back side of the hand. The scar is more visible, but the skin excess will be more even. This skin “lift” results in some improvement, but in order to get better results there has to be added resection of the skin excess on the fingers at the joint between the first and second phalanges. These techniques, at best, only treat the skin excess and not the complexion of the skin.

35.2.2  Dermabrasion The dorsum of the hand reacts remarkably well to mechanical dermabrasion. This technique poses no technical problems. However, the same inconveniences and complications as in facial dermabrasion such as hyperpigmentation, hypopigmentation, and a sharp border with the untreated skin are possible. Although the results are generally good, the long-term results are not known.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_35, © Springer-Verlag Berlin Heidelberg 2010

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35.2.3  Skin Peel Phenol peel has been done by a few surgeons. One hand should be treated first and then the other after a 6–8-day interval so that the patient will not be handicapped. Hypertrophic scars can occur that may be improved with steroid treatment. Some surgeons use the classic phenol solution that has aged for several years. After aging, the solution is weaker and can be used regularly, even on Asians, with reportedly good results. The border between the treated and nontreated areas is not very visible and the wrist or forearm can also be treated. Although lifts, chemicals, and dermabrasion treat the problem of excess skin or pigments, they do nothing for the veins that show up even more than usual. This characteristic disturbs some women who consciously or unconsciously keep their hands held high during a conversation, which makes prominent veins decrease or disappear. Artists and advertisers never show a congested or unaesthetic hand.

35.2.4  Vein Stripping Vein stripping was relatively popular at one time. The operation is very simple because of the short length of the veins. A sufficient “internal stripper” can be a simple plumbline (e.g., a 0.2-mm fuse wire), a hair pin, a thick thread, or even a fine hemostat forceps used like an external stripper that will allow resection where veins are concerned. Not all the veins on the dorsum of the hand are to be automatically stripped. It is remarkable to see the patient choose by saying, “Take that one away, it makes me look old, but not that one which looks normal.” After local anesthesia using 1% lidocaine with epinephrine in the skin where the incisions are to be made and where the vein crosses, the vein is approached at the level of the metacarpophalangeal joint in a crease. The incision is 4–5 mm long. The vein is exposed using a hemostatic forceps and tied with fine catgut or 5–0 absorbable suture. The ligature acts in turn as a tracking wire, and a longitudinal incision is made in the area subadjacent to the ligature. The stripper is then inserted. The author prefers to use a hairpin with a blunt end, after it has been bent into shape. At the wrist level, a small horizontal incision is made at the projection of the exposed vein, and its upper part ligated. The blunt end

P. F. Fournier

of the stripper is exposed. A plastic bead can be placed at the end of the hairpin, as if one were making a necklace, and the pin bent at right angles to obtain a solid construction. Soft traction of the upper part of the pin brings the vein back without a problem. The vein is telescoped on the plastic bead as in a varicose vein stripping of the lower limbs. A pressure dressing is applied for 5–10 min since the tributaries are torn during the procedure. This bandage is applied by an assistant and will not prevent the surgeon from stripping a second vein as far away as possible from the first. After suturing the incision with a fine suture, a moderate pressure dressing is applied. The patient is advised to keep the hand in a raised position for the rest of the day. This can be accomplished by a scarf or sling tied around the neck. This bandage is removed after 24 h. Bruising and edema are variable and will be slowly resorbed. Sutures are removed on the fourth postoperative day. The hand gains its normal appearance in 6–8 days. Once the patient can use the operated hand normally, the other hand can be treated or other veins on the operated hand can be stripped. The author has never seen persistent edema of the hand or exaggerated venous circulation in the remaining veins. Satisfactory results are always obtained. This could be also due to the fact that patients are rigorously selected or highly motivated.

35.2.5  Autologous Fat Autologous fat grafting is an established method for ­tissue augmentation (1–3). The author injects adipose tissue in order to counter the exaggerated appearance of the veins on the dorsum of the hand. Fat is removed with a syringe and a 4-cm-long needle having a 2-mm external diameter (14 gauge), and 10 mL is injected into the entire back of the hand, although sometimes 12–15 mL is used. The hand fill is as justified as the face fill, since it corresponds to loss of tissue. Hand lift or stripping only indirectly and imperfectly corrects the problem, with a heavy scar price to pay if a lift is done. A fill of the dorsum of the hand cannot cause pigmentary blotches to disappear, but the skin darkens because of wrinkling and bunching of the skin over the responsible deep elements. The skin changes that are due to aging will not be altered, but those caused by the loss of volume of the internal structures will be remedied.

35  Fat Transfer to the Hand for Rejuvenation

Even if complete rejuvenation is not accomplished at least the faded complexion problem will disappear or greatly decrease, and the color of the dorsal veins will be lightened and their overall appearance less noticeable. Once the result has been obtained, it is up to the aesthetic surgeon to decide whether a light peel, mechanical dermabrasion, or electrocoagulation of the pigmentary spots is to be advised. Hydrogen peroxide applied by the patient repeatedly over a period of many weeks has shown good results. Electrocoagulation of the pigmentary spots on the dorsum of the hand is an excellent treatment if it is carefully done.

35.2.6  Silicone Hand fill has been practiced in the Philippines and Japan using injectable silicone. The use of injectable silicone is illegal in France and many other countries, even though, in some cases, if silicone is injected in very small amounts at long intervals, it can give good results (e.g., the small wrinkles of the upper lip or forehead can be treated this way). The silicone must also be very pure. It has the drawback of migrating in some cases and can cause unaesthetic mounds on the face. These mounds are impossible to treat because of the possibility of facial paralysis during the treatment. Surface defects caused by their ablation, which is necessary for localized hardening, inflammation, or tissue necrosis, are also possible. The dangers caused by the incorrect use of silicone are much greater than the good results that can be obtained. After a certain amount of time, the silicone can also become yellowed. This is not a problem for Asians but may be a problem for Caucasians. This explains why there has been a wave of injections of small doses of silicone in Asia, which eliminates the need for stripping or lifting the hands.

35.3  Technique for Fat Transfer 35.3.1  Harvesting Zone Markings The extraction zone surface will vary depending on the quantity of adipose tissue to be extracted. This extraction should not leave any surface irregularities.

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The chosen zone should be marked while the patient is standing if this zone is located in the trochanteric region or hip, or with the patient supine if it is located in the lateral buttock or abdominal wall since the morphology is modified by the position. The markings should be a circle, oval, square, or rectangle. The interior of the marked zone should be subdivided into small rectangles approximately 4 cm long and 3 cm wide. Their number should be approximately equal to the number of syringes necessary to do the hand filling. With one syringe, 5 mL of adipose tissue can be extracted. A regular extraction can be easily performed without leaving a residual deformation in the totality of the zone if only 5 mL of adipose tissue is removed from each of the rectangles, which therefore serve as measuring units.

35.3.2  Operative Zone Disinfection Rigorous asepsis is necessary. The integument is usually disinfected with either 90% alcohol, or any other product, according to the surgeon’s preference. The surgeon should be gloved and masked. Draping of the operative zone should be done as for any other operation before anesthesia is given. When using nonsterilized external refrigeration as anesthesia or as a complement to local anesthesia, disinfection should be done and the drapes should be placed when this is finished.

35.3.3  Operative Zone Anesthesia Anesthesia in the operative zone should be different from that used for reduction microlipoextraction. Remember the following: 1. In the case of microlipoextraction for reduction lipoplasty and reinjection of tissues is not foreseen, “The most important thing is not what one extracts, but what one leaves.” 2. In the case of microlipoextraction to reuse the tissues obtained during the extraction, “The most important thing is not what is left, but what one extracts.” In both cases, the tissues must be respected by the surgeon, but the tissues to be respected differ in each case.

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The fraction that must remain is what matters, not the fraction that will be eliminated. A noninfiltrated “dry” extraction is preferable to an infiltrated extraction because of the hydraulic trauma of the injection added to the chemical trauma caused by the injection of lidocaine and epinephrine. Therefore, in the case of microlipoextraction and reutilization of the extracted tissue, utmost care should be taken by the surgeon for the tissue to be reinjected.

and the surgeon can perform the extractions satisfactorily. This type of anesthesia is for ambulatory patients.

35.3.4  Anesthesia of the Harvesting Zone

35.4  Pure Hand Lipofilling Technique

Anesthesia of the donor zone should be performed first.

(a)  Instruments

1. Local anesthesia Even though local anesthesia is not theoretically desirable for the previously mentioned reasons, it is often used. Lidocaine 1% with 1:200,000 epinephrine is used. For anesthesia through infiltration, the greater the surface to anesthetize, the weaker the solution should be. In general, a 2°C solution is used to dilute to 1/4th concentration. A weaker solution is perfectly possible at a fifth, eighth, or tenth. All marked regions should be infiltrated at the same time. It will simply take longer for the anesthesia to take effect. The infiltration should be made throughout the thickness of the layer of adipose tissue, but especially in the depth. External refrigeration with ice bags is used for 20 min. The purpose is to obtain an extraction with as little bleeding as possible and to reinforce the anesthesia. When it is possible to create a thick fold with the left hand (e.g., on the abdomen), one can use a long needle (spinal needle type but finer), anesthetize exclusively the depth of the adipose tissue in this fold, and obtain anesthesia of the overlying tissues where extraction can be easily obtained in a noninfiltrated zone. 2. Cryoanesthesia The best method is cryoanesthesia. 3. General anesthesia Sometimes patients want general anesthesia rather than local. This is inconvenient, since the patient is kept in the clinic longer, but it is the ideal technique for large extractions. Twilight anesthesia can also be used. Two or three zones can be refrigerated simultaneously

4. Observations External refrigeration of the areas to be operated on should be done before any other anesthesia (general, twilight, block, or local) as well as before any kind of extraction or injection of adipose tissue. The refrigeration should be maintained for about 20 min.

Very little equipment is necessary for a hand fill. 1. The “classic” filling needle (2 mm outside diameter and 4 cm long is a useful length). Disposable 14-gauge needles are available. 2. Needles for local anesthesia (30 and 20 gauge). 3. Disposable plastic syringes (10 mL). 4. Saline solution ampule (20 mL) at room temperature or at 2°C that will serve to dilute the local anesthetic to avoid all dead space in the syringe, diminish the impact, facilitate the transportation, and to wash in the adipose tissue. 5. Transfer needle of 2 mm external diameter. 6. Wooden or metal test tube holder. The author no longer uses 2-mL insulin syringes or 5-mL syringes, which do not permit washing of the extracted adipose tissue. If the face fill is done at the same time as body liposculpturing, the adipose tissue extracted with the help of single-orifice cannulas of 3 or 4 mm outside diameter and 50- or 60-mL syringes can be reused if it is transferred to 5- or 10-mL syringes on which the usual 2-mm outside diameter (14 gauge) filling needle has been mounted. (b)  Extraction technique The syringe allows the extraction, preparation, and reinjection of the adipose tissue in a closed space while maintaining the integrity and sterility of the extraction. (c)  Extraction of the adipose tissue Using a filling needle (14 gauge) of 2 mm outside diameter mounted on a 10-mL syringe, 2 mL of saline solution at room temperature or at 2°C is drawn into the syringe. The left hand makes a fold on one of

35  Fat Transfer to the Hand for Rejuvenation

the rectangles marked on the extraction zone, and the needle is pushed through the skin into the middle of the adipose tissue. The left hand is then placed flat on the ­extraction zone and will stay that way throughout the operation. The right hand pulls out the syringe plunger completely and the surgeon begins the extraction. During the whole extraction process, the plunger is kept in the same p­ osition (7). Back and forth movements are made in a fan-shaped fashion almost over the length of the needle. Four to five of these movements are made in one direction before going to the neighboring region without taking the needle out but keeping it below the skin. Once 5 mL has been obtained, the needle is removed and 3 mL of saline is drawn into the syringe. The syringe is placed vertically in a test tube holder with the plunger up. The needle that was used for the extraction is mounted on another syringe for use in another extraction. This takes place while the adipose tissue in the first syringe is going through a period of decanting, which is the first phase of washing. Once 5 mL of adipose tissue has been extracted with the second syringe, 3 mL of saline solution should be added and the syringe placed vertically in the test tube holder. The predetermined amount of adipose tissue will be removed from each of the rectangle marked at the extraction zone. (d)  Washing When the extraction is finished, the surgeon washes the adipose tissue with the saline solution. Once 3 mL of the saline solution has been drawn into the syringe and it is placed vertically in the test tube holder, one can see the mixture separate into two parts with the adipose tissue on the top and bloody saline solution on the bottom. This separation takes place after a few seconds. The washing can also be done with 5% glucose solution. This hydrohematic fraction is emptied into a cup, and 5 mL of saline solution is again drawn into the syringe. The syringe is again placed in the test tube holder in order to obtain separation of the two fractions while performing the same maneuver with the other syringes. There should be as many washings as are necessary to obtain bloodless adipose tissue. In general, two to four washings are necessary, sometimes more if the sample is very bloody or if not enough time is allowed between each wash. A transfer needle will allow the

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adipose tissue to pass from one syringe to another in order to get equal amounts for symmetrical regions. The reinjection can be done when all the syringes have been prepared. Locally, there should be an occlusive, slight compressing dressing made of a few compresses kept in place with several Elastoplast bands or a layer of Elastoplast. This dressing should be removed after 24 or 48 h. It may have to be changed every few hours if bleeding persists. (e)  Reinjection Once the dressing is done, the injections should be performed. The needle used for the reinjection should be of the same caliber as that of the extraction needle, namely, of 2 mm outside diameter. One must inject with caution and make sure of not injecting into a vessel. This maneuver can be performed, if desired, with the needle mounted on an empty syringe. Once this is done, the syringe full of adipose tissue is used and the injection begins. Unless the patient is under general anesthesia or ­twilight anesthesia, a wrist block is used with 5 mL of 0.5% lidocaine containing epinephrine. After waiting for 15 min (the block is accomplished after the fat removal so that no time is wasted), the upper part of the dorsum of the hand is injected with 10 mL of the removed adipose tissue (Fig. 35.1). The veins are fewer and less apparent on the upper part of the hand. The lump thus created is easily spread out by soft pushing. The fat is gently spread through the dorsum of the hand as the initial opening is kept covered with one finger so that no fat comes back out. Before doing this, the patient is asked to make a fist, which makes the operation easier and helps to spread the fat. One must not forget to push a little fat tissue to the base of the fingers since patients will notice the absence of fat in these areas. Bandaging is not used, and the patient can get back to his or her normal life the day after the surgery. The only advice is to place the hand in an inclined position using a scarf knotted around the neck. Edema and some bruising is part of the operation. The bruises can be covered with foundation or Cover Mark until they disappear. Hand filling is done on an ambulatory basis without general or twilight anesthesia. The whole operation including preparation, surgery, and patent rest takes about 1.5–2 h. Vibramycin for 5 days is prescribed,

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a

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P. F. Fournier

is to create an inflammatory condition of the fat tissue and to graft a “healing fat tissue” instead of normal fat tissue. This possibility is explained to the patient, who will choose between “fresh fat grafting” or “prepared fat grafting.” In the latter case, conventional local anesthesia and/ or cryoanesthesia (external) is used with a spinal needle or an ordinary 19-gauge needle stroking repeatedly the whole thickness of the fat layer of the harvesting zone for 1–2 min. No fat is removed. A dressing is applied and the patient is sent home. The future receiving area may be prepared the same way. After 10–12 days, the patient has conventional fat harvesting and the first injection of fat performed. The remaining fat is kept in the freezer for future injections. Histological studies have shown that the specimen of fat obtained with this delayed harvesting has many new vessels, new collagen fibers, and a great number of fibroblasts. This “prepared fat” decrease the number if injections necessary for a long-lasting result.

35.6  Implant Conservation (a)  Conservation of implants in the freezer

Fig. 35.1  Autologous fat transfer. (a) Injecting into the dorsum of the hand. (b) Making a fist to spread the fat and also spreading by manual pressure

more for medicolegal reasons than for risk of infection, which is minimal. Anti-inflammatories (Reparil) are prescribed for 15 days. Analgesics are not necessary.

35.5 “Prepared” Fat Grafting: Delayed Harvesting A few years ago, the author started to prepare the donor area to obtain better results and decrease the number of injections necessary for a long-lasting result. The aim

Conservation of all types of implants coming from adipose tissue is easily possible through cold storage. The results obtained do not differ from those with the fresh implants normally used. The purpose of this conservation is to save the excess implant extracted or to avoid new extraction when repeated injections are foreseen. Tissue conservation by refrigeration is a classic technique, as in the case of other cells (sperm), and the efficiency of the technique has been proven. All types of implants coming from adipose tissue have been kept in the freezer and reused by the author, some after a whole year. Types of implants include the following: 1. Adipose cylinders extracted with a 2-mm-diameter needle (washed with saline solution). 2. Microimplants extracted with 112/10-mm (19 gauge) or an 8/10-mm (21 gauge) needle (washed with saline solution). 3. Implants extracted with 3–4 mm-diameter cannulas and 60-mm syringes that can be used with 5–10-mL syringes and the classic 2-mm-diameter fill needle (washed with saline solution).

35  Fat Transfer to the Hand for Rejuvenation

4. Autologous collagen extracted with an 8/10- or 12/10-cm-diameter needle (washed with distilled water and kept in the freezer). This collagen can be used as a dermal implant (using an 8/10-cm-needle or Dermojet) or as a subcutaneous implant. (b)  Technique After washing with either a saline solution or distilled water to rid the implant of all traces of blood or hemoglobin, in every case the sterile cap of an injection needle is placed on the hub of the syringe. All extraction syringes are placed in a test tube rack and are then placed in the freezer or refrigerator. To reuse the implants thus kept, one needs to only take them out of the freezer compartment 1 h before reutilization. This defrosting of the implant is done at room temperature (22°C) in a test tube holder. As is well known, the freezing should be rapid, whereas the defrosting should be slow. A quicker freezing than that obtained using the freezer can be obtained with liquid nitrogen. The syringe is placed for a short time in a liquid nitrogenfilled container before placing in the freezer. A quicker defrosting can be obtained in warm water (28 or 30°C). The syringe or syringes with the cap are placed in a container with tap water warmed to this temperature. The results obtained with the help of these conserved implants are no different from those obtained with fresh implants (on the face or hands). The repeated operations necessary are more easily accepted by the patients.

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Pain and discomfort are rare complications. The author has never seen liquefaction of the graft or infection. Often a localized, sensitive induration may be noticed in the treated areas, which is more palpable than visible and disappears spontaneously in a few weeks, but sometimes lasting longer. In order to avoid significant reactions, it is important not to overcorrect the volume of the region treated. One wants the patient to return to a normal appearance within a few days. Necessary overcorrection can be done with repeated injections spread out over time. These are more easily accepted than an overcorrection in volume that leaves the patient marked for a much longer period of time as a consequence of the operation. Moreover, small quantities of fat take better than larger ones. The only unfavorable problem is the disappearance of the results obtained due to total reabsorption of the graft. This is noted in a certain number of cases. In about 10% of the cases, the patient has cysts in one or several places on the dorsum of the hand. The surgeon can either crush them or remove them under local anesthesia (Fig. 35.2).

35.7  Complications Edema is not a complication but rather a part of the operation. It varies from patient to patient. Sometimes edema is not severe but sometimes it deforms the area. In most case, after 3 days, the deformation of the treated area is no longer visible except perhaps to the patient. Less often, the treated regions can have abnormal edema for about 8 days. Ecchymoses are rare because the adipose tissue is washed. There can, however, be small ones related to the anesthesia or the adipose tissue injection. Sometimes they are delayed and appear on the second or third day. Ecchymoses can be hidden with makeup.

Fig. 35.2  Cysts of fat excised

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a

P. F. Fournier

of the results is due to the particular structure of the injected area. The rigidness of this area, due to the carpal and metacarpal bones, creates a veritable inner splint. This limits the transfer’s absorption. This sort of splint is not found in the face or even provided by the muscles because these speed up the absorption of the injected implant. Even if the results of the fill on the dorsum of the hand were only temporary, the simplicity of the operation makes it a must in the aesthetic surgeon’s armamentarium. A person’s age can be judged not only by their face but also by their hands.

b

35.9  Conclusions After studying different classic operations to rejuvenate or embellish the hand, the author proposes that the fill of the dorsum of the hand and fingers is more durable than that of the face. This has been one of the most satisfactory operations of fat grafting for the patient and the surgeon (Fig. 35.2). It can be combined with a light peel and electrocoagulation of senile keratoses. Fig. 35.3  Fat transfer to dorsum of hands. (a) Preoperative. (b) Postoperative following fat transfer

35.8  Durability of Results The patient should be warned that multiple injections may be necessary. In the hand fill, 25–50% of the injected implant is viable. Never try to overcorrect since there is some uncertainty as to the degree of resorption, which can be an unaesthetic deformation of the area for several weeks. The author has had to reinject the hands in a few cases where resorption occurred after several weeks. The patient sees a notable change quite soon after the operation but a permanent result follows (Fig. 35.3). About 10% of patients have to be reinjected after 3–6 months in order to obtain a lasting result. The durability

References 1. Gurney CE. Experimental study of the behavior of free fat transplants. Surgery 1938;3:680. 2. Munir CL. Greffe du tissue adipeux autologue. Etude experimentale. Rev Chir Est 1990;58:23. 3. Peer LA. Transplantation of Tissue. Baltimore, Williams & Wilkins 1955. 4. Stevenson TW. Fat grafts to the face. Plast Reconstr Surg 1949;4(5):458–468. 5. Skouge JW, Canning DA, Jefs RD. Long term survival of perivescical fat harvested and injected by microlipo injection techniques in a rabbit model. Presented at the 16th Annual American Society of Dermatologic Surgery Meeting, Fort Lauderdale, FL, March 1989. 6. Wetmore SJ. Injection of fat for soft tissue augmentation. Laryngoscope 1989;99(1):50–57. 7. Fournier PF. Liposculpturing: The Syringe Technique. Paris, Arnette Blackwell 1991.

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

36

Robert F. Jackson and Todd P. Mangione

36.1  Introduction The female form should have a sense of softness with no flatness or irregularities. Persistent gluteal depressions can limit the optimal results of liposculpture for the cosmetic surgeon. Visualization of the waist, buttocks, hips, and thighs as a unit and the perceived end result is extremely important. The goal of liposculpture is to find a continuous smooth profile, which is somewhat S-shaped, wider at the hips than the waist, and with­out dents or indentations (1). The causes of persistent depression can be iatrogenic as in lipolysis, secondary to medication injections, including steroids. It also occurs as a normal anatomic variant such as a bony or  muscular prominence seen after liposuction. This appear­ance affects the artistic profile the surgeon is trying to create. The maximum gluteal depression is the maximum concavity in the convex curve of the hip and lateral thigh (2). A persistent depression in this area following liposuction or without liposuction does not give the round smooth curvature that most consider an attractive derriere. The primary concern during liposculpture is removal of the bulges in the area of the iliac crest and lateral femoral regions. The depressions or bulges that remain need to be contoured using liposculpture, liposhifting, or lipo-augmentation. The surgeon needs to appreciate this profile to achieve the ideal contour. The whole process is a true sculpturing procedure. Fat has been found to be an excellent filler that is autologous, available, and injectible. It has the same consistency as the surrounding tissue, which is an advantage over other fillers (1, 3). Fat treated gently

R. F. Jackson () 330 North Wabash Avenue, Suite 450, Marion, IN 46952, USA e-mail: [email protected]

preserves its integrity and allows for predictable results. Fat grafting can provide long-term results. Fat grafts that survive beyond 3 months should last many years and are often permanent (4). There are numerous studies that show fat survival exceeding 5 years (3). Fat survival is increased in areas of decreased movement (3, 4). The depression left in the trochanteric area is, therefore, an excellent area for fat grafting. Due to the loss of some of the transplanted fat, up to 50% in some studies, it is important to overfill the area slightly at the time of the initial injection (3–5). The buttocks, hips, and lateral thighs need to be considered as a unit. The depressions due to bony structures and lack of fat in the trochanteric area need to be addressed to achieve the optimum feminine physique.

36.2  Surgical Concepts Proper handling of graft material, in this case fat, is of the utmost importance for uniform results. There have been many methods of harvesting and preparing fat for use as an autologous graft. Smith et al. (6) describe various methods for harvesting and preparing fat. They compared syringe versus aspiration liposuction. The study compared other variables including no preparation, centrifugation only, washing with saline and/or ringers lactate, and washings with centrifugation. The samples were then compared histologically, via XTT (sodium 3¢-(1-phenyl aminocarbonyl)-3,4-tetrazolium)bis(4-methoxy-6-nitro)benzene sulfonic acid hydrate) for viability at various times. There was no significant difference in aspiration techniques in any of the sample groups in the first hour after harvest. At 90 min, the centrifugation samples showed decreased viability versus the other samples and at 2 h the viability of the no

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preparation sample was significantly (p = 0.001) better than the rest. There is no data to support superiority of any preparation technique. The increased training, time and equipment costs of washing the fat, and centrifugation seem unnecessary based on this data. Centrifugation could theoretically traumatize fat cells and inhibit their survival. The authors’ technique, therefore, has evolved to the point that the fat is only washed if it appears bloody and the harvested fat is never centrifuged.

36.3  Technique The evaluation of the patient for liposuction centers on the areas that are troubling to the patient and proceeds to what can be done to give patients the profile that a

c1

Fig 36.1  (a) Female derriere with curves and roundness. (b) Postoperatively the patient demonstrates an excellent result with lack of flatness. (c1, c2) Thirty-year-old female postoperatively with round pleasing female appearance after liposuction concentrated on lateral thighs with a small amount of contouring in hips. The accrual buttocks per se were untouched

they desire. One must begin with a thorough history and physical examination. During the history and physical examination it is very important to determine if the patient has realistic expectations and if there are any outside forces contributing to the consultation. Beware of an impulsive patient with unrealistic expectations. It is extremely important to discuss in detail with the patient both common and rare complications. If you are planning lipo-augmentation the patient must be aware that it may require more than one series of treatments and grafts to achieve the final result. Point out defects to the patient preoperatively on photographs or digital scanning. Be sure to tell the patient you may or may not be able to totally correct those defects. A round derriere is very feminine and important to most patients (Fig. 36.1). To shape the buttocks and late­ral thighs one must have an idea of the ­postoperative b

c2

36  Correction of Deep Gluteal and Trochanteric Depressions

Fig 36.2  Gasparotti’s technique to help visualize end result

appearance. A good way to appreciate this roundness is to place each hand with the thumb, and index finger at a 90° angle at the level of the gluteal crease. The thumb is placed along the crease with the index finger in line with the new profile (Fig. 36.2). In this position one can ascertain the amount of fat that needs to be removed and the shape one wants to attain. Gasparotti’s point is noted at the base of the angle made by the thumb and index finger. This point is the area where the lateral thigh joins the buttocks. This area is marked and a small hollowing of this area will add contour to the buttock and give the illusion of longer legs (Fig. 36.3).

a

Fig. 36.3  (a) Slight hollowing of the G-point. (b) Visual lengthening of leg and rounding of silhouette

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The preoperative work-up should include a complete blood count or at least a hemoglobin and hematocrit. Bleeding and clotting times, a basic chemical panel, and an HIV study also should be included. The markings that are performed in the preoperative area are very important. Separate colors are used to differentiate those areas that are to be liposuctioned versus those to be lipo-enhanced. All of these markings are made with the patient in the upright position as the contour looks different when the patient is placed in a supine position. The tissue to be removed under the marked skin remains constant even with the patient in the supine position. The markings used are similar to a topographic map with concentric circles indicating increasing elevation (Fig. 36.4). Depressions are marked in a similar fashion with another color ink or labeled “fill” (Fig. 36.5). It is very important to determine the maximum point of gluteal depression so that as you sculpture you can achieve a roundness with that area now being the point of maximum convexity. To do this, the author’s method is to have the patient laterally abduct their leg. The area that becomes prominent as a depression is then marked with a series of hash marks (Fig. 36.6). This indicates the point of maximum depression and is usually found just above the greater trochanter. This provides an excellent point on which to base the new profile for the patient. Another helpful guideline is to make a vertical line of the patient’s proposed new profile on their skin with a different color ink (Fig. 36.7). Taking a moment during the preoperative

b

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Fig. 36.5  The central area to be filled with fat marked either with a different color or labeled “fill”

Fig. 36.4  Concentric markings indicating elevation

marking is an excellent time to again describe to the patient asymmetries that she may have. One should also describe the condition of the skin tone and dermal irregularities that may exist and may persist after surgery has been accomplished. The patients are all given a preoperative prophylactic antibiotic, either Kefzol 1 g or Cipro 500 mg (if there is a history of allergy to cephalosporins or penicillin). This is administered intravenously (IV) in the preoperative holding area. Patients take oral antibiotics for 5 days postoperatively. When performing liposuction of larger areas of the body, 8–12 mg of Decadron

is administered, which is useful in decreasing postoperative inflammation. Tumescent fluid is infiltrated into the areas to be liposuctioned. One liter of normal saline (0.9%) with 50 mL of 1% Lidocaine and 1 mg of epinephrine is utilized. For pure tumescent technique with no IV sedation or general anesthesia, the concentration of the Lidocaine is increased to 100 mL of 1% Lidocaine. The more appropriate specification is 500 mg of Lidocaine per 1,000 mL. According to Klein the current recommendation for tumescent liposuction totally by local anesthesia is 500–1,500 mg of Lidocaine per liter and 0.65–1.0 mg of epinephrine per liter of normal saline (2). The addition of 12.5 meq of sodium bicarbonate will decrease the pain associated with the infiltration of the tumescent fluid. Once the patient is in the operating room the surgeon needs to make sure that he or she can conceptually visualize where fat needs to be removed and where the patient may need lipo-augmentation. A round smooth

36  Correction of Deep Gluteal and Trochanteric Depressions

a

b1

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b2

Fig. 36.6  (a) Maximum gluteal depression. Leg extended slightly. (b) Markings for filling

Fig. 36.7  Vertical line demonstrating the outline desired. Anterior margin defined. Combination of liposcultpturing with lipo-augmentation can result in round contour

derriere needs to be created and it is important to realize that the superior lateral portion of the buttock may need to be rounded and the waist may need to be narrowed to achieve that perception of roundness and softness. The surgeon needs to know that the fat is oriented in a more superior medial plane in the high hip area than the fat of the lateral thigh (Fig. 36.8). Superficial liposuction may be required to prevent flaccidity of the skin (7). In the area of the lateral thighs, it is important to perform liposuction in a vertical fashion along the long axis of the inner and outer thighs. This helps to decrease “divot” formation, which is the natural contraction of

the tunnels made by liposuction. Horizontal tracts ­contract vertically and vertical tracts contract horizontally. One must use both visual and tactile modalities while sculpturing. It is important to remember what Fournier has often been quoted as saying, “ What you take away is not nearly as important as what you leave behind.” It is imperative that you follow your preoperative markings. During the initial liposculpturing, begin with either a Coleman or an Amar harvesting cannula (Fig. 36.9). If the areas superior and inferior to the point of maximum depression need to be lowered to give a more rounded and less angulated appearance to the buttock, lateral

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Fig. 36.8  Marking high hip

Fig. 36.9  Coleman harvesting cannulas

a thighs and greater trochanteric area, fat is harvested from those areas to be transferred later into the gluteal depression. If concomitant liposuction is not needed or cannot be performed in the adjacent areas and no other liposuction is being done at the same time, the medial aspects of the knees are an excellent, very forgiving area from which to harvest fat for augmentation. The authors’ technique is to use Byron VacLok 10-mL syringes (Fig. 36.10). As the fat is aspirated, always visualize and evaluate by feeling the areas from which you are removing fat. It truly is a sculpturing procedure. Each of the 10-mL syringes is filled with one or 2 mL of saline. The theory is that the saline cushions the fat as it is aspirated. The fat with little or no blood is transferred into a large 60-mL syringe with the plunger removed. The syringe is left standing upright in a basin and the tumes­ cent fluid and saline are allowed to drain out of the syringe. Multiple syringes are filled until enough fat has been obtained to correct the defect and also allows sufficient fat left over to freeze for later potential treatments. After the completion of the harvesting procedure, the

b

Fig. 36.10  Using the VacLok syringe. (a) Harvesting with Coleman Extractor. (b) Coleman Extractor

36  Correction of Deep Gluteal and Trochanteric Depressions

tumescent layer diffuses into the saline container along with the saline, and then the oil layer on top is skimmed off leaving the adipocytes. This remaining fat graft is placed in multiple 10-mL syringes to be stored in a freezing environment. The area to be augmented is field blocked with Lidocaine or a small amount of the Klein’s solution if the patient is not under IV sedation or general anesthesia. The authors try to use as little epinephrine as possible in this area since they want to preserve a good blood supply at the time of the initial graft. The cannulas used for injection are the same that are used for face augmentation, namely the Amar and Coleman cannulas (Fig. 36.11). The depression is normally filled to about 125% of the expected volume. The fat is layered, first in the muscle, then in the deep subcutaneous layer, and finally in the superficial fatty layer just below the dermis. This layering is done with multiple passes until the desired contour is reached. It is important to place the fat by using small controlled aliquots of fat. Remember to aspirate as the cannula is being inserted and inject as you are removing the cannula to prevent inadvertent injection of fat into a vascular structure and also to make sure that there is no bleeding into your graft. Blood in the graft is one of the causes of failure of the graft to survive. After completion of the fat augmentation, the area is taped with Microfoam tape along Langer’s tension lines to help mold the graft in to proper position. The patient is placed in a compression garment, typically a girdle, and topical foam either Reston or Topifoam as needed for 72–96 h. The garments are changed in the office by the physician the first time they are changed. The patients are informed that at least one touchup ­session will likely be required in the office and that this is desirable for fat grafting and is not to be looked upon

Fig. 36.11  Fat injection needles

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as a deficiency of the original procedure, but rather as an opportunity to enhance the patient’s look. The frozen fat is kept for 1 year for future augmentation.

36.4  Results The expected 50–60% take of the graft is typical, usually requiring at least one touch-up procedure to achieve optimum filling. The texture and feel of the graft is ideal and identical to native tissue as long as lumps are avoided. At the time of the initial grafting we will mold and smooth any areas that have nodular, lumpy appearance or feel. There have been numerous patients with long-lasting results using fat as the only filler. Complications of fat augmentation that have been reported include lumps, infection, and a few extremely rare cases of fat embolism. The above complications have occurred mainly from facial fat augmentation (4). The authors have not seen any of these. Careful injection of intralesional triamcinolone will help resolve lumps, should they occur. The results using lipo-augmentation for various defects including the angular appearance of the gluteal depression have been excellent (Figs. 36.12–36.15). The authors have had no problems with intravascular injection of fat, but the fat injected is always done while withdrawing the blunt tipped syringe (4).

36.5  Discussion There are many ways to achieve an aesthetic goal. The combination of liposuction, fat grafting, and gluteal implants can all be used to contour the buttocks (8). The retro trochanteric depression is a common site that lends itself well to fat grafting. The surgeon must be able to visualize the end result before proceeding to surgery. The fat stored in a freezer for 3 months and up to 1 year, in the authors’ experience, has been found to be viable. Aiache (8) has found that cleansing of harvested fat is unnecessary if the fat is taken early in the procedure and there is no visible blood in the syringe. The Klein’s solution is easy to separate from the fat. Centrifugation and washing the fat is now thought to decrease fat cell viability and is labor-intensive. The less the handling of fat, the greater chance there is, for survival.

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a

Fig. 36.12  (a) Area to be treated with lipo-augmentation. (b) Postoperatively note the rounding of the derriere

a

b

b

Fig. 36.13  (a) Marking prior to surgery. (b) Two weeks post procedure

36.6  Conclusions Contouring the female form remains a sculpturing procedure that requires not only surgical skill, but a certain degree of artistic ability. The surgeon needs to be able to visualize the perceived roundness and softness of the female form to achieve the results that most of

our patients desire. The indentation or depression in the area of the maximum depression of the convex curve that is made up of the lateral hip, thigh, and buttock needs to be addressed to achieve the optimum S-curve as described by Lewis in the early 1990s (1). The newer techniques in lipo-augmentation combined with liposculpture and liposhifting can lead to excellent reproducible long-term results See Figure 36.16.

36  Correction of Deep Gluteal and Trochanteric Depressions Fig. 36.14  (a) Repair of iatrogenic problem of large defect in buttock secondary to medical procedure. (b) Three-months postoperative lipo-shifting and lipoaugmentation

a

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b

Pre-Op

a

Fig.36.15­  (a) Area of Flatness and indentation. (b) Corrected with lipo–­ agumentation, Note: post-op roundness.

Post-Op

b

290 Fig 36.16  (a) Pre-op. (b) Post-op following lipo­agumentation and ­lipo-shifting

R. F. Jackson and T. P. Mangione Large defect in buttock secondary to medical procedure

a

References   1. Lewis CM. Correction of deep gluteal depression by autologous fat grafting. Aesthetic Plast Surg 1992;16(3):247–250.   2. Jackson RF. Superficial liposcultpure: Rational and technique. In Shiffman MA, Di Giuseppe A (Eds), Liposuction: Principles and Practice, Berlin, Springer, 2006, pp. 185–197.   3. Kaufman MR, Miller TA, Huang C, Roostaien J, Wasson KL, Ashley RK, Bradley JP. Autologous fat transfer for facial recontouring: Is there science behind the art? Plast Reconstr Surg 2007;119(7):2287–2296.   4. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: Indications, technique, and complications. Dermatol Surg 2007;33(5):572–578.   5. Kaufman MR, Bradley JP, Dickinson B, Heller JB, Wasson K, O’Hara C, Huang C, Gabbay J, Ghadjar K, Miller TA.

b

Autologous fat transfer national consensus survey: Trends on techniques for harvest, preparation, and application, and perception of short and long-term results. Plast Reconstr Surg 2007;119(1):323–331.   6. Smith P, Adams WP Jr, Lipschitz AH, Chau B, Sorokin E, Rohrich RJ, Brown SA. Autologous human fat grafting: Effect of harvesting and preparation techniques on adipocyte graft survival. Plast Reconstr Surg 2006;117(6):1836–1844.   7. Gasparotti A. Three-dimensional superficial liposculpture for aged and relaxed skin. In Shiffman MA, Di Giuseppe A (Eds), Liposuction: Principles and Practice, Berlin, Springer, 2006, pp. 198–205.   8. Aiache AE. Gluteal recontouring with combination treatments: Implants, liposuction, and fat transfer. Clin Plast Surg 2006;33(3):395–403.

Buttocks and Legs Fat Transfer: Beautification, Enlargement, and Correction of Deformities

37

Lina Valero de Pedroza

37.1  History

37.2  Technique

The author started with this technique in early 1992 following the requests and expectations of her patients who were very sensitive about the culture of beauty and requested in a high percentage an enlargement of the volume of buttocks, calves, and ankles. Surgical techniques to enhance buttocks’ or calves’ volume consisted of placement of silicone implants below the gluteus maximus muscle in the buttocks or over the internal gemellus muscle in the calves. There were no techniques known to enlarge the ankles.These surgical techniques for the placement of silicone im­­ plants were performed by the author; however, they were inconvenient because of (1) severe pain for 20 post­ operative days, (2) very poor aesthetic results, and (3) permanent and/or long-term disabilities that consisted of persistent pain when in the sitting position and when wearing heels. Seeking to obtain optimal aesthetic results, reduce the recovery period, search for the ideal and persistent filler material which would reduce side effects, and avoid physical or aesthetic complications, it was decided to adopt the fat grafting tissue as a technique of beautification and reconstruction of the human body using large volumes of fat tissue harvested by liposuction. Supporting this theory was the history of extensive related uses of small quantities of fat tissue described in medical literature since 1893 to correct defects in soft tissues. Also, there was encouragement by the pure concept of a graft as is described in plastic surgery such as skin graft and hair graft.

1. Fat retrieval is from any anatomical area below the neck that is good to retrieve fat tissue. There are major areas of concentration of volume such as the arms, back, abdomen, hips, knees, and buttocks. 2. Tumescence with 1,000 mL saline containing 1 mL epinephrine is performed in any area used as a donor site about 5–10 min before harvesting to achieve maximum hemostasis and to obtain clean tissue. 3. Liposuction is performed with a mixture of ultrasoundassisted liposuction and traditional liposuction with a machine at low pressure. Ultrasound-assisted liposuction has been in use since September 1997 till date. From 1991 to 1997, machine suction was performed at low pressure. 4. The fat tissue graft is placed in sterile glass flasks that have been vapor sterilized. About 1 L or more is kept sterile for about 15–25 min with no contact with air until decantation of the cells is done. 5. After the natural separation of fat occurs with the fat cells rising to the surface and the tumescent liquid settling at the bottom of the flasks, the harvested tissue is ready to be transferred to a sterile syringe. 6. For large volumes a 60-mL syringe is used and for small volumes a 10-mL syringe is used to inject the graft.

L. Valero de Pedroza Carrera 16 No. 82-95-Cons: 301, Bogotá, D.C. Colombia e-mail: [email protected]

37.3  Materials 1. Cannulas of 3–5 mm are used to harvest tissue. If tissue is retrieved with a 3-mm cannula, injection of the graft is performed with a 3-mm cannula. 2. Blunt cannulas are used to harvest and graft.

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3. Suction machine at a low pressure of 350 Hg is used to preserve the integrity of the cells that could be disrupted under high vacuum pressure. 4. Syringe suction is recommended for small amounts of fat tissue transplant. 5. Centrifugation of a small amount of fat tissue that is to be transplanted over the face and hands is recommended in order to obtain a more precise quality of graft free of liquid thus avoiding unnecessary edema. 6. No washing or exposing to air is a priority in managing the graft to preserve its viability and preventing its contamination.

37.4  Fat as a Tissue Filler Fat tissue has three characteristics that make it the ideal tissue filler: (1) It is composed of cells that have the property to be hypertrophic; (2) it is composed of cells able to grow in volume and at the same time is a hyperplastic tissue; and (3) it has large amount of cells able to grow in volume (hyperplastic nature). These properties make it the ideal “Soufflé” to fill a depressed or deformed anatomical area.

37.5  Placement of the Fat Graft The nature of human anatomy places fat tissue under the skin surface and over the muscular structure. Intraperi­ tonealy, it covers all the abdominal organs and ­structures and we find a large quantity of fat cushion denominated “Epiplon.” The author’s work is based on sculpting the normal anatomy of the human body by reshaping and relocating fat tissue, and the initial goals were based on enhancing the volume of buttocks, ankles, and calves for beautification. The graft was placed under the skin following the normal anatomic growth and existence of the fat tissue. After 16 years of clinical experience in grafting large volumes of fat tissue, the author has found it as a great total body tissue filler – great to reconstruct body deformities from traumatic, congenital, or iatrogenic defects. It produces excellent results in cosmetic enhancement, is a long-term survival tissue, is well tolerated, and is low in risks if the graft is ­adequately

L. Valero de Pedroza

manipulated (preventing its contamination and preserving the survival of its cells while harvesting it).

37.6  Synopsis of Technique (a)  Materials 1. 3–5 mm cannulas 2. Syringe suction 3. Machine suction low pressure 4. 3–5 mm cannulas blunt for injection 5. Tumescence with 1,000 cc saline and 1 mg ­epi­nephrine 6. 1,000 mL sterile glass flasks (b)  Donor site areas 1. Arms 2. Back 3. Hips 4. Abdomen 5. Buttocks 6. Knees (c)  Methods 1. Traditional suction machine 2. Syringe suction 3. Ultrasound-assisted liposuction 4. Centrifugation of small quantities of fat transplant tissue (for face and hands) (d)  Recipient areas 1. Buttocks 2. Hips 3. Muscular atrophies in legs, arms, ankles (e)  Manipulation of the graft 1. No washing 2. Natural decantation 15–25 min in the sterile glass flasks 3. Storage for 30–45 min with no contact with air 4. Direct suction from patients, to flasks, to sterile syringes, to patients again as a graft (f)  Amount of fat volume transplanted Area Each buttock Each leg Each ankle Each hip

Amount (mL) 240–700 150–400 120–280 300–750

37  Buttocks and Legs Fat Transfer: Beautification, Enlargement, and Correction of Deformities

37.7  Qualities of Fat Transplant 1. It is an autologous tissue 2. Hyperplastic tissue (large number of cells) 3. Each fat cell has an hypertrophic capacity to grow in volume (the “soufflé” effect) 4. Normal to the touch 5. No side effects if adequately sterile 6. Easy handling 7. Long lasting – permanent in life 8. No functional changes 9. It is a fat-cells graft, not a fat (liquid) or oil injection

37.8  Complications In the author’s cases there were a few complications varying from skin vesicles from the skin tape, redness without injection, edema of the ankles for 20 days postoperatively, and one case of erysipelas occurred from

a

Fig. 37.1  (a) Preoperative 58-year-old female with aging process of the buttocks with wrinkles and loss of volume. (b) Eight months postoperative after 300 mL of fat transfer to each side

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trauma that was treated with penicillin and without losing the fat transplant volume injected over the legs.

37.9  Discussion Over the past 16 years we performed fat transplant to the buttocks on 3,720 cases of whom 1,300 cases also had both calf and ankle enlargements, 722 cases for reconstructive purposes, and 1,698 cases for cosmetic purposes. The average age of those patients ranged from 18 to 75 years. Eighty-nine percent of the patients were female. Aging produces an early appearance of sagging buttock, as early as in the 47-year-old females, and progresses every 5 years. The ideal filler product for rejuve­nating an aging buttock area is fat tissue harvested in large volumes. The author recommends fat transfer to all patients for reconstructive and cosmetic purposes because of the clinical results, satisfaction of the patients, and the long-term follow up of up to 16 years.

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Fig. 37.4  (a1, a2) Preoperative 72-year-old male with “skinny” legs. (b1, b2) Two and one-half years after 300 mL fat transfer to each calf and ankle

37  Buttocks and Legs Fat Transfer: Beautification, Enlargement, and Correction of Deformities Fig. 37.3  (a) Preoperative 27-year-old male with agenesis of gemellus muscle of the right leg. (b) Seven years after 350 mL fat graft over the agenetic musculature of the right leg

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Autologous Fat Transfer for Gluteal Augmentation

38

Adrien E. Aiache

38.1  Introduction

38.2  Indications

The use of autologous fat for buttock augmentation has evolved from the use of fat in many areas of the body. It has been the result of the learning experience in autologous fat transfer for tissue augmentation in many parts of the body such as the ankles, dorsum of the hands, the deltoid area, and inner thigh. This technique is derived from prior techniques of autologous fat aspiration and grafting. History shows that autologous fat has been used since the end of the nineteenth century. Surgeons such as van der Meulen (1), Neuber (2), Lexer (3), Willi (4) Peer (5), Fischer (6), Illouz (7), and others have shown the advantages of using fat for soft tissue augmentation. These pioneers paved the way for the actual use of fat in body augmentation. The surgeon uses fat transfer quite often instead of facial and body implants. Using fat is relatively acceptable to patients, gives relatively good results, and has very little postoperative problems. The meeting of the American Society of Plastic Surgeons Ad Hoc Committee on Autologous Fat Trans­ plantation (8) estimated that approximately 30% of the autologous fat injected survives, although the surgeon/ author was present at the session and objected by stating that only approximately 5–10% of injected fat might survive. The difference in these estimated percentages of fat survival can be obviated by repeated injections of fat in order to achieve the wanted result.

Patients desiring soft tissue augmentation are often overweight and have excessive amounts of anterior abdominal and chest fat as opposed to the buttocks that have not really increased. This seems to be a genetic problem, since many women coming to the surgeon for buttock and hip liposuction are not the same as women who come for buttock augmentation and abdominal reduction by liposuction or abdominoplasty. The surgeon has found that the latter type of patient is a good source for autologous fat. This type of patient was treated with performing buttock implants and abdominal liposuction with occasional injection of aspirated fat into the buttocks in an attempt to improve the shape and contour of the buttock implant. This technique led to purely autologous fat augmentation of the buttocks since the gluteal implants are often prone to many problems such as infection, displacement, seroma, and wound breakdown. The technique of autologous fat transfer to the buttocks is simple and often can be used as a complement to abdominal liposuction since the fat is available and can be put to use.

A. E. Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA e-mail: [email protected]

38.3  Technique The zone to be augmented is marked. This encompasses the medial portion of the buttock and is reduced laterally in a triangular form down to the infragluteal fold. Some patients are eager to have the lateral crease implanted in an effort to augment the buttocks laterally. Areas of liposuction are also marked including the iliac crest, waist, and abdomen.

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298 Fig. 38.1  (a1, a2) Preoperative patient. (b1, b2) Postoperative following buttock implants with liposuction of lower buttocks and iliac crest

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The surgery is performed under general anesthesia. Liposuction is performed first, in many cases with the patient prone, so as to remove fat from the iliac crest and waist area through two parasacral incisions or sometimes a supracleft incision that can be used for fat augmentation subsequently (Fig. 38.1). Liposuction is performed through two parasacral incisions, a central spinal incision, or a central cleft incision using a tumescent solution consisting of 1,000 mL saline containing Xylocaine 500 mg with epinephrine 1:1,000,000 in the area of liposuction. The same ­solution is injected into the premarked areas for fat injection in order to reduce bleeding following fat injection.

38.4  Liposuction Liposuction is performed through a syringe technique with 60 mL Toomey syringes with 3-mm cannulas for aspiration of the waist and iliac crest areas. Early in the

liposuction the fat is extremely clean but later in the process some bloody fluid may be aspirated at the same time. The fat is deposited in a sterile container until an acceptable amount of fat is obtained (approximately 300 mL for each buttock) and allowing the fat to float to the top. The fat is transferred to 60-mL syringes, the bloody fluid ejected. Fat may then be liposuctioned by machine to shape better the iliac crests and waist when there is no plan for a secondary procedure in the future and when the surgeon desires a smooth result (Fig. 38.2).

38.5  Fat Injection The fat is injected through the prior incisions for fat retrieval into the buttocks in a fan-like fashion depositing small amounts of the fat into multiple tunnels as the cannula is withdrawn. This process is repeated until all the fat has been used. The wounds are then sutured (Fig. 38.3).

38  Autologous Fat Transfer for Gluteal Augmentation Fig. 38.2  (a1, a2) Preoperative patient. (b1, b2) Postoperative after buttock implants and liposuction of lower buttocks

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38.6  Further Liposuction and Injection

38.8  Complications

The patient is turned into the supine position and the epigastrium, lateral anterior waist and lower abdomen are injected with tumescent fluid and liposuctioned through umbilical and suprapubic incisions that can be supplemented with lateral waist incisions. Liposuction is performed with the 60-mL syringes with 3- and 4-mm cannulas, and the aspirate is deposited in a sterile container for further cleansing and use for fat transfer. Machine liposuction is used to refine the areas that have been liposuctioned. The wounds are the sutured. The patient is turned into a prone position if ­additional fat is necessary for injection and the areas sterilely prepped. The wounds are reopened in the parasacral and superior cleft areas. Additional fat is injected into multiple tunnels into the zone to be further augmented. In some cases, an inferior lateral gluteal fold incision is made bilaterally to complete injection of fat into the infragluteal portion of the buttocks. A maximum of 300 mL of fat is used since more fat will not get an increased survival of the excess. Excess fat is preserved in sterile condition and frozen for use within 3–6 months if necessary.

Ecchymosis, rare hematomas, pain, and soreness have been seen. No cysts have been encountered and no induration has been found. No infection has been encountered bearing in mind that the location of the surgery dictates extreme care in the washing and prepping, often using Betadine fluffs sutured to cover the anal opening.

38.7  Postoperative Care The patient is not to sit on her buttocks for 3–4 days in order to avoid compression in the area of the injection and to allow some revascularization of the injected fat. Autologous fat will only survive if a certain mount of new circulation develops into it and, from experience and studies no longer/ only the, after 3–4 days if the fat has not obtained neovascularization it is reabsorbed by the body as dead tissue adipocytes that have been supplied with neovascularization are going to survive.

38.9  Results Fat transfer has given acceptable results in many patients. Pure adipose implantation is becoming more common as it shows promising results with good augmentation and no significant complications or problems. Fat can be used in cases of unsatisfactory gluteal implants and as an additional procedure with gluteal implants concomitantly or at a later date.

References   1. van der Meulen, Richard MA. Considérations générales sur les greffes graisseuses et serograisseuses épiploiques et leurs principales applications. Paris, Thèse 1919, pp. 11.   2. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir. 1893;22:66.   3. Lexer E. Freie Fettransplantation. Deutsch Med Wochenschr 1910;36:640.   4. Willi CH. The Face and its Improvement by Aesthetic Plastic Surgery. London, MacDonald & Evans, 1926.   5. Peer LA. Cell survival theory versus replacement theory. Plast Reconstr Surg 1955;16(3):161–168.   6. Fischer G. Surgical treatment of cellulitis. IIIrd Congress Inter­ national Academic Cosmetic Surgery, Rome, May 31, 1975.   7. Illouz Y-G. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123.   8. ASPRS Ad-Hoc Committee on New Procedures. Report on Autologous Fat Transplantation. Plast Surg Nurs 1987;7(4): 140–141.   9. Aiache, Adrien E. Gluteal recontouring with combination treatments: Implants, Liposuction, and Fat Transfer.

Autologous Fat for Liposuction Defects

39

Pierre F. Fournier

39.1  Introduction Liposuction is a blind and tactile operation and even in the best of hands defects may occur. Excellent training and experience are needed to avoid such defects. The liposuction surgeon has to think not only as a surgeon but also as an architect and an artist. A very rigorous technique may decrease or avoid such defects. The use of tumescent anesthesia, multiple approaches (to allow criss-crossing tunnels), superficial work, a syringe to measure the exact amount of fat removed through the different approaches, and good pre-estimation of the amount of fat to be removed are required. All this is acquired with time, experience, and observing the work of many colleagues.

of the patient’s own fat, 60–100 mL or more, which will give a more homogeneous result. The reinjected fat should be harvested at the beginning of the operation using the syringe technique. Even if no defect has to be feared, reinjection of a certain amount of fat after a liposuction procedure has always been recommended by Fischer (Fig. 39.1). This is a routine procedure for many surgeons. a

39.2 Defects Occurring During Liposuction The pinch test that should be routinely performed during the operation is the best sign warning the liposuction surgeon that the removal of fat has been uneven. Liposcu­lpturing with small cannulas (2 or 3 mm in diameter) in a thick area has to be performed to obtain the same thickness as in a thinner neighboring area using several approaches. The operation proceeds with the pinch test being used frequently to avoid a new uneven area. Should the liposuction surgeon be unhappy with the correction, he or she should reinject a variable amount P. F. Fournier 55 Boulevard de Strasbourg, 75 010 Paris, France e-mail: [email protected]

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Fig. 39.1  Liposuction defects. (a) Depressed area on inferior thigh below area of liposuction. (b) Following fat transfer to depressed area

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39.3  Defects Following Liposuction

The surgeon must follow a very careful and thorough technique:

Postliposuction defects may be seen shortly after the operation if they are significant or 4–6 months after surgery if they are not (Fig. 39.2). The areas involved most of the time are the outer and inner thighs or the abdomen but defects can occur in any treated area of the body. They are visible and palpable and are seen more often when only one approach has been used. The skin may be very adherent to the aponeurosis in some places or a thin layer of fat may be present. Skin depressions and skin elevations appear alternately, sometimes irregularly displayed or linear. The only possibility in such cases is to remove fat tissue in the elevations where too much has been left if there is excess that does not correspond to the normal layer and to reinject harvested fat in the depressed places.

1. Mark the elevations and depressions very accurately. 2. Use either local anesthesia with or without general anesthesia. 3. A mesh undermining of all the defects should be done using small cannulas through several approaches before harvesting the excess fat in the elevated places. 4. Liposculpturing in the elevated places should be performed very carefully using two or three approaches with the syringe technique. The extracted fat should be reinjected in the depressed areas that were carefully mesh-undermined using two or three approaches. In certain cases, the whole of the uneven area can be treated together. In other cases, each elevation and each depression is treated separately. When there is not enough fat to remove for grafting in the uneven areas, fat is very carefully taken from another area of the patient’s body. Uneven results after liposuction are rather frequent and may need several operations 3–6 months apart to correct each of them. Before liposuction, the patient should be forewarned that there is always a risk of an uneven result according to the amount of fat tissue that has to be removed and the quality of the skin. The culprit is not always the liposuction surgeon. When the surface defect is minimal, superficial liposculpturing can be performed and may be sufficient. Several procedures may also be necessary in such cases.

39.4  Conclusions

Fig. 39.2  Postliposuction defects

Liposuction defects during and after surgery are rather frequent and very often touch-up is necessary. This touchup should be performed after 6 months when the final results of the liposculpture are really obtained. Sometimes if the defect is very visible, restoring a normal or subnormal surface can be performed after 3 months. Syringe fat grafting is the best technique to correct such defects. Repeated procedures are often necessary.

Periorbital Fat Transfer with Platelet Growth Factor

40

Julio A. Ferreira and Gustavo Ferreira

40.1  Introduction

40.3  Periorbital Fat Graft

Autologous fat transfer is an adequate method to increase the volume of different body areas to achieve pure aesthetic results and can also be used as a reconstructive technique. It is well tolerated by patients, protocols are easy to follow, extraction is easy, it requires minimum instruments, and large quantities of the material are available for possible reinjection if necessary.

Fat graft in the periorbital region gives good results, especially in the treatment of lower eyelid and malar areas, and achieves improvements in the “tear trough.”

40.2  Technique Injection of the fat tissue is done with minimum hypercorrection criteria. The material is washed with saline solution (previously added) inside the extraction syringe, thereby avoiding contact with the exterior. The syringe is left for decantation in order to eliminate blood and local anesthesia. The author uses the “Pearl” technique with small quantities of fat tissue injected through a 1-mL Luer-lock syringe and a 20-gauge microcannula. Platelet growth factor obtained by the classic technique of double centrifugation of blood is added to the fat tissue at the moment of injection. Preliminary results are promising.

40.4  Technique The procedure is done under local anesthesia but, if necessary, regional blockade cans be performed. A 1-mm incision is made with a #11 surgical blade or with a needle near the lateral aspect of the orbit. In case of wrinkles, one opening is made and a second point of injection is seldom used. Fat injection is performed with a flexible blunt-tip cannula into the suborbicularis layers in a retrograde fashion. A 1-mL syringe with a 20–22-gauge, flexible, single-hole cannula gives excellent control of the injected material. Generally, about 5 mL per session is used in the inferior periorbital area. A higher amount is required for the malar area. A second session is performed in about 2–3 months. The results are excellent (Fig. 40.1).

J. A. Ferreira (*) Santiago Del Estero 102 (1640), Buenos Aires, Argentina e-mail: [email protected] M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_40, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 40.1  (a1–a5) Pretreatment. (b) Markings. (c) Injecting from lateral orbital position. (d1, d2) Intraoperative with left side treated. (e) Immediately postoperative with both sides

treated. (f1a–f3b) Five days postoperative. (g1a–g3b) Three months postoperative. (h) Four months postoperative after second session

Cryopreserved Fat

41

Bernard I. Raskin

41.1  Introduction Cryopreservation of autologous fat is a topic in which the basic science answers to important questions are only now being elucidated. Considerable inconsistency exists in clinical practice and in the lipofilling literature. Clinical results with frozen fat have been confirmed in the literature, yet controlled studies are infrequent and fat viability after ordinary freezing is variable and may be questionable. Simple issues are as yet unresolved, such as freezing temperature and storage duration. The understanding of preadipocytes and adipocyte stem cells is altering the clinical approach to cryopreservation. Issues of safety will be discussed in this chapter. It is anticipated that frozen autologous fat injections will become more effective and predictable with the integration of cryopreservation methods of freezing and storage and as clinical techniques become standardized.

41.2  Review of the Literature Cryopreservation of fat is commonly utilized and noted in various review publications and texts (1–4). Within the lipofilling literature, relatively infrequently are comments rendered specifically detailing aspects of the cryopreservation procedure such as storage temperature (2, 5, 6). Detailed technique ­recommendations for cryopreservation and subsequent thawing exist in

B. I. Raskin Department of Medicine, Division of Dermatology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA e-mail: [email protected]

much of the autologous fat grafting literature bereft of references, such as comments about utilizing slow freezing in contrast to rapid freezing. Recommen­dation for storage may be as general as advocating storage in a freezer or refrigerator (7). Recommended reinjection times commonly range from 2 to 18 months or longer (3, 8, 9). An uncontrolled literature report documents reinjection after storage for up to 7 years (10). In addition to the inconsistency in the overall cryopreservation literature, there is a paucity of studies comparing cryopreserved to fresh autologous fat in a human clinical setting (11). Frozen fat has been repeatedly reported to cause less swelling than fresh fat, for unknown reasons (12). However, the entire issue of the survival of frozen fat has been characterized as a point of significant debate (13). Comments on the duration of frozen fat injections may not be well substantiated (14). The overall opinion among authors is that frozen fat injections are at least as efficacious as those for fresh autologous fat and appear to cause less postoperative inflammation, but there are little controlled data. More problematic is an author’s advocated technique for cryopreservation or maintenance temperature based on another publication which has referenced the method to a prior article in which there is no substantiation other than opinion. Early observational clinical studies documented and established that fat may be frozen and reinjected (10,  15). Clinical experience based on several studies confirms the utility of preserved frozen fat for augmentation (16). However, only recently have detailed studies begun to emerge, including evaluating the viability of frozen fat and comparing frozen fat to fresh fat in animal models and humans. Commonly, practitioners’ procedures are currently based on anecdotal and empirical observations. Yet there exist well-established and scientifically sound freezing and preservation protocols

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in other fields such as reproductive medicine and hematopoietic marrow preservation. Even veterinary reproductive medicine depends on tested frozen product methods to enhance the procreation of expensive racehorses (17). With human fat preservation, basic questions are only now under investigation, and substantial questions remain as the entire field is evolving. The inconsistent clinical approaches and variable results for fresh fat harvesting, manipulation, and grafting in studies conducted over more than 30 years provide an indistinct picture when adding cryopreservation as a variable. However, cryopreservation has become an important consideration as practitioners recognize that multiple small-volume sessions are preferred over a single injection with overcorrection (18). Aspirating and processing small amounts of fresh fat for brief touchup sessions is inefficient and expensive, thereby making fat preservation an important component in the office environment. The issue of cryopreservation is further complicated by the various methods advocated for aspirating, processing, and injecting fresh fat. The numerous recommendations that exist for harvesting, preparing, and injecting speak of the empirical nature of fat injections. Various factors may contribute to fat cell survival: harvesting method, manipulation of fat, exposure to blood or lidocaine, recipient site, donor site, centrifugation, injection method including syringe and needle size, and correction volumes. These factors have been reviewed (19–23) without definitive results, although differing opinions exist (24). However, a review of survival rates has demonstrated that good results might occur independent of technique, but with the use of small volumes (21). In histologic studies, the diameter of fat should be less than or equal to 3 mm for effective neovascularization (25). Longevity is the elusive and problematic aspect of autologous fat transplantation, and cryopreservation is but adding one more variable in this important process. Longevity of fresh fat transplants has been extensively studied, although consistent results in the literature vary (26–28). Theories include replacement fibrosis, neovascularization of transplanted fat, and differentiation of lipocyte stem cells into mature adipocytes (21, 29–32). Duration may be more accurately studied in scars. One study of depressed post-surgical scars in 30 patients utilizing a subcision technique followed by  autologous fat grafting through a 4-mm cannula revealed 27 cases with very good results at 3 years  (33).

B. I. Raskin

Two patients required an additional treatment at 6 months due to partial recurrence. A case of autologous fat transplantation into a large post-radiation thigh defect  that persisted over 2 years has been reported, although several sessions were required over 3 years to obtain satisfactory benefit (34). Thus long-term results with autologous fresh fat are well established. Over the last decade, the literature suggests that both traumainduced fibrosis and fat cell survival are relevant to graft longevity (18). Adipose stem cells may be the most important factor, however (35). The etiology of longevity in frozen fat transplants has been variable (10). Only infrequent controlled studies in animals and humans exist. The viability of frozen fat cells has been questioned. Current belief is that stromal cells from adipose tissue are more resilient and probably survive the freezing process, explaining longevity in frozen fat transplants (36). Recent research focuses on lipocyte stem cells rather than mature adipocytes as the driving force in long-term clinical benefit for fresh fat injections of post-radiation depressed scars (30). It has been established that adipose tissue contains a clonogenic pool of stromal cells having the same functional and immunophenotypic properties of bone marrow mesenchymal stem cells. Mesenchymal changes have been seen in early stages after adipose stem cell transplant, and after maturation the tissue showed normal mature lipocytes. Based on recent studies (37, 38), administering the stromal vascular component of adipose tissue that is stem-cell-rich elicits an angiogenic factor response resulting in formation of new vessels and an environment facilitating the development of mature adipocytes from stem cells. This mechanism is thought to be responsible for the effect of frozen fat transplantations (36). Understanding fat physiology, stem cells, and metabolism facilitates understanding the longevity possible with fat transfer (39). Fat is no longer considered simply a calorie storage cell, but rather is a complex structure with exocrine, endocrine, and immunologic properties. Thus fat should be considered dynamic, as adipocyte number and quality may not be stagnant. Fat cells can differentiate and dedifferentiate into preadipocytes and stem cells, or may develop fibroblast morphology from fibroblast-like fat cell precursors (40). Adipogenesis requires the proliferation of adipocyte precursor cells known as preadipocytes. The preadipocytes segue through differen­tiation into mature fat cells. The process is a tightly controlled sequence regulated

41  Cryopreserved Fat

by multiple inhibitory and stimulatory signaling in a complex environment affected by hormonal, paracrine, and neuronal controls and also involves pivotal cell-tocell interactions (41). The most important chemical factor controlling the adipocyte differentiation process appears to be the transcription factor peroxisome proliferator­activated receptor gamma (38, 41). Applying this knowledge to cryopreserved fat is in its infancy. Determining frozen fat viability is part of the problem in interpreting studies. Standard cell growth pro­ tocols do not work for fat, so early studies relied on various staining techniques which are now recognized as inaccurate. Only recently have investigators utilized complex mitochondrial and cell function studies to assess the viability of adipocytes after freezing and thawing. Early authors used primarily observational clinical endpoints to document the benefit of frozen fat, while current methods involve multiple tissue measurements of weight and volume along with histologic evaluation in a mouse model. The nude mouse model is now an accepted standard. Injections are made in the pericranial area with subsequent volume measurements over time. The nude mouse has no pericranial fat and does not have an immunologic reaction to human fat. Thus human fat can be placed in a nonadipose pocket and subsequently removed for study. Unfortunately, the uncontrolled early observational studies did not clarify the storage temperature. In the literature, the storage temperature may not be noted, or numbers such as +4, −4, −20, −30, −40, or −70°C are listed (2, 27, 31, 42, 43). Slow freezing to −20°C was advocated by one author, while another utilized flash freezing with liquid nitrogen but did not list the storage temperature (21, 44). Early authors felt that a substantial number of viable cells existed based on trypan blue staining after thawing (45). One study showed that fat frozen at −20°C and down to −70°C for up to 2 years showed only fat cells and no fibrous debris upon thawing (46). One of the early controlled studies was performed by Shoshani et al. in 2001 (47). Human adipose tissue obtained by liposuction was stored in a domestic refrigerator at −18°C for 2 weeks. After a 1-h thaw time, the fat was injected into nude mice. Fifteen weeks post injection, the grafts were dissected and no significant differences were found in weight, volume, or histologic parameters compared to fresh fat injections. Another study published by Bertossi et  al. (48) evaluated fat stored at −30°C, showing that the adipocytes retained

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normal anatomical features. They obtained good clinical results in multiple stages in 99 patients. This would seem to confirm the earlier studies on fat viability and clinical effectiveness. However, it has now been determined that normal anatomical features after thawing do not correlate with adipocyte activity or viability. Further studies subsequent to Shoshani’s 2001 work were not confirmatory. A study on nude mice with fat stored at −20°C for only 24 h showed a 50% difference in fat volume at 3 months compared to fresh fat. Increased fibrosis and cysts were present in the frozen side (49). A different study on nude mice with fat stored 7 months at −18°C showed inferior histologic parameters in the frozen side, with the weight and volume reduced by 20%. These authors cautioned against longer term freezing (50). In a recent controlled clinical evaluation, Butterwick performed a side-by-side two-hand comparison pilot study on the aesthetic dorsum of the hands of 10 patients (11). Fresh fat was compared to fat frozen 17 days with a 5-month clinical follow-up. The fat was obtained by tumescent harvesting and processed with fluid removal and centrifugation. The fat was frozen in a commercial laboratory freezer at −40°C and thawing occurred over 2 h. Clinical results of the aesthetic units indicated the frozen fat side was deemed superior to the fresh fat transplants. The authors also indicated their opinion that the hands injected with frozen fat suffered less adverse events such as painful swelling and discoloration, which is consistent with various observations in the literature. The authors conclude by stating that this was a 5-month study of fat frozen for 2 weeks and may not apply to other clinical situations such as longer storage times. Clearly, clinical studies documented adequate and satisfactory benefit from frozen fat, although considerable inconsistency existed in storage temperatures and duration. The study discussed above by Butterwick represented the first controlled human clinical evaluation. And while initial encouraging results were shown with controlled studies in the pericranial region of nude mice, consistent results in later studies have been elusive. All these controlled studies were based on the assumption that the thawed fat was viable. What was missing from these studies was a detailed evaluation of the cells upon thawing. Determining fat cell viability has been problematic. In early studies, normal morphology was assumed to document viability; however, stained cells are fixed

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(dead) and thus viability cannot be measured. Normal proliferation testing is ineffective on fat cells because little cell turnover occurs. Trypan blue stains were utilized to differentiate live from dead adipocytes, but the staining may be scant even in live cells making distinctions difficult. Current studies use more sophisticated techniques for evaluating viability. One recent study indicates substantial fat cell viability with standard freezing at −20°C and similar results with liquid nitrogen snapfreezing at −195°C utilizing spectrophotometer assays with storage duration up to 8 days (51). However, more current studies utilizing mitochondrial viability definitely show that fat cell viability is lost or substantially reduced with routine freezing. These newer techniques have demonstrated the benefits of cryoprotectants to minimize loss of viability during the freezing and preservation process. Instituting cryoprotectants brings fat preservation closer to the standard existing commercial techniques for hematopoietic stem cell and umbilical cord blood storage (52). In a study comparing cooling from −20 to −80°C, with and without cryoprotectants, viability was measured utilizing cell stains, metabolic activity, and cell stability (53). Results demonstrated that simple freezing reduced metabolic activity by about 93%. However, adding cryoprotectants preserved 54% of metabolic activity. Lower storage temperatures resulted in more cell destruction but higher viability in remaining cells. The authors conclude that the widely utilized practice of simple freezing results in the injection of primarily nonviable tissue. It was further demonstrated that cryoprotectants added to the fat resulted in a significantly higher survival of frozen cells based on measurements of mitochondrial activity. Freezing is harmful because of the osmotic effects of freezing with intracellular ice formation, and the thawing process also damages cells. The low levels of viable fat after simple freezing are consistent with cryobiological principles and observations for other cell types. The authors feel that cellular activity may persist at various storage temperatures, but storage can be unlimited at below the glass transition temperature of −130°C because there is no cellular activity. However, achieving such temperatures is complex, and they advocate −80°C as a practical storage temperature, which is available with commercial freezers. In another detailed study, the temperature was held steady at −20°C, and the effect of cryoprotectants was analyzed. When comparing simple freezing to freezing

B. I. Raskin

with various cryoprotectants, storing at −20°C without cryoprotectants demonstrated few viable adipocytes and no viable adipocyte stem cells (54). These authors found that no cellular proliferation occurred in culture after simple −20°C freezing, even though 30% of adipocytes appeared viable initially. A complex protocol including slow and controlled freezing to test various cryoprotectants was performed. The results demonstrated 50–64% viable fat after thawing, depending on the cryoprotectants utilized. Fluorescein diacetatepropidium iodide staining analysis was performed. This established technique of staining allows distinguishing viable from nonviable cells. The nonpolar fluorescein diacetate can cross the cell membrane. Metabolically active cells can hydrolyze the ester to release the polar fluo­ rescein molecule, which is not membrane-permeable, leading to accumulation in viable cells. Nearly all samples frozen at the controlled rate with a cryoprotectant established proliferating cultures derived from both mature adipocytes and stromal cells. This was a laboratory study with a complex protocol not easily transferable to clinical use. Another investigation involved cryopreservation with trehalose (55). In this study cryopreservation was performed with slow cooling and rapid thawing, and three assays were utilized to evaluate the adipocytes. More viable adipocytes with better cellular function were found in the cryoprotected group, but results were still less than ideal according to the authors. These authors opined that additional studies were needed to refine the method. The science of cryoprotectants (CPA) is well established. Adding CPA improves cell survival. Avoiding osmotic stress and intracellular ice formation is facilitated by addition of the protectant. CPA can be either membrane-permeating substances such as glycerol and DMSO, or non-membrane-permeating substances like hydroxyethyl starch (HES). Permeating substances prevent intracellular ice formation but must be removed from thawed cells by thorough washing. Non-permeating biodegradable CPA avoid the washing steps and will probably be more beneficial for adipose freezing in the physician’s office. Thus answers to enhancing cell viability with cryopreservation are now established. The problem with adding CPA is that protocols for straightforward application in the physician’s office have yet to be determined. Commercially the process has been well established for hematopoietic stem cell preservation. This was recently

41  Cryopreserved Fat

reviewed and the strategy has been proven safe and well documented to minimize engraftment failure (52). Current recommendations after collection of aspirate involve reduction of bulk by centrifugation and the addition of HES. DMSO 10% is added as a cryoprotectant along with human serum albumin and normal saline. Freezing may be performed at a controlled or un­controlled rate. With freezing utilizing the vapor stage of liquid nitrogen, the freeze is at a controlled rate of 1–2°C/min. The ultimate temperature of −156°C is attained with the vapor phase of liquid nitrogen. Alter­ natively, freezing may be accomplished at an uncon­tro­ lled rate in a commercial freezer to −80°C. Thawing uses a warming bath at 37°C. The DMSO is reduced after thaw by washing with human serum albumin and Dextran 40 in isotonic saline solution, and transplantation occurs. The next question is safety and prevention of bacterial contamination. This issue has also been investigated on frozen fat for up to 24  months with serial bacterial cultures, with no occurrence of contamination (56). The conclusion was that fat could be stored in a sterile manner for at least 24 months without bacterial contamination as an issue. Another issue that has not been investigated is whether fat can be refrozen after thawing or partial thawing. Typically refrigerators in physicians’ offices do not have back-up systems so thawing or partial thawing could potentially occur due to prolonged power failure. More problematic are variable storage temperatures from automatic defrosting cycles – fat should not be stored near the ceiling of a freezer because during the defrost cycle air temperature in this area could be as high as 55°C (57). A relatively inexpensive electrical thermal monitor with battery backup can be easily installed for less than $1,000. These commercially available units are simply plugged into a standard electrical wall outlet, and the freezer probe cables (thermisters) placed in the freezer. The unit can be set to sample temperatures every 15 s and store the data every 10 min. Thus 40 sample readings will be taken and the average plotted every 10 min. The temperature averaging prevents aberrant readings showing momentary dips and rises that occur when the door is opened. These thermal monitor units hold months of data and can be downloaded to a personal computer (Fig. 41.1). An autodialer can be installed so that significant temperature variations trigger a phone call. This type of unit conforms to JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Standards PC.17.10 for

309

Fig. 41.1  Monitoring unit attached to a commercial refrigerator. An autodialer can also be connected. Stored data can be downloaded to a computer

hospitals to maintain continuous temperature monitoring for storage refrigerators and freezers containing cell­ ular and tissue-based transplant products (57). Another method to prevent undesirable thawing includes a battery back-up unit similar to those that physicians have in certified ambulatory office surgical suites. In some locations, fat must be stored in accordance with approved tissue bank protocols, and tissue bank certification or licensing may be legally required (58). Licens­ing may require monitoring, back-up power, adherence to established protocols and procedures, and appropriate staff training. As a final safety issue, correct labeling is of the utmost importance. The author uses a double wrapping system for any patient-specific item. The material is placed in a container and sealed in the patient’s presence, and the patient identification data including name, birthdate, and procedure date are written on the container. The patient then verifies that the data is correct. The container is then placed inside another container such as a clear laboratory envelope and sealed. Again, the name, birthdate, and procedure date are entered and the patient verifies the information. If the patient is under sedation, the same procedure is followed but two staff members sign off the labeling on each container, and the final packaged is photographed to show the patient. At a later date when the follow-up procedure will occur, the patient reads and verifies the labeling on the outer container prior to unsealing the container, and also verifies the label on the inner container.

310

41.3  Conclusions Cryopreservation of adipose tissue (autologous fat) is evolving. Much of the early literature and initial studies were uncontrolled and anecdotal. Basic research questions on storage methodology and temperature have only recently been clarified. Appropriate clinical regimens for cryoprotectant-facilitated fat storage are being developed. Adipose stem cells appear important in the viability of adipocytes and this area is under active investigation.

References ­  1. Rivera AE. Acne scarring: A review and current treatment modalities. J Am Acad Dermatol 2008;59(4):659–676.   2. Narins RS, Tope WD, Pope K, Ross EV. Overtreatment effects associated with a radiofrequency tissue tightening device: Rare, preventable, and correctable with subcision and autologous fat transfer. Dermatol Surg 2006;32(1): 115–124.   3. Goodman GJ, Baron JA. The management of postacne scarring. Dermatol Surg 2007;33(10):1175–1188.   4. Matarasso SL, Sadick NS. Soft tissue augmentation. In: Bolognia JL, Jorizzo JL, Rapini RP (Eds), Dermatology. New York, Mosby, 2003, pp. 2445–2447.   5. Coleman WP. Fat transplantation. Dermatol Clin 1999;17(4): 891–899.   6. Sattler G, Sommer B. Liporecycling: Immediate and delayed. Am J Cosmet Surg 1997;14:311–315.   7. Fournier PF. Fat grafting: My technique. Dermatol Surg 2000;26(12):1117–1128.   8. Guidelines of care for soft tissue augmentation: Fat transplantation. American Academy of Dermatology. J Am Acad Dermatol 1996;34(4):690–694.   9. Takasu K, Takasu S. Long term frozen fat for tissue augmentation. J Cosmet Surg Aesthetic Dermatol 1999;1:173–178. 10. Takasu K, Takasu S. Long term frozen fat transplantation. Int J Cosmet Surg 1999;7:33–38. 11. Coleman SR. Long term survival of fat transplants: Con­ trolled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425. 12. Saylan Z. Frozen fat: Better than fresh fat. Int J Cosmet Surg 1999;7:39–42. 13. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: Indications, technique, and complications. Dermatol Surg 2007;33(5):572–578. 14. Fulton J, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865. 15. Jackson RF. Frozen fat - does it work? Am J Cosmet Surg 1997;13:339–343. 16. Kaminer MS, Omura NE. Autologous fat transplantation. Arch Dermatol 2001;137(6):812–814.

B. I. Raskin 17. College of Veterinary Medicine and Biomedical Science, Department of Biomedical Science. Equine Reproduction Laboratory at Colorado State University. Available at http:// www.cvmbs.colostate.edu/bms/ERL/erl_semenserv.htm. Accessed October 8, 2008. 18. Butterwick KJ. New trends in fat augmentation techniques with an introduction to the FAMI technique. In: Goldman MP, Weiss RA (Eds), Advanced Techniques in Dermatologic Surgery. New York, Taylor & Francis, 2006, pp. 71–92. 19. Coleman SR. Long term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425. 20. Butterwick KJ. Autologous fat transfer: Evolving concepts and techniques. In Robinson JK, Hanke CW, Sengelman RD, Siegel D (Eds), Surgery of the Skin: Procedural Dermatology. London, Mosby, 2005, pp. 535–548. 21. Sommer B, Sattler G. Current concepts of fat graft survival: Histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166. 22. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: A quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004; 113(1):391–395. 23. Ramon Y, Shoshani O, Peled IJ, Gilhar A, Carmi N, Fodor L, Risin Y, Ullmann Y. Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 2005;115(1):197–203. 24. Markey AC, Glogau RG. Autologous fat grafting: Compar­ ison of techniques. Dermatol Surg 2000;26(12):1135–1139. 25. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994;18(1):17–19. 26. Guerrerosantos J. Long term outcome of autologous fat transplantation in aesthetic facial recontouring: Sixteen years of experience with 1936 cases. Clin Plast Surg 2000; 27(4):515–543. 27. Eremia S, Newman N. Long term follow up after autologous fat grafting: Analysis of results from 116 patients followed at least 12 months after receiving the last of a minimum of two treatments. Dermatol Surg 2000;26(12):1150–1158. 28. Butterwick KJ. Lipoaugmentation for aging hands: A comparison of the longevity and aesthetic results of centrifuged versus noncentrifuged fat. Dermatol Surg 2002;28(11): 987–991. 29. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005;31(11 Pt 2):1496–1505. 30. Rigotti G, Marchi A, Galie M, Baroni G, Benati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose derived adult stem cells. Plast Reconstr Surg 2007;119(5):1409–1422. 31. Donofrio LM. Structural lipoaugmentation: A pan-facial technique. Dermatol Surg 2000;26(12):1129–1134. 32. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S. 33. Benito J, Fernandez I, Nanda V. Treatment of depressed scars with a dissecting cannula and an autologous fat graft. Aesthetic Plast Surg 1999;23(5):367–370. 34. Jackson IT, Simman R, Tholen R, DiNick VD. A successful long term method of fat grafting: Recontouring of a large

41  Cryopreserved Fat subcutaneous postradiation thigh defect with autologour fat transplantation. Aesthetic Plast Surg 2001;25(3):165–169. 35. Park BS, Jang KA, Sung JH, Park JS, Kwon YH, Kim KJ, Kim WS. Adipose derived stem cells and their secretory factors as a promising therapy for skin aging. Dermatol Surg 2008;34:1323–1326. 36. Goldman MP, Course Director. Minimally invasive facial rejuvenation. Discussion by presenters at Symposia #344 at Annual meeting of American Academy of Dermatology, San Antonio, 5 February 2008. 37. Rehman J, Traktuev D, Li J, Merfeld-Clauss S, Temm-Grove CA, Bovenkerk JE, Pell CL, Johnstone BH, Considine RV, March KL. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation 2004;109(10): 1292–1298. 38. Cao Y, Sun Z, Liao L, Meng Y, Han Q, Shao RC. Human adipose tissue derived stem cells differentiate into endothelial cells in vitro and improve postnatal neovascularization in vivo. Biochem Biophys Res Commun 2005;332(2):370–379. 39. Rigotti G, Marchi A, Galie M, Baroni G, Benati D, Krampera M, Pasini A, Sbvarbati A. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007;119(5):1409–1422. 40. Kaminski MV, Lopez de Vaughan R. Fat autograph retention: Use of albumin to correct physiologic perturbation caused by klein solution. Am J Cosmet Surg 2007;24:123–134. 41. Avram MM, Avram AS, James WD. Subcutaneous fat in normal and diseased states 3. Adipogenesis: From stem cell to fat cell. J Am Acad Dermatol 2007;56(3):472–492. 42. Coleman WP 3rd, Sherman LN, Reed RJ, Pinski KS. Autologous collagen? Lipocytic dermal augmentation. A histopathologic study. J Dermatol Surg Oncol 1993;19(1): 1032–1040. 43. Butterwick KJ, Nootheti PK, Hsu JW, Goldman MP. Autologous fat transfer: An in depth look at varying concepts and techniques. Facial Plast Surg Clin N Am 2007; 15(1):99–111. 44. Markey AC, Glogau RG. Autologous fat grafting: Compar­ ison of techniques. Dermatol Surg 2000;26(12):1135–1139. 45. Schuller-Petrovic S. Improving the aesthetic aspect of soft tissue defects on the face using autologous fat transplantation. Facial Plast Surg 1997;13(2):119–124.

311 46. Sattler G, Sommer B. Liporecycling: Immediate and delayed. Am J Cosmet Surg 1997;14:311–316. 47. Shoshani O, Ullmann Y, Shupak A, Ramon Y, Gilhar A, Kehat I, Peled IJ. The role of frozen storage in preserving adipose tissue obtained by suction-assisted lipectomy for repeated fat injection procedures. Dermatol Surg 2001;27(7): 645–647. 48. Bertossi D, Kharouf S, D’Agostino A et al. Facial localized cosmetic filling by multiple injections of fat stored at –30 degrees C. Techniques, clinical follow-up of 99 patients and histological examination of 10 patients. Ann Chir Plast Esthet 2000;45(5):548–555; discussion 555–556. 49. Kanchwala SK, Bucky LP. Facial fat grafting: The search for predictable results. Facial Plast Surg 2003;19(1):137–146. 50. Ullmann Y, Shoshani O, Fodor L, Ramon Y, Carmi N, Shupak A, Lincoln R, Gilhar A. Long term fat preservation. J Drugs Dermatol 2004;3(3):266–269. 51. MacRae JW, Tholpady SS, Ogle RC, Morgan RF. Ex vivo fat graft preservation effects and implications of cryopreservation. Ann Plast Surg 2004;52(3):281–282. 52. Berz D, McCormack EM, Winer ES, Colvin GA, Quesenberry PJ. Cryopreservation of hematopoietic stem cells. Am J Hematology 2007;82(6):463–472. 53. Wolter TP, Von Heimburg D, Stoffels I, Groeger A, Pallua N. Cryopreservation of mature human adipocytes in vitro measurement of viability. Ann Plast Surg 2005;55(4):408–413. 54. Moscatello DK, Dougherty M, Narins RS, Lawrence N. Cryopreservation of human fat for soft tissue augmentation: Viability requires use of cryoprotectant and controlled freezing and storage. Dermatol Surg 2005;31(11 Pt 2): 1506–1510. 55. Pu LLQ, Cui X, Fink BF, Cibull ML, Gao D. Cryopreservation of adipose tissues: The role of trehalose. Aesthetic Surg J 2005;25:126–131. 56. Narins RS. Long term sterility of fat frozen for up to 24 months. J Drugs Dermatol 2003;2(5):505–507. 57. Two Dimensional Instruments, LLC. Application note: 308, Installation and Setup. Available at http://www.e2di.com. Accessed October 15, 2008. 58. The California tissue bank law is found in Chapter 4.1 of the California Health and Safety Code (Sections. 1635–1643.2). Web access address for specifics and applications: http:// www.cdph.ca.gov/programs/lfs/Pages/Tissuebank.aspx.

Part Techniques for Non-Aesthetic Procedures

IV

Fat Transfer for Non-Aesthetic Procedures

42

Melvin A. Shiffman, Enrique Hernández-Pérez, Hassan Abbas Khawaja , José Enrique Hernández-Pérez, and Mauricio Hernández-Pérez

42.1  Introduction

42.2.3  Congenital Short Palate

Most often, autologous fat transplantation has been used for aesthetic purposes to fill defects and augment tissues. However, it has also been used for nonaesthetic purposes such as migraine headaches, clival chordoma surgery, congenital short palate, vocal cord paralysis, lumbar laminectomy, sulcus vocalis, vocal cord scar, hemifacial atrophy, myringoplasty, eye socket reconstruction, frontal sinus fracture, temporomandibular joint reconstruction, and other disorders.

DeJonckere and van Wijngaarden (3) described the use of retropharyngeal autologous fat transplantation to augment the posterior pharyngeal wall for congenital short palate with velopharyngeal insufficiency. Seventeen patients were treated successfully with this procedure.

42.2.4  Eye Socket Reconstruction The dermis-fat graft has been used in the reconstruction of the contracted socket (4–9).

42.2 Nonaesthetic Procedures Using Fat Transfer 42.2.1  Breast Reconstruction Missana et al. (1) have used fat transfer to further improve the cosmetic outcome of breast reconstruction.

42.2.5  Frontal Sinus Fracture The management of frontal sinus fractures includes the need to obliterate the cavity. Autologous fat graft has been used to fill this need (10, 11). Weber et al. (12) stated that the clinical result in obliteration of the frontal sinus appears to be independent of the viability of the fat graft.

42.2.2  Clival Cordomas Harsh et al. (2) reported on the use of layers of abdominal fat with fibrin glue and fascia lata graft to cover the exposed dura following removal of clival chordomas in ten patients.

M. A. Shiffman () Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham DriveTustin, CA 92780-2302, USA e-mail: [email protected]

42.2.6  Growth Plate, Partial Closure Langenskiöld (13, 14) has performed resection of bone bridges of growth plates in children and filled the defects with free grafts. The cavities were elongated and enlarged during growth after the surgery. Langenskiöld et al. (15) showed that these cavities filled with fat became elongated in pigs, similar to the case in children, and showed histologically to be filled with living adipose tissue for periods up to 9 months.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_42, © Springer-Verlag Berlin Heidelberg 2010

315

316 Fig. 42.1  (a) Preoperative patient with left hemifacial atrophy. (b) Postoperative after fat transfer (photos courtesy of author Enrique Hernandez-Perez)

M. A. Shiffman et al.

a

42.2.7 Hemifacial Atrophy (Parry-Romberg Syndrome, Romberg Syndrome, Progressive Facial Hemiatrophy, Progressive Hemifacial Atrophy) Soft tissue defects such as hemifacial atrophy can be treated with autologous fat transfer to correct the defect (Fig. 42.1) (16–19). Free dermis-fat graft has been used to correct hemifacial atrophy (20). Cotton (21) used finely cut fat from the gluteus and modeled it by hand to bring the fat to a normal level, and used it seven times in a patient with hemifacial atrophy secondary to scleroderma. There was no shrinkage or distortion of the grafts at the time of a 2-year follow-up.

b

42.2.9  Lumbar Disk Herniation Studies in animals and humans have shown that intraspinal scar tissue is reduced using fat transplantation (24–28). Some clinical studies have shown no change in the findings of scar with or without fat transfer (29, 30). Jacobs et al. (25) found fewer sciatic symptoms in patients who had fat transfer than those who had Gelfoam. Jensen et al. (31, 32) utilized autologous fat transfer placed in the laminectomy site following lumbar disk removal, flavectomy, and hemilaminectomy in 50 patients. There appeared to be less dural scarring but no better clinical outcome.

42.2.10  Lupus Erythematosis Defects from fat atrophy in lupus erythematosis profundus have been treated with fat transfer (Fig. 42.2).

42.2.8  Intrinsic Web Space Paralysis Simultaneous tendon transfer and dermofat graft augmentation was used by Ghobadi et al. (22) and Al-Qattan (23) to correct the first web space volume of the hand with intrinsic paralysis.

42.2.11  Malar Fracture Malar fracture with depression has been treated with fat transfer (Fig. 42.3).

42  Fat Transfer for Non-Aesthetic Procedures Fig. 42.2  (a) Preoperative patient with lupus erythematosis profundus. (b) Post­ operative after fat transfer (photos courtesy of author Enrique Hernandez-Perez)

317

a

b

a

b

Fig. 42.3  (a) Patient had a left malar fracture. (b) Post­ operative following fat transfer over the malar bone plus upper and lower lid blepharoplasty and a Kunt Zsymanowsky procedure (photos courtesy of author Enrique Hernandez-Perez)

42.2.12  Migraine Headaches Guyuron et al. (33) used fat grafting to the site of removal of the corrugator supercilii muscle while performing temporal release and transection of the zygomaticotemporal branch of the trigeminal nerve to

resolve migraine headaches. The fat was obtained from the medial aspect of the upper eyelid when using the transpalpebral approach or from the temporal region, deeper than the intermediate or deep temporal fascia. Of 22 patients who underwent this surgery 21 responded positively.

318 Fig. 42.4  (a) Young female with morphea zoniforme affecting the left lower extremity. (b) Postoperative following harvesting of fat from right lower extremity and abdomen and fat transfer to left leg (photos courtesy of author Enrique HernandezPerez)

M. A. Shiffman et al.

a

42.2.13  Morphea Zoniform Fat deficit from morphea zoniform has been treated with fat transfer (Fig. 42.4).

b

Other symptoms include nasal crusting, discharge, and bad smell. Girgis (36) utilized dermofat grafting to fill the nasal defect.

42.2.17  Pectus Excavatum 42.2.14  Myringoplasty Landsberg et al. (34) reported on the use of autologous fat for small and medium-size chronic tympanic membrane perforations. Of 38 perforations 31 were repaired with long-term success.

42.2.15 Orbicularis Oculi Resection for Crow’s Feet Viterbo (35) described the use of adipose tissue with superficial muscular aponeurotic system from the preauricular or temporal region during facelift, forehead lift, or blepharoplasty to fill the defect caused by vertical excision of the lateral aspect of the orbicularis oculi muscle to treat crow’s feet.

42.2.16  Ozena Treatment Ozena is a disease of the nose that shows wasting away of the bony ridges and mucous membranes inside.

Pereira and Sterodimas (37) described the use of fat transfer to treat mild pectus excavatum.

42.2.18  Postradiation Defect The effect of radiation can be fat atrophy. Fat transfer for recontouring radiation defects is possible even with the probable poor vascularity of the recipient site (38).

42.2.19  Sulcus Vocalis Sulcus vocalis is a disorder in which a furrow occurs along the medial edge of the vocal cords. The disorder is divided into three types. Type I is a physiologic type with normal lamina propria and does not cause vocal disturbance. Type II (sulcus vergeture) shows loss of lamina propria with a linear depression. Type III (­sulcus vocalis) has loss of lamina propria with a penetrating furrow extending into the vocal ligament or thyroary­ tenoid muscle.

42  Fat Transfer for Non-Aesthetic Procedures

a

319

42.2.21  Thin Toes Unusually thin toes in a patient who was disturbed by the appearance was treated with fat transfer (Fig. 42.5).

42.2.22  Transsphenoidal Surgery

b

Dumas et al. (44) used harvested fat and synthetic dural substitutes to close the dural defect following transsphenoidal approach to a variety of tumors. Fat was also placed in the sphenoidal sinus.

42.2.23  Vocal Cord Paralysis There have been multiple reports of the use of autologous fat transfer to close the open glottis in patients with vocal cord paralysis (45–53).

Fig. 42.5  (a) Preoperative patient with thin toes. (b) Postoperative following fat transfer to the toes (photos courtesy of author Enrique Hernandez-Perez)

Nishiyama et al. (39) developed the technique of intracordal transplantation of fat and fascia for sulcus vocalis. Hsiung et al. (40) demonstrated good results but resorption of fat and fascia is associated with the procedure and may require repeated sessions.

42.2.20  Temporomandibular Joint Wolford and Karras (41) described the use of autologous fat as an adjunct to prosthetic joint reconstruction to prevent fibrosis and heterotopic bone formation. These complications were minimized by the use of the fat graft. Dimitroulis (42, 43) performed arthroplasty for temporomandibular joint ankylosis and the space was filled with autogenous dermis-fat grafts harvested from the groin.

42.2.24  Vocal Fold Scar Sakaloff et al. (54) reported on the use of autologous fat transplantation for vocal fold scar.

42.3 Use of Autologous Adipose Stem Cells for Nonaesthetic Transfer Human adipose stromal cells have been found to secrete vascular endothelial growth factor, hepatocyte growth factor, transforming growth factor, angiogenic and antiapoptotic factors in hypoxic conditions that may be used to enhance angiogenesis (55). There has been a report of the use of autologous adipose stem cells to cause new bone formation for the repair of traumatic calvarial defects (56). Eight Crohn’s fistulas in four patients were inoculated with mesenchymal stem cell transplantation resulting in closure of the external opening by the epithelium of six of the fistulas within 8 weeks (57).

320

42.4  Conclusions Autologous fat has had extended use in nonaesthetic situations. This opens the door to many more applications of the procedure. Further research is important to find other uses for fat transfer.

References   1. Missana MC, Laurent I, Barreau L, Balleyguier C. Autologous fat transfer in reconstructive breast surgery: Indications, technique and results. Eur J Surg Oncol 2007;33(6):685–690.   2. Harsh G, Ojemann R, Varvares M, Swearingen B, Cheney M, Joseph M. Pedicled rhinotomy for clival chordomas invaginating the brainstem. Neurosurg Focus 2001;10(3):1–6.   3. DeJonckere PH, Wijngaarden HA. Retropharyngeal autologous fat transplantation for congenital short palate: A nasometric assessment of functional results. Ann Otol Rhinol Laryngol 2001;110(2):168–172.   4. Smith B, Petrelli R. Dermis-fat graft as a movable implant within the muscle cone. Am J Ophthalmol 1978;85(1):62–66.   5. Smith B, Bosniak SL, Lisman RD. An autogenous kinetic dermis-fat orbital implant. An updated technique. Ophtha­ lmology 1982;89(9):1067–1071.   6. Soll DB. The anophthalmic socket. Ophthalmology 1982; 89(5):407–423.   7. Guberina C, Hornblass A, Meltzer MA, Soarez V, Smith B. Autogenous dermis-fat orbital implantation. Arch Ophtha­ lmol 1983;101(10):1586–1590.   8. Bullock JD, Brickman KR. Dermis-fat graft in socket reconstruction: Theoretical and experimental considerations. Ophthalmology 1984;91(2):204–206.   9. Collin JR. A Manual of Systematic Eyelid Surgery, 2nd edition, Edinburgh, Churchill Livingstone, 1989, pp. 121–133. 10. Goodale RL, Montgomery WW. Experiences with the osteoplastic anterior wall approach to the frontal sinus: Case histories and recommendations. AMA Arch Otolaryngol 1958; 68(3):271–283. 11. Rohrich RJ, Mickel TJ. Frontal sinus obliteration: In search of the ideal autogenous material. Plast Reconstr Surg 1995; 95(3):580–585. 12. Weber R, Draf W, Kahle G, Kind M. Obliteration of the frontal sinus-state of the art and reflections on new materials. Rhinology 1999;37(1):1–15. 13. Langenskiöld A. The possibilities of eliminating premature partial closure of an epipyseal plate caused by trauma or disease. Acta Orthoped Scand 1967;38:267–279. 14. Langenskiöld A. An operation for partial closure of an epiphyseal plate in children, and its experimental basis. J Bone Joint Surg Br 1975;57(3):325–330. 15. Langenskiöld A, Videman T, Nevalainen T. The fate of fat transplants in operations for partial closure of the growth plate. J Bone Joint Surg Br 1986;68(2):234–238. 16. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesthetic Plast Surg 1986;10(2): 115–117.

M. A. Shiffman et al. 17. Moscona R, Ullman Y, Har-Shai Y, Hirschowitz B. Free-fat injections for correction of hemifacial atrophy. Plast Reconstr Surg 1989;84(3):501–507. 18. Roddi R, Riggio E, Gilbert PM, Vandrager JM, van der Meulen JCH. The value of microfat injection “lipofilling” in the treatment of soft tissue deformities of the face in ParryRomberg syndrome. Eur J Plast Surg 1994;17(2):79–83. 19. Xie Y, Li Q, Zheng D, Lei H, Pu LLQ. Correction of hemifacial atrophy with autologous fat transplantation. Ann Plast Surg 2007;59(6):645–653. 20. Wells JE, Edgerton MT. Correction of severe hemifacial atrophy with a free dermis-fat flap from the lower abdomen. Plast Reconstr Surg 1977;59(2):223–230. 21. Cotton FJ. Contribution to technic of fat grafts. New Engl J Med 1934;211(33):1051–1053. 22. Ghobadi F, Zangeneh M, Massolud BJ. Free fat autotransplantation for the cosmetic treatment of first web space atrophy. Ann Plast Surg 1995;35(2):197–200. 23. Al-Qattan MM. Simultaneous tendon transfer and autogenous augmentation of the first web space of the hand with intrinsic paralysis. J Hand Surg 1996;21(4):486–487. 24. Yong-Hing K, Reilly J, de Korompay V, Kirkaldy-Willis WH. Prevention of nerve adhesion after laminectomy. Spine 1980;5(1):59–64. 25. Jacobs RR, McClain O, Neff J. Control of postlaminectomy scar formation. Spine 1980;5(3):223–229. 26. Long DM. Free fat graft in laminectomy. J Neurosurg 1981;54(5):711. 27. Chen PQ, Yang CY, Su CJ, Lee F. Prevention of postlaminectomy membrane: Experimental and clinical observations. Taiwan Yi Xue Hui Za Zhi 1989;88(1):57–61. 28. Henderson R, Weir B, Davis L, Mielke B, Grace M. Attempted experimental modification of the postlaminectomy membrane by local installation of recombinant tissue-plasminogen activator gel. Spine 1993;18(10):1268–1272. 29. Bryant MS, Bremer AM, Nguyen TQ. Autogenic fat transplants in the epidural space in routine lumbar spine surgery. Neurosurgery 1983;13(4):367–370. 30. Van Akkerveekwn PF, Van De Kraan W, Muller JW. The fate of the free fat graft. A prospective clinical study using CT-scanning. Spine 1986;11(5):501–504. 31. Jensen TT, Asmussen K, Berg-Hansen E-M, Lauritsen B, Manniche C, Vinterberg H, Jensen LE, Kramhøft J. Firsttime operation for lumbar disk herniation with and without free fat transplantation: Prospective triple-blind randomized study with reference to clinical factors and enhanced computed tomographic scan 1 year after operation. Spine 1996;21(9):1072–1076. 32. Jensen TT, Asmussen KH, Rose-Hansen EB, Lauritsen BU, Manniche C, Vinterberg H, Jensen LE, Kramhøft J. Operation for lumbar disk herniation with and without free fat transplantation: A prospective triple-blind randomized study. Ugeskr Laeger 1997;159(14):2091–2095. 33. Guyuron B, Tucker T, Davis J. Surgical treatment of migraine headaches. Plast Reconstr Surg 2003;112(5 Suppl): 164S–170S. 34. Landsberg R, Fishman G, DeRowe A, Berco E, Berger G. Fat graft myringoplasty: Results of a long-term follow-up. J Otolaryngol 2006;35(1):44–47. 35. Viterbo F. New treatment for crow’s feet wrinkles by vertical myectomy of the lateral orbicularis oculi. Plast Reconstr Surg 2003;112(1):275–279.

42  Fat Transfer for Non-Aesthetic Procedures 36. Girgis IH. Surgical treatment of ozena by dermofat graft. J Laryngol Otol 1966;80(6):615–627. 37. Pereira LH, Steodimas A. Free fat transplantation for the aesthetic correction of mild pectus excavatum. Aesthetic Plast Surg 2008;32(2):393–396. 38. Jackson IT, Simman R, Tholen R, DiNick VD. A successful long-term method of fat grafting: Recontouring of a large subcutaneous postradiation thigh defect with autologous fat transplantation. Aesthetic Plast Surg 2001;25: 165–169. 39. Nishiyama K, Hirose H, Iguchi Y, Yamamoto K, Suzuki T, Yamanaka J, Hirayama M, Okamoto M. A new surgical technique combining autologous intracordal transplantation of fat and fascia for sulcus vocalis. Nippon Jibiinkoka Gakkai Kaiho 2001;104(120):1151–1155. 40. Hsiung MW, Kang BH, Pai L, Su WF, Lin YH. Combination of fascia transplantation and fat injection into the vocal fold for sulcus vocalis: Long-term results. Ann Otol Rhinol Laryngol 2004;113(5):359–366. 41. Wolford LM, Karras SC. Autologous fat transplantation around temporomandibular joint total joint prostheses: Preliminary treatment and outcomes. J Oral Maxillofac Surg 1997;55(3):245–251. 42. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33(8):755–760. 43. Dimitroulis G, Trost N, Morrison W. The radiological fate of dermis-fat grafts in the human temporomandibular joint using magnetic resonance imaging. Int J Oral Maxillofac Surg 2008;37(3):249–254. 44. Dumont AS, Kanter AS, Jane AJA Jr, Laws ER Jr. Extended transsphenoidal approach. Front Horm Res 2006;34:29–45. 45. Mikaelian DO, Lowry LD, Sataloff RT. Lipoinjection for unilateral vocal cord paralysis. Laryngoscope 1991;101(5): 465–468. 46. Brandenburg JH, Kirkham W, Koschkee D. Vocal cord augmentation with autogenous fat. Laryngoscope 1992;102(5): 495–500.

321 47. Zaretsky LS, Shindo ML, deTar M, Rice DH. Autologous fat injection for vocal cord paralysis: Long-term histologic evaluation. Ann Otol Rhinol Laryngol 1995;104(1):1–4. 48. Bauer CA, Valentino J, Hoffman HT. Long-term result of vocal cord augmentation with autogenous fat. Ann Otol Rhinol Laryngol 1995;104(11):871–874. 49. Mikus JL, Koufman JA, Kilpatrick SE. Fate of liposuctioned and purified autologous fat injections in the canine vocal fold. Laryngoscope 1995;105(1):17–22. 50. Brandenburg JH, Unger JM, Koschkee D. Vocal cord injection with autogenous fat: A log-term magnetic resonance imaging evaluation. Laryngoscope 1996;106(2 Pt 1):174–180. 51. Shindo ML, Zaretsky LS, Rice DH. Autologous fat injection for unilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1996;105(8):602–606. 52. Shaw GY, Szewczyk MA, Searle J, Woodroof J. Autologous fat injection into the vocal folds: Technical consideration and long-term follow-up. Laryngoscope 1997;107(2):177–186. 53. Hsiung MW, Woo P, Minasian A, Schaefer Mojica J. Fat augmentation for glottic insufficiency. Laryngoscope 2000; 110(6):1026–1033. 54. Sakaloff RT, Spiegel JR, Hawkshaw M, Rosen DC, Heuer RJ. Autologous fat implantation for vocal fold scar: A preliminary report. J Voice 1997;11:238–246. 55. Rehman J, Traktuev D, Li J, Merfeld-Clauss S, Temm-Grove CJ, Bovenkerk JE, Pell, CL, Johnstone BH, Considine RV, March KL. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation 2004;109(10): 1292–1298. 56. Lendeckel S, Jodicke A, Christophis P, Heidinger K, Wolff J, Fraser JK, Hedrick MH, Berthold L, Howaldt HP. Autologous stem cells (adipose) and fibrin glue used to treat widespread traumatic calvarial defects: Case report. J Craniomaxillofac Surg 2004;32(6):370–373. 57. Garcia-Olmo D, Garcia-arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes JA. A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum 2005;48(7): 1416–1423.

Fat Transplantation for Mild Pectus Excavatum

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Luiz Haroldo Pereira and Aris Sterodimas

43.1  Introduction Pectus excavatum (a Latin term meaning hollowed chest) or funnel chest, a congenital depressive malformation of the sternum, was described in 1594 by Johannes Schenk and has successively been the subject of many studies because of its various inherent problems (1). It usually involves the lower one-half to two-thirds of the sternum and is the most common congenital deformity of the chest wall that is present in one in 400 cases and one in 1,000 live births (Fig. 43.1). There are many different shapes of the pectus, and multi­ ple  factors probably contribute to the final form (2). Disturbances in endochondral ossification and overgrowth of the third to seventh costal cartilages seem to be the main cause of this deformity (3). Evidence exists that pectus excavatum is an inherited disorder, possibly of the connective tissue, and of multifactorial inheritance (2). The aesthetic defect, often the first aspect to attract the attention of the patient and the doctor, has serious psychological implications, especially for what concerns the affective life and relationships in general (1). Patients with pectus deformities are often asymptomatic but experience embarrassment and shame due to the perceived abnormality in their appearance and the indication for surgery is often for aesthetic purposes. Severe pectus chest deformities are common and in some patients can cause cardiopulmonary function

A. Sterodimas () Department of Plastic Surgery, Ivo Pitanguy Institute, Pontifical Catholic University of Rio de Janeiro, Rua Dona Mariana 65, 22280–020 Rio de Janeiro, Brazil e-mail: [email protected]

impairment. These patients who do not undergo repair during childhood often experience progressive worsening of their symptoms during adulthood (4). a

b

Fig. 43.1  (a, b) Frontal and lateral views of male patient with pectus excavatum

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The majority of patients with moderate to severe pectus deformity are usually operated on during childhood. The surgical techniques that have been described include modified Ravitch’s procedure with the placement of a stainless steel substernal strut, modelling osteochondroplasty, insertion of silicone implant, and the Nuss procedure, a technique for minimally invasive repair of the pectus excavatum (MIRPE) which has gained increasing acceptance among pediatric patients (5–7). The authors have introduced a new method for transplantation of autologous fat in order to restore the visible and nonfunctionally disturbing deformation of mild funnel chests (8).

L. H. Pereira and A. Sterodimas

attached to a 2.5-mm blunt cannula is inserted through a small stab incision in the abdomen. 4. Fat is aspirated using the syringe method (Fig. 43.4).

43.2  Surgical Technique 1. Marking of the pectus excavatum area to be treated is made with the patient standing up, sitting down and in supine position (Fig. 43.2). Marking of the areas to be liposuctioned (Fig. 43.3). 2. Preoperative sedation in the surgical suite is administered. Anesthesia consists of intravenous sedation and peridural anesthesia. The patient is placed in supine position with the arms spread out. 3. After the injection of normal saline wetting solution containing 1: 500,000 of adrenaline by a small bore cannula and waiting for 15  min, a 10-mL syringe

Fig. 43.2  Marking of the pectus excavatum area to be treated

Fig. 43.3  Marking of the areas to perform liposuction

Fig. 43.4  Aspiration of fat using the syringe method

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Fig. 43.7  A 10-mL syringe attached to a 2.5-mm blunt cannula filled with the prepared fat is used for the autologous fat transplantation

Fig. 43.5  Different stages of fat preparation using isotonic saline

5. The fatty tissue is aspirated using the syringe held vertically with the open end down and the fat and fluid are separated. Isotonic saline is added to the syringe, the fat and saline are separated and the ­exudate discarded (Fig. 43.5). The procedure is repeated until the fat becomes yellow in color and free of blood and other contaminants (Fig. 43.6). 6. Xylocaine 0.5% with adrenaline 1/200,000 dilution is used to infiltrate the incision point, avoiding infiltration of the recipient area. A 10-mL syringe attached to a 2.5-mm blunt cannula filled with the prepared fat  is used for the autologous fat transplantation (Fig. 43.7). The fat is inserted into tunnels beginning at the deep layer and working up into the more superficial. Different trajectories are created. The fat is injected as the cannula is withdrawn. Care should be taken not to inject more than 4–5 mL of fat per tunnel. Approximately 30–70 mL is placed in each session. 7. Immediate postoperative dressing is done in the area that was lipoaspirated, avoiding though any pressure in the chest area.

43.3  Patient Selection

Fig. 43.6  Fat free of blood and other contaminants and ready for grafting

Candidates are patients over 18 years old with mild pectus excavatum. Preoperative symptoms such as dyspnea on exertion, shortness of breath at rest, chest pain, and

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palpitations are indications for more complex surgical repairs. A full preoperative series of exams and CT scan of the thoracic area needs to be done.

43.4  Sample Cases A 35-year-old male was highly concerned about the aesthetic appearance of his pectoral area especially when he was exposed on the beach. On examination the patient was diagnosed with a mild form of pectus excavatum (Fig. 43.8). The patient expressed the desire

L. H. Pereira and A. Sterodimas

to undergo the least invasive and complex intervention that could produce an aesthetically acceptable result. It was decided to perform autologous fat transplantation. A total of 60 mL was injected on the pectus excavatum area. In order to get symmetry with the right superomedial pectoral area, it was decided to insert 80 mL of fat in the supero-medial part of the left pectoral area. At 18 months follow-up there were no complications and a satisfactory aesthetic result was achieved (Fig. 43.8). A 27-year-old woman with mild pectus excavatum requested aesthetic correction, using the least aggressive possible procedure (Fig. 43.9). Autologous fat transplantation was performed with insertion of 35 mL of fat.

a1

b1

a2

b2

Fig. 43.8  (a1, a2) Preoperative 35-year-old male with pectus excavatum. (b1, b2) After fat grafting

43  Fat Transplantation for Mild Pectus Excavatum

a1

327

b1

b2

a2

Fig. 43.9  (a1, a2) Preoperative 27-year-old female with pectus excavatum. (b1, b2) Postoperative after two sessions of fat grafting

Six months after the first intervention, a second procedure was done, inserting 18 mL of fat. The follow-up for the patient has been 24 months with no complications and a satisfactory aesthetic result (Fig. 43.9).

43.5  Discussion Traditionally, the correction of pectus excavatum malformations has been geared toward interventions that modify the architecture of the rib cage. While moderate

to extensive deformities of the ventral chest wall are classically corrected nowadays using a so-called minimally invasive repair of the pectus excavatum, plastic surgeons are mostly challenged with the aesthetic corrections of mild funnel chests (9). Good results have been achieved with the insertion of silicone implant, but patients often experience complications (10). Since the presternal area is prone to hypertrophic scarring, this type of scar may be a disturbing complication of the silicone insertion. A new technique has been recently published using a high density linear polyethylene implant and omental flap via endoscopic approach

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(11). Displacement of the implant and seroma formation are common complications with this technique. The authors’ experience with autologous fat transplantation in treating various tissue defects led us to use this technique for the correction of mild pectus excavatum (12). The donor site for fat harvesting can be chosen according to the preference of the surgeon and the patient. There is no statistical difference in adipocyte viability demonstrated among abdominal fat, thigh fat, flank fat, or knee fat as donor sites (13). Recent reports have shown that mechanical centrifugation does not appear to enhance immediate fat ­tissue viability before implantation (14). An important consideration for harvesting and refinement in preparation for grafting is to respect and maintain the tissue architecture of living fat. Any mechanical or chemical insult that damages the fragile tissue architecture of fat will result in eventual necrosis of the injected fat. For predictable results, the surgeon should refine the fat into relatively pure living tissue, using sterile conditions and avoiding external contact, thus preventing contamination. Transplanting a high percentage of nonviable components such as blood and local factors reduces the potential for accurate volume estimation (15). It is known that partial fat graft resorption is encountered in autologous adipose tissue transfer (16). The patient needs to know that a secondary procedure may be needed. The creation of multiple tunnels ensures adequate blood supply of the grafted fat. Surgeons have come to realize that transplanted fat can not only create satisfying changes in contour, but also produce longlasting results (17). No consensus exists concerning the indications for surgery, the technique to be used, or the suitable age of the patient in pectus excavatum cases of a mild form (18). There is a surprisingly high demand for surgical correction of pectus excavatum and the number of referred patients continues to increase (7). Overall, patients often live with extreme psychological discomfort when the malformations are minor (11). Less invasive methods should be applied in the mild cases, considering the higher degree of tolerance of the intervention, the absence of postoperative complications and the minor cost due to a shorter hospital stay. The autologous fat transplantation technique avoids major reconstruction of the chest wall with its inherent risks and complications. The major advantages are the minimally invasive operation, the short hospital stay, good aesthetic results, and high patient satisfaction.

L. H. Pereira and A. Sterodimas

43.6  Conclusions With careful patient selection, the autologous fat transfer achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for the aesthetic treatment of pectus deformities.

References   1. Paolini A, Ruggieri M, Leone Sossi FL, Paolini G, Dal Prà G, Scuderi N. Pectus excavatum in adults: destructive surgery or simple correction of an aesthetic defect? Riv Eur Sci Med Farmacol 1996;18(1):11–17.   2. Creswick HA, Stacey MW, Kelly RE Jr, Gustin T, Nuss D, Harvey H, Goretsky MJ, Vasser E, Welch JC, Mitchell K, Proud VK. Family study of the inheritance of pectus excavatum. J Pediatr Surg 2006;41(10):1699–1703.   3. Serafin J, Swiatkowski J, Majkusiak R. Nowakowski P: 40-year experience in surgical treatment of congenital chest deformations-etiopathogenesis, operative techniques and clinical results. Acta Chir Orthop Traumatol Cech 2003; 70(4):207–213.   4. Jaroszewski DE, Fonkalsrud EW. Repair of pectus chest deformities in 320 adult patients: 21 year experience. Ann Thorac Surg 2007;84(2):429–433.   5. Prévot J. Treatment of sternocostal wall malformations of the child. A series of 210 surgical corrections since 1975. Eur J Pediatr Surg 1994;4(3):131–136.   6. Horch RE, Springer O. Minimally-invasive endoscopic correction of funnel chest deformity via an umbilical incision. Aesthetic Plast Surg 2002;26(4):295–298.   7. Pilegaard HK, Licht PB. Early results following the Nuss operation for pectus excavatum-a single-institution experience of 383 patients. Interact Cardiovasc Thorac Surg 2008; 7(1):54–57.   8. Pereira LH, Sterodimas A. Free fat transplantation for the aesthetic correction of mild pectus excavatum. Aesthetic Plast Surg 2008;32(2):393–396.   9. Horch RE, Stoelben E, Carbon R, Sultan AA, Bach AD, Kneser U. Pectus excavatum breast and chest deformity: indications for aesthetic plastic surgery versus thoracic surgery in a multicenter experience. Aesthetic Plast Surg 2006; 30(4):403–411. 10. Wechselberger G, Ohlbauer M, Haslinger J, Schoeller T, Bauer T, Piza-Katzer H. Silicone implant correction of pectus excavatum. Ann Plast Surg 2001;47(5):489–493. Erratum in: Ann Plast Surg 2001;47(6):611. 11. Grappolini S, Fanzio PM, D’Addetta PG, Todde A, Infante M. Aesthetic treatment of pectus excavatum: a new endoscopic technique using a porous polyethylene implant. Aesthetic Plast Surg 2008;32(1):105–110. 12. Haroldo Pereira L, Sterodimas A. Aesthetic restoration of axillary contour deformity after lymph node dissection. J Plast Reconstr Aesthet Surg 2008;61(2):231–232.

43  Fat Transplantation for Mild Pectus Excavatum 13. Ullmann Y, Shoshani O, Fodor A, Ramon Y, Carmi N, Eldor L, Gilhar A. Searching for the favorable donor site for fat injection: in vivo study using the nude mice model. Dermatol Surg 2005;31(10):1304–1307. 14. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg 2004;113(1):391–395; discussion 396–397. 15. Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower limbs. Aesthetic Plast Surg 1996;20(5):409–416.

329 16. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg 2008;32(2):313–328. 17. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425. 18. Poupon M, Duteille F, Casanova D, Caye N, Magalon G, Pannier M. Pectus excavatum: what treatment in plastic surgery? About 10 cases. Ann Chir Plast Esthet 2007;53(3): 246–254.

Correction of Hemifacial Atrophy with Fat Transfer

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Qing Feng Li, Yun Xie, and Danning Zheng

44.1  Introduction Progressive hemifacial atrophy syndrome, also called Romberg’s disease is an acquired facial soft tissue disease that is a craniofacial deformity. Parry (1852) and Romberg (1846) were the first who described the features of this disease (1). It progresses gradually; usually the onset is from 5 to 15-years of age and going on for 2–10 years. It is more common in the female population with a femaleto-male ratio of 1.5:1, and bilateral incidence is almost 5%. The right and left sides of the face are involved with an equal frequency. About 7% of the patients will be involved with unilateral limb and trunk atrophy (2). Pensler (3) reported that 85% of patients affected not only have soft tissue but also bone atrophy. If the patient began having atrophy after the age of 10 when his/her facial bones had developed almost completely, only his/her facial soft tissue would be affected. If the patient began his/her atrophy before the age of 10, when his/her facial bone had not developed completely, then he/she would have a malformed face and distorted facial organ (4). In 1964, Rogers reported 773 cases of hemifacial atrophy, but up till now, the etiology of this disease is still not distinct. There are eight theories about it (5): (a) infection theory, (b) sympathetic nerve theory, (c) trigeminal theory, (d) scleroderma theory, (e) trauma theory, (f) inheritance theory, (g) neurocutaneous syndromes theory, and (h) abnormalities of neural tube crest cell migration theory.

Q. F. 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 e-mail: [email protected]

The traditional treatment of hemifacial atrophy used to be free autologous tissue transplantation such as (a) dermal-fat or aponeurosis fat transplantation that was suitable for the mild and moderate localized atrophic area but cannot be used in large areas. Moreover, the operations have to be done stage by stage on different operative sites, and the interval between procedures is at least 6 months. The absorption of the dermal fat is 20–40%; (b) tubed flap where the flap contracted less, but it is still necessary to transfer in stages; (c) vessel anastomosis for tissue transplantation; (d) larger omentum transplantation; (e) muscle transplantation and; (f) fat and aponeurosis flap transplantation. The last two methods can avoid the complications of laparotomy, such as ileus, intestine adhension. Although all these methods can ameliorate the asymmetric appearance of the face (6–11), there will be obvious scars dysfunctions and malformation in the donor site. The recipient areas always showed a bulky appearance and an unnatural expression, and one or several more operations is/ are necessary to trim the bulky flap. If the skin from another part of body does not match the color of facial skin then scars will be left. Patients have to arrange their time to be in hospital and have an operation under general anesthesia that costs more than the procedures done under local anesthesia in an outpatient ward. Patients might be dissatisfied with the expense, poor color match of skin, length of hospitalization, and the bulky appearance after a flap. Alloplastic materials were utilized in plastic surgeries during the 60s and 70s of the last century (12, 13). Historically, many filling materials have been used to treat hemifacial atrophy. Alloplastic materials included silicone rubber, expanded Teflon, PTFE, etc. All of them could cause an unnatural sensation in the filled area and displacement and exposure of the filler or implant. Heterologous soft tissue fillers such as collagen could

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give good results but only for a very short time, while other surgeons indicated that collagen might also lower the immune mechanism (14). Neuber (14) and Lexer (15) used free autologous fat tissue transplantation to cure soft tissue defects, hypogenesis, and malformation. Although they did not get affirmative results, they gave us a nice feedback. In 1950, Peer (16) reported that the absorption rate of autologous fat graft was 50% in 1 year after the operation. Complications like liquefaction, cyst, fibrosis, and necrosis frightened some surgeons. With the appearance of silicone, the research of autologous fat transplantation almost ceased until 1975, with the invention of liposuction that facilitated fat acquisition. Physicians began to realize that the ideal soft tissue fillers should be safe, stable, and have good histocompatibility. Therefore, autologous fat transplantation became popular again. It is nonallergenic, less traumatic, facilitate early recovery, good palpation, and can be repeated. Currently there are some reports of autologous fat transplantations in treating hemifacial atrophy (17–21). The follow-up was longer than 5 years. Not only cases of facial rejuvenation and aesthetic treatment of scars or local defects in the face were treated but also hemifacial atrophy with autologous fat injection, and all these obtained satisfied results. Although some early cases had complications of cysts, liquefaction, and necrosis, more cases have been reported with improved autologous fat injection technique with less or without the complications.

44.2  Technique 44.2.1  Timing of Operation Many of the underlying causes of facial atrophy have a progressive nature. Before the surgical operation it is important to ensure the case is during its stable phase. It is better to wait 1 or 2 years after atrophy stops progressing. In patients with severe defects who have correctable skeletal abnormalities need to be operated on the skeletal contour before correcting the soft tissue coverage. When the subcutaneous tissue is almost completely atrophic, earlier intervention can improve or prevent further atrophy of the overlying skin and may prevent or lessen subsequent skeletal wasting.

Q. F. Li et al.

44.2.2  Preoperative Preparation Each patient should be well informed about autologous fat transplantation as an alternative option for treatment of hemifacial atrophy including its potential benefits, limitations, and complications. Maximal efforts during preoperative teaching were made in order to ensure good compliance from each patient postoperatively. Each patient fully understood that he or she potentially could require fat injections 2–3 times with intervals of 3–6 months. Additional attention was paid during the preoperative visit to confirm the extent and thickness of facial recontouring required and to determine the quantity of autologous fat grafts needed. The standard preoperative photos were taken for each patient.

44.2.3  Fat Graft Harvesting The authors prefer to choose donor sites in the lower part of the body using low pressure for harvesting and low speed for centrifugation. The lower abdomen or thigh in each patient is chosen as the donor site for fat graft harvesting. Tumescent solution containing 0.08% lidocaine and 1:500,000 of epinephrine are infiltrated into the donor site. A 2.5-mm suction cannula with two holes in the tip is connected to a 60-mL syringe for fat graft harvesting. An appropriate amount of fat is gently aspirated with finger pressure on the plunger of the syringe without using a suction machine in order to minimize trauma to the fat grafts. The fat grafts are then washed with normal saline inside the syringe in sterile condition to remove lidocaine, oil, and residual blood cells and are then spun at low speed (1,000 rpm) for 2 min. After centrifugation, the middle layer primarily consisting of usable fat parcels is used for fat injection. The entire procedure is done in 30 min and the temperature is controlled at 25°C throughout the procedure.

44.2.4  Fat Graft Injection Fat grafts are injected into multiple tissue areas, within the subcutaneous tissue and under the superficial musculoaponeurotic system (SMAS), and in multiple tissue planes and tunnels with a syringe having a blunt needle

44  Correction of Hemifacial Atrophy with Fat Transfer

333

Fig. 44.1  Fat transfer during the operation (photos with permission from Lippincott Williams & Wilkins)

whose external diameter is 1.5 or 3 mm (Fig. 44.1). Care is taken to inject fat grafts in only small quantities in one place each time, radially from the distal to the proximal. In the buccal area the needle should be paralleled to the facial nerve to avoid direct injury to the nerve. The syringe should be drawn back before each injection to check blood return in order to avoid hematoma or to inject fat grafts into blood vessels causing possible fat emboli. The authors routinely inject about 20–30% more than the required volume of fat grafts to each patient for overcorrection possibly because of absorption of the fat later on after facial recontouring.

44.2.5  Postoperative Care and Follow-Up The grafted site of the face should be immobilized with pressure dressing for a week. Patients are instructed to reduce or avoid movements of facial muscles such as frontalis, temporalis, and masseter if possible because these movements might traumatize the newly formed blood vessels around injected fat grafts. All patients were seen at postoperative days 7, 30, and 90, and standard photos were taken during each visit. These photos were used to compare the facial contour in the injected site with those taken preoperatively. If the volume of the injected area was stable but the outline of hemifacial atrophy was not completely ameliorated in 3 months after the first injection then a second injection, usually after 6 months, was indicated to add more volume of fat grafts to the hollow area. Some mild hemifacial atrophy

patients who only need to be injected small amount of fat may be reinjected at an interval of 3 months.

44.3  Complications During the follow-up only a few patients showed transiently slight swelling and bruising for a week. No infection, subcutaneous mass, or any other complication was noted.

44.4  Discussion Although the clinical features of progressive hemifacial atrophy may be different in each case, the main pathologic problem is insufficiency in the affected side in both the soft tissue and bone tissue with especially the soft tissue being insufficient (22, 23). Therefore surgeons are continuously looking for suitable soft fillers to treat hemifacial atrophy. Historically many filling materials have been used to treat hemifacial atrophy such as alloplastic materials or heterologous tissue and are compared to autologous fat in Table 44.1. Compared to autologous fat (Table 44.2), autologous flaps or dermal fat flap caused long surgical incisions and bulky appearance of the recipient area. Sometimes it is difficult to estimate the volume to fill, so it is necessary to do several more operations in order to thin the flaps.

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Table  44.1  Comparing autologous fat to other soft tissue fillers Compare

Alloplastic

Autologous fat

Source

Produced

Histocompatibility

Allergenic response Some will inhibit immune system Expensive Poor Unnatural sensation

Abundant, easy to obtain Nonallergenic

Immune influence

Cost Safety Therapeutic effect

No inhibiting

Cheap Good Natural feeling, good palpation

Table  44.2  Comparing autologous fat with flaps Compare

Flap transplantation

Autologous fat

Source Donor

Limited Obvious scar, ­deformation, hypofunction Long, complex Long Poor Difficult to estimate Bulky, additional operation Severe traumatic, long

Abundant Almost no problem

Operation Hospitalization Repetition Graft volume Effective Recovery time

Fig. 44.2  (a1, a2) Atrophic right face with defect. (b) During the operation (1) first stage filling then (2) second stage filling (photos with permission of Lippincott Williams & Wilkins)

Relative short, easy Outpatient can do Good Easy to estimate Natural, good palpation Small injury, soon

Some scholars have reported the transplantation of free vascularized dermal-fat flap to treat hemifacial ­atrophy (24). As the blood supply was abundant, the retraction was limited. But if the patients were treated during their progress phase, the flap would retract more. However if the time from postoperative to retraction is 1  year, patients could get a better appearance than the ­preoperative one. To these patients, if they needed one or more flap transplantations, the technique could be used. There arise two questions.How many flaps can be offered? Can the patient accept so many scars in the body or dysfunction in the donor site? The answer being if patients are treated with autologous fat injection, even if the fat graft is absorbed after operation, repeated injections will give the patients a symmetrical face. Fat is always more abundant than flaps and each injection can help patients gain better appearances at least 3 months without a large scar or high cost of hospital fees. Autologous fat is the ideal soft tissue filler (Figs. 44.2–44.4). All patients had satisfactory therapeutic effect, especially the slight and moderate groups. As to the severe ones autologous fat injection can be an adjuvant operation to traditional surgery.

a1

a2

b1

b2

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a

b

c

d

e

f

g

h

Fig. 44.3  (a1, a2) Preoperative 22-year-old woman with severe hemifacial atrophy of her left face with and some degree of skin pigmentation in the area. (b1, b2) Eight months after autologous fat transplantations. (c1, c2) Thirteen months after second autologous fat transplantations. She had reasonably good symmetry

of the face with decreased skin pigmentation in the area after two injections. The final results evaluated by the patient, plastic surgeon, and layperson were all “mostly satisfactory” (Photos with permission from Lippincott Williams & Wilkins)

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a

b

c

d

e

f

g

h

i

Fig. 44.4  (a1, a2) Preoperative 24-year-old female with severe hemifacial atrophy of her right face with significant skin pigmentation in the mandibular area. (b1, b2) Seven months after first fat transfer. (c1, c2) Six months after second fat transfer. (d1, d2) Twenty seven months after third injection. (e1, e2) Six years after the first injection and 4 years after the third ­injection

with natural smile expression. She has good symmetry of the face with decreased skin pigmentation of the affected side. The final results evaluated by the patient, plastic surgeon, and laypersons were “mostly satisfactory,” “satisfactory,” and “mostly ­satisfactory” (photos with permission from Lippincott Williams & Wilkins)

44  Correction of Hemifacial Atrophy with Fat Transfer Fig. 44.4  (continued)

337

j

k

l

m

In the study by the surgeon, all the patients had more or less volume reduction postoperatively. The probable reasons would be: (a) swelling after operation because injury to tissue that is brief sp that swelling time is short and normal; (b) residual impurities, though the fat was washed and centrifuged it was impossible to purify the fat 100%. So when the residuary impurities were absorbed, the volume reduced; (c) injured fat granules during manipulation, after infection, insufficient oxygen, insufficient blood supply can result in necrosis; (d) mature adipocyte lipolysis or dedifferentiation in a malnourished environment. The second and third cause can be ameliorated through technique

improvement. The fourth cause can be ameliorated by adding some growth factors before injection or more careful postoperative care. Experiments in vivo or ex vivo both proved that many kind of growth factors such as insulin, b-FGF, DEAE, sodium butyrate, IGF, EGF, TGF, NGF, PDGF, Vitamin E and so on all can influence the growth of fat (25–28). But whether it can be applied in clinical procedures should be studied further. As all patients in this study were during their stable phase, the therapeutic effect can be evaluated. When the technique has been proven to be efficient, not only stable phase patients but also progressive patients may be able to be treated.

338

There are many questions. With increased times of injection more and more fat survived. What causes the survival rate to become higher and higher? The probable reason would be that the atrophic side of face had poorer blood supply than the normal side. After transplanting the fat granules from normal sites of the body, some vascular growth factors, inducing factors, or micro-vascularization of the fat granules would allow better growth from the increased blood and nutrition. Thus when the new fat graft was transplanted again, the blood supply was better than the last time and it was favorable for good fat survival. Fu et al. (29) has reported that endothelial progenitor cell (EPC) can be extracted from the aspirated fat. Is the live fat graft able to grow its own neovascularization? Recent research reported that the adipose-derived stem cells (ADSCs) that can be extracted from adipose tissue have the same ability as medullary derived stem cells. They can promote angiogenesis, secrete growth factors, and promote differentiation of the vascular endothelial cells (30–32), which may be the main reasons to explain the above phenomenon. According to the literatures, Illouz (19) also found better fat survival after injecting multiple times. His explanation was that there was 5% precursor cells injected into the recipient site from each injection. The precursor cells induced neovascularization. The more times we inject, the more precursor cells will be transplanted together with fat granules and can induce an acceptable result in addition to the fibrosis induced. In addition, the noticeable improvement of skin hyperpigmentation in the affected site of the face in our patients indicate that fat grafts may have an ability to improve the quality of skin over the recipient site as suggested by Coleman (33). It is know that fat can survive well in good blood supply sites (34, 35). Blood supply in the face and cranial areas is better than other sites of the body, so when we transplant fat into faces we can get better results. However Schuller-Petrovic (36) reported that the best results were gained from the patients with scars and atrophies. These sites have poor blood supply. How can fat survive in these site and why? Another observation from the follow-ups showed that the survival rate in different recipient areas was: frontal site > zygomatic site > mandibular site > buccal site. The probable reason may be that the activity of muscles may squeeze the neovessels in the fat graft. Thus, the more active the place, the less the survivalrate. Further research of autologous fat granules transplantation is still being carried out. Currently, studies about

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fat revascularization has had many results (37, 38). It helps to know that blood supply is important for fat survival but. But it is still unclear about the fat growth mechanism after transplantation. What influences are the mature adipocytes transferring to immature adipocytes? Are there preadipocyte or adipose stem cells contained in the fat tissue? How to distinguish them or are they the same adipocytes? The answer is unkown, it needs further research based on animal experiments and molecular biology experiments. In clinics different judgment standards from different reports that concluded different results still exist. How to establish the standard autologous fat transplantation and let it become a routine soft tissue defect treatment? The following should hence be resolved: (a) establish the golden standard to test the fat viability, then look for the factors which influence the fat survival rate; (b) institute an objective judgment standard for the curative effect of fat transplantation postoperative then compare the effect from different methods; (c) in this study “3L3M” technique was successfully used to treated hemifacial atrophy patients. It can also be applied to more different disorders to treat more cases.

44.5  Conclusions The autologous fat graft injection technique established by the authors, “3L3M,” ameliorates the whole operative procedure: lower body donor sites give more viable fat granules; low negative pressure minimizes the mechanical injury to the fat granules; low speed centrifuge improves the purity of fat; multi-point, multi-tunnel, and multi-plane injection prevent the central of graft liquidation and necrosis. Meanwhile controlling the operative time and postoperatively fixing the recipient site well can reduce hematoma and bleeding while avoiding squeezing the fat granules and neovessels will allow the better survival of fat. Autologous fat transplantation can be an excellent choice of treatment for patients with progressive hemifacial atrophy and serves as a good alternative to free tissue transfer for “facial recontouring” with minimal morbidity and improved long-term outcome. The surgeons’ preferred techniques in fat-graft harvesting, processing, and injection are important factors that may have contributed to the success. One or more subsequent injections may be required to ensure improved outcome in these patients after autologous fat transplantation.

44  Correction of Hemifacial Atrophy with Fat Transfer

References   1. Hunt JA, Hobar PC. Common craniofacial anomalies: Con­ ditions of craniofacial atrophy/hypoplasia and neoplasia. Plast Reconstr Surg 2003;111(4):1497–1508.   2. Wang LN, Gao XS. Plastic Surgery. Beijing, People’s Medical Publishing House, 1996.   3. Pensler JM, Murphy GF, Mulliken JB. Clinical and ultrastructural studies of Romberg’s hemifacial atrophy. Plast Reconstr Surg 1990;85(5):669–674; discussion 675–676.   4. Roddi R, Riggio E, Gilbert PM, Hovius SE, Vaandrager JM, van der Meulen JC. Clinical evaluation of techniques used in the surgical treatment of progressive hemifacial atrophy. J Craniomaxillofac Surg 1994;22(1):23–32.   5. Tao S, Lai G. The progress of etiology of progressive facial hemiatrophy. Chin J Aesthet Med 2007;16(6):859–862.   6. Xiu Z, Chen Z. Correction of hemifacial atrophy by use of a chest dermal-fat flap with the platysma pedicle. Zhonghua Zheng Xing Wai Ke Za Zhi 2002;18(6):348–349.   7. de la Fuente A, Jimenez A. Latissimus dorsi free flap for restoration of facial contour defects. Ann Plast Surg 1989;22 (1):1–8.   8. Wang X, Qiao Q, Liu Z, Zhao R, Zhang H, Yang Y, Wang Y, Bai M. Free anterolateral thigh adipofascial flap for hemifacial atrophy. Ann Plast Surg 2005;55(6):617–622.   9. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: Combined surgical methods in morphological restoration of hemifacial progressive atrophy. Plast Reconstr Surg 2005;116(3):699–711. 10. Masaki F. Correction of hemifacial atrophy using a free flap placed on the periosteum. Plast Reconstr Surg 2003;111(2): 818–820. 11. Jurkiewicz MJ, Nahai F. The use of free revascularized grafts in the amelioration of hemifacial atrophy. Plast Reconstr Surg 1985;76(1):44–55. 12. Ashley FL, Rees TD, Ballantyne DL, Jr., Galloway D, Machida R, Grazer F, McConnell DV, Edgington T, Kiskadden W. An injection technique for the treatment of facial hemiatrophy. Plast Reconstr Surg 1965;35:640–648. 13. Pearl RM, Laub DR, Kaplan EN. Complications following silicone injections for augmentation of the contours of the face. Plast Reconstr Surg 1978;61(6):888–891. 14. Neuber, F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66. 15. Lexer, E. Freie fettransplantation. Deutsch Med Wochenschr 1910;36:640. 16. Peer, LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217. 17. Chajchir A, Benzaquen I. Fat-grafting injection for soft-­ tissue augmentation. Plast Reconstr Surg 1989;84(6): 921–934; discussion 935. 18. Matsudo PK, Toledo LS. Experience of injected fat grafting. Aesthetic Plast Surg 1988;12(1):35–38. 19. Illouz YG. Adipoaspiration and “filling” in the face. Facial Plast Surg 1992;8(1):59–71. 20. Kang SS, Zhang ZW, Chou HY. Mild face concave treated with autologous fat granule graft. Chin J Clin Rehab 2003;7 (20):2880. 21. Xie Y, Li Q, Zheng D, Lei H, Pu LL. Correction of hemifacial atrophy with autologous fat transplantation. Ann Plast Surg 2007;59(6):645–653.

339 22. Zheng DN, Li QF. Treatment of hemifacial atrophy and facial depression by injecting transplantation of autologous fat granules. Chin J Aesthet Med 2005;14(1):25–26. 23. Ruff G. Progressive hemifacial atrophy: Romberg’s disease. In McCarthy JG (Ed), Plastic Surgery. Philadelphia, WB Saunders, 1990, pp. 3135–3143. 24. Yano H, Tanaka K, Murakami R, Kaji S, Hirano A. Microsurgical dermal-fat retransfer for progressive hemifacial atrophy. J Reconstr Microsurg 2005;21(1):15–19. 25. Zheng DN, Lei H, Li QF. Study on the effect of several growth factors and DMEM on grafted fat survival. Chin J Aesthet Med 2005;14(1):34–36. 26. Har-Shai Y, Lindenbaum ES, Gamliel-Lazarovich A, Beach D, Hirshowitz B. An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg 1999;104(4): 945–954. 27. Eppley BL, Sidner RA, Platis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6): 1022–1030. 28. Yuksel E, Weinfeld AB, Cleek R, Wamsley S, Jensen J, Boutros S, Waugh JM, Shenaq SM, Spira M. Increased free fat-graft survival with the long-term, local delivery of insulin, insulin-like growth factor-I, and basic fibroblast growth factor by PLGA/PEG microspheres. Plast Reconstr Surg 2000;105(5):1712–1720. 29. Fu QH, Wang HF, Cui L. The research advancement of the adipose tissue derived endothelia progenitor cell. J Tissue Eng Reconstr Surg 2005;1(6):348–352. 30. Matsumoto D, Sato K, Gonda K, Takaki Y, Shigeura T, Sato T, Aiba-Kojima E, Iizuka F, Inoue K, Yoshimura K. Cellassisted lipotransfer: Supportive use of human adiposederived cells for soft tissue augmentation with lipoinjection. Tissue Eng 2006;12(12):3375–3382. 31. Moseley TA, Zhu M, Hedrick MH. Adipose-derived stem and progenitor cells as fillers in plastic and reconstructive  surgery. Plast Reconstr Surg 2006;118(3 Suppl): 121S–128S. 32. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast augmentation: Supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg 2008;32(1):48–55; discussion 56–57. 33. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S. 34. Guerrerosantos J. The fate of intramuscularly injected fat autografts: An experimental study. Aesthetic Plast Surg 2005;29(1):62. 35. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P. Long-term survival of free fat grafts in muscle: An experimental study in rats. Aesthetic Plast Surg 1996;20(5):403–408. 36. Schuller-Petrovic S. Improving the aesthetic aspect of soft tissue defects on the face using autologous fat transplantation. Facial Plast Surg 1997;13(2):119–24. 37. Bartynski J, Marion MS, Wang TD. Histopathologic evaluation of adipose autografts in a rabbit ear model. Otolaryngol Head Neck Surg 1990;102(4):314–321. 38. Langer S, Sinitsina I, Biberthaler P, Krombach F, Messmer K. Revascularization of transplanted adipose tissue: A study in the dorsal skinfold chamber of hamsters. Ann Plast Surg 2002;48(1):53–59.

Recontouring Postradiation Thigh Defect with Autologous Fat Grafting

45

Richard H. Tholen, Ian T. Jackson, Richard Simman, and Vincent D. DiNick

45.1  Introduction Correction of contour deformities caused by subcutaneous fat loss has been an ongoing reconstructive challenge, particularly as fat grafting has been utilized with varying degrees of success over the past century. Fat was first transplanted clinically in 1893 by Neuber (1) who used small pieces of fat to fill out depressed scars. Peer, in 1950, (2, 3) studied the histology of fat transplantation and reported that 50% of autologous transplanted fat was lost. Despite the obvious observation that 50% of the transplanted fat survived, the loss of this proportion of the grafted volume resulted in a search for other materials. Liquid silicone was introduced in 1965, and many thought that this would be the ideal soft tissue replacement since silicone was thought to neither reabsorb nor induce tissue reaction (4, 5). After several reports of serious complications (6), the search for a fat replacement material continued. With the advent of liposuction in the 1980s, large volumes of autologous fat were suddenly available for use, and reinjection of a patient’s own liposuction aspirate (immediately, or later after being frozen) was performed to correct subcutaneous contour deformities, for soft tissue augmentation, and even for breast enlargement. In 1986, lllouz and Pflug (7) and Chajchir and Benzaquen (8) published their experience with reinjection of liposuctioned fat tissue. In addition to liposuctioned fat, excised fat tissue has been used for the same purpose (9). In 1988, Guerre­ rosantos et al. (10) published a 5-year study of fat injections to the face and neck region.

R. H. Tholen () Minneapolis Plastic Surgery, Ltd., 4825 Olsen Memorial Highway, Suite 200, Minneapolis, MN 55422, USA e-mail: [email protected]

In spite of these studies, the use of fat as an implant material did not find much favor because the method of harvest (i.e., standard liposuction), preparation (rinsing, filtering, centrifuging, and/or treating the cells with one or more adjuncts), or storage and later use (freezing and then thawing) caused poor graft take and irregular results (11–16). Variations in these techniques among operators increased irregularity of results, causing some to abandon and decry fat autotransplantation, and others to refine and promote it. Horl et al. (17) studied the long-term volume maintenance of autotransplanted fat to correct facial defects using magnetic resonance imaging (MRI) and concluded that 49% of the initial volume was lost in 3 months. In 6 months, the average volume had reduced to 55%, but in 9–12 months, no further loss could be detected when viable fat cells were transplanted. They subsequently stated that autogenous fat transplantation after liposuction is only suitable for the repair of small soft-tissue defects, especially in the face. It was then suggested that defects be overcorrected in one stage to compensate for the high rate of resorption. Clearly, some surgeons were able to show reliable, long-term results with autologous fat grafting, utilizing various techniques; others were injecting nonviable fat as a temporary volume filler without actual graft survival as long-term living tissue. We sought to define a technique that was easy to perform, caused minimal damage to the fat grafts while being harvested, and provided viable fat cells to correct various subcutaneous contour defects in the long run. Critical to the success of any transplanted material surviving in its recipient bed are a number of factors: (a) atraumatic harvest of tissue, (b) timely reintroduction into a suitable host environment (adequate blood flow, minimal adjacent debris – blood, nonviable cells, fluid, or pathogens), and (c) immobilization for adequate time

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_45, © Springer-Verlag Berlin Heidelberg 2010

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to allow nutrient vessel ingrowth and stable healing. In the early days of liposuction, one-third of the aspirate volume was blood, and fat was removed via large cannula avulsion into a high-vacuum, low-pressure collection apparatus. Significant cellular damage, as we later describe, has been shown to occur. Freezing aspirate for later use caused ice crystal rupture of fragile adipocytes, further decreasing viable cell counts for successful autologous grafting. Present-day liposuction techniques include ultrasonic emulsification of fat tissues prior to high-vacuum removal, high-fluid environment for liposuction (“tumescent” or “super-wet” technique), powerassisted lipoplasty, or even laser-assisted liposuction techniques, all of which cause additional damage to whatever proportion of viable cellular fat that enters the system. Simply overcorrecting the defect by injecting more (nonviable) graft material is not the answer. Improvement in results is possible if a minimal vacuum system of fat harvesting is adopted together with part of the technique suggested by Coleman (18, 19). In a large laboratory and clinical study carried out by the senior author in 1985, but unpublished, it was noted that fat obtained from standard liposuction (high vacuum, low-pressure) contained few, if any, intact and viable fat cells. Microscopic analysis of fat obtained by various techniques showed that standard liposuction caused significant damage (rupture of cell membranes and subsequent death of cells) in a majority of the aspirated lipocytes. Grafts using this material are volume-correcting and not rejected, but they are not viable and therefore do not persist (survive as living tissue) in the long term. Fat harvested with an atraumatic, low-vacuum syringe technique was shown to have significantly higher numbers of intact and viable lipocytes for transfer, and therefore it seemed reasonable to believe that this would allow improvement in long-term graft take and allow permanent contour correction. In a series of 100 consecutive clinical cases studied at that time in which this technique of fat harvest was used for filling of small facial contour defects, and with a 1-year follow-up, patient satisfaction was 96%, although it must be said that the volume “take” was not always sufficient for complete correction in the observers’ opinions. In this report, a case of a very extensive lower limb defect resulting from radiation therapy is presented, chosen to illustrate the efficacy and reliability of this technique. If fat can exhibit long-term survival in the less-optimal vascularity of an irradiated limb, then it

R. H. Tholen et al.

must be accepted that fat harvested with this technique is a satisfactory material for soft tissue augmentation.

45.2  Case Report A 39-year-old female presented with extensive subcutaneous fat loss involving the total circumference of the left thigh. This resulted from radiation therapy administered to treat a neurofibrosarcoma 34 years ago (Fig. 45.1). The skin was taut over a very thin subcutaneous layer. Many complex treatments were discussed at our own center and at a “cry for help” in one international meeting. Finally, however, it was decided to treat this defect with our technique of multiple fat injections.

a

b

Fig. 45.1  Preoperative patient. (a) Anterior. (b) Posterior

45  Recontouring Postradiation Thigh Defect with Autologous Fat Grafting

In the first session, 80 mL of subcutaneous fat was harvested from the abdomen using the method to be described and injected in multiple small “tunnels” into the subcutaneous region and to the super­ficial area of the thigh musculature. The patient underwent two subsequent treatments at 8 monthly intervals, utilizing graft volumes of 140 and 200 mL, respectively (Fig. 45.2). Eleven months later, a final 150 mL of fat was injected. The consistency of the recipient site became soft and has remained so; the final aesthetic result is very acceptable to the patient, although it is far from perfect (Fig. 45.3). All donor sites healed well without scarring or infection; and the contour of the thigh is amazingly smooth.

a

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45.3  Technique 45.3.1  Harvest The method of harvesting of fat for injection has been unchanged over a period of 23 years since the original study mentioned above; this is a low-vacuum extraction system (18). The fine needle aspiration apparatus is used together with a 20-mL syringe. The needle for fat harvesting is the one used by veterinarians to inject antibiotics into the udders of cows (Fig. 45.4), and is fitted to a 20-mL syringe. The harvest cannula (Udder Infusion Cannula, Jorgenson Laboratories, Loveland, CO) has a wide bore with a blunt tip and several side holes. The periumbilical area is chosen, and with rapid back and forward movement and low-vacuum intermittent aspiration, a large amount of intact fat particles can be quickly harvested. The fat is immediately placed on a sterile towel, into which liquid fat, local anesthesia fluid, and blood are absorbed.

45.3.2  Injection

b

The pure fat is loaded into 2, 5, or 10-mL syringes fitted with a 14-gauge needle, and is then injected into the subcutaneous fat and/or underlying muscle in multiple tiny doses until the volume required is achieved. Proper placement requires a small amount of grafted fat surrounded by a maximum of healthy recipient tissue in numerous interlacing and overlapping tunnels. If overcorrection is planned, this should be achieved with minimal subcutaneous tension. It is imperative to understand that this is a graft of living cells and should be handled with gentle manipulation and placed in a vascular, tension-free recipient bed. The ability to be vascularized from the recipient site is the key to survival. More than one course of fat grafting will be necessary in large defects.

45.4  Discussion

Fig. 45.2  Five months postoperative after the second injection. (a) Anterior. (b) Posterior

Long-term results after autologus fat transplantation for contour defect correction remain unpredictable due to incomplete take or partial graft resorption. Many

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a1

a2

b1

b2

Fig. 45.3  (a1, a2) Four months after the final injection. (b1, b2) Nine months after the final injection

a

b

Fig. 45.4  (a) Fine needle aspiration apparatus with syringe and needle in place. (b) Veterinarian’s needle used to inject cow udders

investigators have used various techniques to improve the longevity of these grafts (9, 20–25). Overcorrection and/or multiple procedures alone are not sufficient to obtain a lasting effect. Atraumatic harvesting techniques will maintain the viability of adipocytes, as we have shown in our previous study; this increases the amount of graft survival and provides long-term contour improvement and patient satisfaction. Fagrell and coworkers (26), in an animal model, demonstrated that the resorption rate was higher for aspirated fat compared with excised fat or harvested fat cylinders. They proposed that to maintain adipocyte viability and subsequent graft survival, the capillary structure of the transplant should be preserved.

45  Recontouring Postradiation Thigh Defect with Autologous Fat Grafting

Conflicting data regarding the use of autologous fat transplantation for breast augmentation have been published; only a few reports have been favorable (23, 27, 28). There has been concern expressed regarding necrosis of transplanted fat which can result in formation of microcalcifications and nodularity. This may interfere with mammographic interpretation and clinical examination, thus raising the suspicion of malignancy (29). For this reason, we do not recommend this technique for use in the breast, whereas areas injected elsewhere have always remained soft. In the case presented, which was considered to be a significant challenge in a poorly vascularized recipient area, a large postradiation defect of the thigh was reconstructed with multiple fat graft injections using the method described. Four outpatient procedures were required over a period of 3 years, and a long-lasting, cosmetically acceptable result was maintained at 2-year follow-up from the last injection. It was also noted that the consistency of the thigh, both the skin and the underlying tissue, became much softer and mobile with time. Autologous fat may be used to fill small or large defects in any area if microsurgical free tissue transfer or other tissue replacement is not possible because of the size or position of the defect. Other indications may be concurrent illness or lack of patient acceptance of a more invasive procedure. The described method is simple to perform and safe and may be repeated if necessary, with no donor site morbidity. It must be stressed that the method of fat harvesting is critical and the one described is recommended. It is also essential that the method of fat delivery is undertaken with care as emphasized by Coleman (18, 19). Using these techniques over the past 23 years has resulted in successful results in a high proportion of patients with defects of varying size and in different anatomical sites. A note of caution must, however, be inserted; fat grafting with the technique described is successful, but does require more than one session in many patients, and as such is not a predictably quantifiable method. This must be strongly emphasized when a patient is being counseled for fat injection therapy.

References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   2. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217–230.

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  3. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18(4):233–250.   4. Ashley FL, Thompson DT, Henderson T. Augmentation of surface contour by subcutaneous injections of silicone fluid: A current report. Plast Reconstr Surg 1973;51(1):8–13.   5. Rees TD, Ballantyne DL, Jr, Hawthorne GA. Silicone fluid research: A follow up summary. Plast Reconstr Surg 1970;46 (1):50–56.   6. Edgerton MT, Wells JH. Indications for and pitfalls of soft tissue augmentation with liquid silicone. Plast Reconstr Surg 1976;58(2):157–165.   7. Illouz YG, Pflug ME. Die selektive lipektomie oder lipolyse nach IIIouz. Handchir Mikrochir Plast Chir 1986;18(3): 118–121.   8. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesth Plast Surg 1986;10(2): 115–117.   9. Ellenbogen R. Free autogenous pearl fat grafts in the face – a preliminary report of a rediscovered technique. Ann Plast Surg 1986;16(3):179–194. 10. Guerrerosantos J, Flores M, De-Leon O. Free fat autografting for cervical-facial augmentation: A 5-year study. Plast Surg Forum 1988;11:216. 11. Bystrom J, Norberg KA. Free autogenous grafts into the penile cavernous tissue: An experimental study in dogs. Urol Res 1975;3(3):145–148. 12. Conley JJ, Clairmont AA. Dermal-fat-fascia grafts. Otolar­ yngology 1978;86(4 Pt 1):641–649. 13. Long DM. Free fat graft in laminectomy (letter). J Neurosurg 1981;54(5):711. 14. Moszkowicz L. Fettplastik bei hemiatrophia faciei. Med KIm 1930;26:1478. 15. Schroeder S, Lackner K, Koster O, Anders G. Computer tomographische darstellung der frelen fettplastik im laminektomiebereich. Z Orthop Ihre Grenzgeb 1982;120(1):71–72. 16. Williams HB, Crepeau RJ. Free dermal fat flaps to the face. Ann Plast Surg 1979;3(1):1–12. 17. Horl HW, Feller AM, Biemer E. Technique for liposuction fat reimplantation and long-term volume evaluation by magnetic resonance imaging. Ann Plast Surg 1991;26(3):248–258. 18. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech Plast Reconstr Surg 1994;1:120. 19. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367. 20. Niechajev I, Sevcuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 21. Uebel CC. Facial sculpture with centrifuged fat-collagen graft. In UT Hinderer (Ed), Plastic Surgery, Vol. II. Amster­ dam, Elsevier 1992. 22. Sidman RL. The direct effect of insulin on organ culture of brown fat. Anat Rec 1956;124(4):723–739. 23. Bircoll M, Novack BH. Autologous fat transplantation employing liposuction techniques. Ann Plast Surg 1987;18 (4):327–329. 24. Hiragun A, Sato M, Mitsui H. Establishment of a clonal cell line that differentiates into adipose cells in vitro. In Vitro 1980;16(8):685–693. 25. Eppley BL, Sidner RA, Platis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6):1022–1030.

346 26. Fagrell D, Enestrom S, Berggen A, Kniola B. Fat cylinder transplantation: An experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996; 98(1):90–96. 27. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987; 79(2):267–271.

R. H. Tholen et al. 28. Illouz YG. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 29. Hartrampf CR, Jr, Ettelson CD, Linder RM. Fat autografting. Plast Reconstr Surg 1987;80(4):646–647.

Management of Migraine Headaches with Botulinum Toxin and Fat Transfer

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Devra Becker and Bahman Guyuron

46.1  Introduction Migraine headaches can be debilitating, and can cost billions of dollars annually for treatment and loss of productivity (1). Migraine headaches are classified by the International Headache Society (2) and have a set criteria “(A) At least five attacks meeting B–D; (B) Headaches lasting 4–72 h (untreated or unsuccessfully treated); (C) headaches have at least two of the following characteristics/ unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs); (D) During headache at least one of the following occurs: nausea and/ or vomiting, photophobia, and phonophobia; and (E) Not attributable to any other disorder”. Migraine pathogenesis is probably a complex interplay of several mechanisms. It is helpful to think of those mechanisms as conditions affecting the susceptibility of an individual to attacks and conditions affecting the headache state. In addition, the aura, which precedes migraine in some patients (3, 4) is associated with independent cortical changes (namely, cortical spreading depression). Thus, migraine headaches involve both central and peripheral neurological dysfunction. Individuals who are susceptible to migraine headaches have been shown to have “central neuronal excitability” (3), whose etiology derives from different mechanisms but includes calcium channelopathies in certain genetic forms of migraine. Patients with migraine have, in addition, central sensitization of the trigeminal system.

B. Guyuron () Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH 44124, USA e-mail: [email protected]

All of these create a profile of a “susceptible” individual. The mechanism of headache itself is thought to be due to vasoactive peptides, such as calcitonin generelated peptide, substance P, and neurokinin A. These are all found in the cell bodies of the trigeminal neurons. These substances, when released, cause dilation of trigeminal-innervated vessels (5, 6). An event in the peripheral nervous system (irritation of a terminal branch of the trigeminal nerve) can trigger a migraine headache, which can be manifested by both central (such as prolonged pain (3) and peripheral (such as pain associated with a particular location) phenomena. Thus, migraine headaches can occur in the temporal area where the trigger is the zygomaticotemporal branch of the trigeminal nerve, and in the supraorbital and frontal area when the trigger is the supraorbital and supratrochlear branches. Occipital headaches can be triggered by irritation of the greater occipital nerve. Current pharmacologic treatments target the central neurologic axis. In contrast, current surgery for migraine headaches targets the peripheral neurological axis. As the theory behind a peripheral etiology of migraine pathogenesis is that there is a mechanical irritation of the terminal branches of the trigeminal nerves from adjacent anatomic structures (7, 8), the goal of surgery is to change the anatomic relationship between the nerve and adjacent structures such that it will no longer be irritated. The technical details of how this is accomplished vary from site to site. For the purposes of this chapter, we will focus on the glabellar trigger site, because this is the area in which fat grafting plays a significant part of the management. The adipose flap used in occipital headaches helps to shield the greater occipital nerve. All migraine patients should be evaluated by a neurologist trained in the diagnosis and treatment of migraine headaches and should continue to see their neurologist throughout their course of treatment with the surgeon.

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The neurologist, in addition, should manage migraine medications and should oversee any changes in the regimen both before and after surgery. Communication between the teams about changes in medication, as well

as the progress of the patient, is critical. Furthermore, an objective recording of headache characteristics helps clinicians to evaluate the progress. We use a standard headache log and questionnaire for this purpose (Fig. 46.1).

Fig. 46.1  Standard questionnaires for patients. Patients keep a headache journal at home, and fill out questionnaires characterizing their headaches at each visit. This information is useful for tracking progress, quantifying responsiveness to interventions,

and identifying changing characteristics of the headaches. (a) Pretreatment migraine headache questionnaire. (b) Posttreatment migraine headache questionnaire

46  Management of Migraine Headaches with Botulinum Toxin and Fat Transfer

Fig. 46.1  (continued)

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Fig. 46.1  (continued)

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Fig. 46.1  (continued)

46.2  Glabellar Region

appearance to the brow is an additional benefit for the migraineur.

46.2.1  History Fat grafting for soft tissue, augmentation has been performed for decades. Indeed, fat grafting to the glabellar region has been described for forehead rejuvenation (9–11). It is fortuitous for the surgeon performing migraine surgery, that fat has an intimate relationship with nerves and surrounds the nerves in vivo. Sunderland described interfascicular adipose tissue that he postulated protected the nerves “by acting as a buffer or cushion for the fasciculi” (12). Using a fat graft for the glabellar site and a transposition flap for the occipital site, it, mimics the natural mechanism of the body for protecting peripheral nerves. That it provides an aesthetic advantage in a rejuvenated

46.2.2  Anatomy The glabellar muscles consist of the corrugator supercilii muscle (CSM), the depressor supercilii, and the procerus. The CSM and depressor supercilii, together with the medial portion of the orbicularis oculi, act to depress the medial brow. Vertical glabellar rhytids are due to the action of the CSM, and horizontal glabellar rhytids are due to the action of the procerus. The CSM has been described as having two heads: (a) a larger transverse head that originates from the superomedial orbital rim, traverses the frontalis and orbicularis oculi muscles, and inserts into the dermis of the middle third

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of the brow, innervated by temporal branch of the facial nerve (13, 14) and (b) a smaller oblique head that runs parallel to the depressor supercilii, and is innervated by the zygomatic branch of the facial nerve (13). A recent anatomic study, however, noted that the two heads converged beyond the origin of the oblique head, and a division between the two heads could not be seen within the muscle mass (15). A dissection study of twenty-five fresh cadavers (15) catalogued the average dimensions of the CSM in relation to fixed bony landmarks (the nasion and lateral orbital rim). The medial-most origin of the CSM was 2.9 (+/−1.0) mm from the nasion, while the lateral-most origin was 14.0 (+/−2.8) mm from the nasion. The apex was 32.6 mm from the nasion-lateral orbital rim plane, and the muscle extended laterally to a distance 43.3 mm from the nasion. The relevance of knowing the total dimensions of the CSM is that the resection has been shown to be variable (16), particularly in the lateral aspects of the muscle. As the muscle itself is thought to be the point of irritation, it is important to remove the muscle completely in migraine surgery (8). Understanding the relationship of the supratrochlear and supraorbital nerves to the muscle further aids the surgeon in the dissection and the resection of the CSM. The supratrochlear nerve is the more medial of the two, and is found slightly lateral to the origin of the CSM. It travels superiorly in the superficial substance of the muscle after branching (13, 15), and the course and branching patterns are relatively consistent. The supraorbital nerve, in contrast, is more variable in its anatomy. The supraorbital nerve trunk exits in several points 14–16% of the time (17). The trunk then divides into a superficial branch (SON-S) and a deep branch (SON-D); each one may send off branches associated with the CSM (SON-Scsm and SON-Dcsm). The SON-S is oriented vertically and perpendicular to the fibers of the CSM, while the SON-D travels parallel to the fibers of the CSM. Janis’s cadaver study (18) noted four branching patterns. Type one (deep division) is characterized by a single SON-Dcsm branch from the SON-D. Type II (deep and superficial division) is characterized by a SON-Scsm branch from SON-S and a SON-Dcsm branch from SON-D. Type III (Superficial division) is characterized by a single SON-Scsm branch from SON-S. Type IV has no branching within the CSM. Types I–III represent 78% of the total; the surgeon must be aware of potential branches that may be compressed within the CSM.

D. Becker and B. Guyuron

46.2.3  Botulinum Toxin When discussing botulinum toxin A and migraine headaches, an important distinction must be made: the use of botulinum toxin A for the treatment of migraine headaches and its use as a diagnostic aid. The use of botulinum toxin A as treatment of migraine headaches has been controversial (19–21), fueled in part by the lack of large-scale, randomized, and blinded studies. Some studies have shown a benefit (22, 23), but are limited by study design (3). The American Academy of Neurology recently published a review of the therapeutic uses of botulinum toxin A and concluded from a one Class one and two Class two studies that botulinum toxin A is probably ineffective – Level B evidence – in treating migraine headaches (24). The authors use botulinum toxin as a diagnostic aid (25). Based on the history given by the patient, including location of the headaches, 12.5 units of botulinum toxin A are injected into the trigger site. A reduction in the intensity or frequency of headaches by greater than 50% is considered an indication for surgical decompression of the nerve.

46.2.4  Role of Fat Graft The fat graft to the glabellar area after resection of the muscles helps to avoid several potential consequences of surgery. First, removal of the corrugator muscle produces contour irregularity; the fat graft helps to alleviate any discrete contour deformities. The presence of overall convexity in the area further provides a more youthful appearance (26), which is relevant in aesthetic surgery, and often welcome in migraine surgery. In addition, it provides a physical barrier to the reattachment of the muscle fibers (27). The fat graft provides a cushion for the supraorbital and supratrochlear nerves.

46.3  Techniques There are several ways to access the glabellar muscle group, including the open, endoscopic, and transpalpebral approaches. The two most commonly used in our

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practice for treatment of migraine headaches are endoscopic corrugator resection and transpalpebral muscle resection (27).

46.3.1 Surgical Technique: Fat Graft Harvest in Endoscopic Approach The corrugator muscle is resected as follows: after the surgical field is prepared and the endoscopic instruments are introduced through a midline incision and two lateral incisions (7 and 10 cm from midline). When inserting the endoscopic instruments, it is important to begin in the right plane, which is immediately above the deep temporal fascia. Thus, one begins by incising the lateral-most site (10 cm from midline) and dissecting with baby Metzenbaum scissors until the deep temporal fascia is seen. It is a dull white color, and cannot be picked up with forceps. The identity can be confirmed by making a small incision in the fascia and seeing the temporal muscle underneath (26). Using a sweeping motion with the periosteal elevator, this plane is kept. All fat and areolar tissue should be above the elevator. In this plane, one can easily transfer to the subperiosteal plane medially for the corrugator resection. Furthermore, the temporal branch of the facial nerve will be above the plane of dissection. Dissection proceeds in the subperiosteal plane to the level of the supraorbital and lateral orbital rims. The periosteum is released and the corrugator muscle is seen. The supraorbital nerves are identified coming out of the supraorbital notch, and the supratrochlear nerves are identified medially (Fig. 46.2). These nerves are preserved. The corrugator muscle is removed fractionally, starting laterally, using a grasper. The central portion of the periosteum is preserved, to prevent separation of the medial eyebrows. The fat graft harvest is taken from the infratemporal fossa, located deep to the very deep temporal fascia immediately cephalad to the zygomatic arch (26). After dissection along the lateral orbital rim in a plane deep to the superficial and intermediate layers of the deep temporal fascia, the zygomatic arch is exposed. The dissection is then subperiosteal along the arch. A curved periosteal elevator is used to make a rent in the deep layer of the deep temporal fascia immediately superior to the zygomatic arch. Normally, fat can be

Fig. 46.2  Appearance of the supraorbital and supratrochlear nerves in the endoscopic technique. Understanding the relationship between the branches of these nerves and the corrugator supercilii muscle (CSM) aids in performing a thorough resection of muscle while preserving the nerves

a

b

Fig. 46.3  Infratemporal fat harvest. Fat can be seen after the surgeon makes a small rent in the fascia. The fat is teased out with graspers and used as a graft. (a) Left. (b) Right

354 Fig. 46.4  Fat graft placement in endoscopic technique of CSM resection. (a) Left. (b) Right

D. Becker and B. Guyuron

a

seen through the rent (Fig. 46.3). Pressure on the buccal area will help expose it more and make its harvest easier. The fat graft is placed in the area of CSM resection (Fig. 46.4). The fascia is resuspended with 3–0 polydioxanone sutures, and a #10 TLS suction drain is placed in the lateral incision. The incisions are then repaired with 5–0 polygalactin and 5–0 plain catgut (28).

46.3.2 Surgical Technique: Fat Graft Harvest in Transpalpebral Approach With intravenous sedation monitored by an anesthesiologist, the patient is prepped and draped. A 1-in. blepharoplasty incision is marked on the upper tarsal crease. After infiltration of 0.5% lidocaine with 1:100,000 epinephrine, an incision is made and carried through the orbicularis oculi muscle. The dissection proceeds superiorly

b

using scissors in the plane between the orbicularis oculi muscle and the septum, although other authors have reported success in the deep surface of the orbital septum. The CSM is dark in color (16, 27), and has transverse fibers. The muscle is removed around the nerves. Fat is harvested from the medial compartment of the upper eye (Fig. 46.5). An incision is made in the septum overlying the medial compartment using Bovie electrocautery at a low setting. Medial compartment fat is teased out using a small curved clamp. Prior to resection, the base of the fat is clamped and the fat is injected with 0.5% lidocaine with 1:100,000 epinephrine. The fat is excised and the remaining fat is cauterized to prevent bleeding. The graft is placed in the site of CSM resection, and can be secured with 6–0 polygalactin. The skin is closed with 6–0 plain catgut (26, 28).

46.4  Complications The primary risks of surgery are paresthesias and anesthesia of the forehead and scalp, and inadequate or asymmetric resection of muscle. Because the fat graft is small with the lobular structure preserved, the rate of resorption of the fat graft is reduced (29, 30). The amount of fat harvested from the infratemporal fossa is small, and no patients in a study of the technique were reported to have donor site contour deformities (26).

46.5  Occipital Area 46.5.1  Anatomy

Fig. 46.5  Fat graft harvest from medial fat compartment, through a blepharoplasty incision

The muscles of the occipital region can be thought of in layers. Because of the differing orientation of muscle fibers as they overly one another, portions of the neck

46  Management of Migraine Headaches with Botulinum Toxin and Fat Transfer

have been subdivided into triangles. The trapezius muscle is the most superficial of the occipital region muscles. The anterior border of the trapezius muscle and the posterior border of the sternocleidomastoid muscle form the posterior and anterior borders (respectively) of the posterior (lateral) triangle of the neck. The floor of the occipital division of the posterior triangle is formed by the splenius capitis (31). The semispinalis capitis muscles are deeper than the splenius capitus muscles, and work synergystically with them to extend the neck. The paired semispinalis capitus muscles originate from the transverse processes of the inferior cervical and superior thoracic vertebrae and insert onto the occiput between the nuchal lines, posterior to the insertion of the splenius capitis. Piercing the semispinalis capitis muscle at approximately 15 mm lateral to the midline raphe and 30 mm inferior to the occiput, is the Greater Occipital Nerve. The nerve itself is approximately 2.6–2.8 mm wide at its point of emergence (32). The greater occipital nerve is implicated in occipital migraine headaches, through a mechanism of mechanical irritation of the nerve by the semispinalis capitis muscle. The lesser occipital nerve runs laterally to the greater occipital nerve and can be seen travelling superomedially from the posterior border of the sternocleidomastoid muscle. In some cases of occipital headaches that are unreponsive to surgical release of the greater occipital nerve, irritation of the lesser occipital nerve is thought to be an etiologic factor.

46.5.2  Role of Fat Transposition Flap As with the supraorbital and supratrochlear nerves, the greater occipital nerve is protected after its release. A transposition flap consisting of fat and fascia is placed under the nerve and serves the same purpose as the fat graft to the glabella: it cushions it and prevents reattachment of muscle fibers.

46.5.3  Surgical Technique In the preoperative holding area, the patient is asked to identify with one finger the point of maximal tenderness in the occipital area. This point is marked. A vertical

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incision is marked in the midline just below the occipital protuberance. Once under general anesthesia, the operation proceeds with the patient in the prone position. The hair surrounding the incision site is trimmed with clippers and the area is prepped and draped. A skin incision is made and carried to the midline raphe. The dissection proceeds laterally just above the muscle plane. Several trapezius fibers are usually seen first; they are obliquely oriented and retracted out of the way. The semispinalis capitis, which has vertically oriented fibers, is then seen. As described by Mosser, the nerve is seen approximately 15 mm lateral to the midline and 30 mm inferior to the occiput (32). Once identified, a 1-in. swath of muscle medial to the nerve is resected. The nerve is followed proximally and freed of any remaining compressing muscle fibers. The nerve is then protected by the placement of an approximately 2 cm flap of subcutaneous tissue and adipose tissue underneath it. The flap is secured to the midline to prevent retraction. The incision is closed in layers over a drain.

46.6  Conclusions 1. Surgery can be a useful treatment for Migraine headaches in patients who are refractory to pharmacologic treatment. 2. Botulinum toxin is used as a diagnostic aid in determining migraine trigger sites. 3. Fat grafting to the glabella following corrugator muscle resection helps to protect the supratrochlear and supraorbital nerve branches, alleviates contour deformities, and has a rejuvenating effect on the appearance of the glabella.

References   1. Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: Disability and economic costs. Arch Intern Med 1999;159(8):813–818.   2. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24(Suppl 1): 9–160.   3. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology 2003;61(8 Suppl 4):S2–S8.   4. Russell MB, Rasmussen BK, Thorvaldsen P, Olesen J. Prevalence and sex-ratio of the subtypes of migraine. Int J Epidemiol 1995;24(3):612–618.

356   5. Feindel W, Penfield W, McNaughton F. The tentorial nerves and localization of intracranial pain in man. Neurology 1960;10:555–563.   6. Novak VJ, Makek M. Pathogenesis and surgical treatment of migraine and neurovascular headaches with rhinogenic trigger. Head Neck 1992;14(6):467–472.   7. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii muscle resection through blepharoplasty incision. Plast Reconstr Surg 1995;95(4):691–696.   8. Guyuron B, Varghai A, Michelow BJ, Thomas T, Davis J. Corrugator supercilii muscle resection and migraine headaches. Plast Reconstr Surg 2000;106(2):429–434; discussion 435–427.   9. Michelow BJ, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997;24(2): 199–212. 10. Guyuron B. Subcutaneous approach to forehead, brow, and modified temple incision. Clin Plast Surg 1992;19(2): 461–476. 11. Guyuron B, Behmand RA, Green R. Shortening of the long forehead. Plast Reconstr Surg 1999;103(1):218–223. 12. Sunderland S. The adipose tissue of peripheral nerves. Brain 1945;68:118–122. 13. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast Reconstr Surg 1995;95(1): 52–60; discussion 61–52. 14. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996;97(7):1321–1333. 15. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg 2007;120(6):1647–1653. 16. Walden JL, Brown CC, Klapper AJ, Chia CT, Aston SJ. An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection. Plast Reconstr Surg 2005;116(5):1479–1487; discussion 1488–1479. 17. Beer GM, Putz R, Mager K, Schumacher M, Keil W. Variations of the frontal exit of the supraorbital nerve: An anatomic study. Plast Reconstr Surg 1998;102(2): 334–341. 18. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. The anatomy of the corrugator supercilii muscle: Part II. Supraorbital nerve branching patterns. Plast Reconstr Surg 2008;121(1):233–240. 19. Blumenfeld A. Botulinum toxin type A for the treatment of headache: Pro. Headache 2004;44(8):825–830.

D. Becker and B. Guyuron 20. Smuts JA, Schultz D, Barnard A. Mechanism of action of botulinum toxin type A in migraine prevention: A pilot study. Headache 2004;44(8):801–805. 21. Welch KM. Botulinum toxin type A for the treatment of headache: Con. Headache 2004;44(8):831–833. 22. Binder WJ, Brin MF, Blitzer A, Schoenrock LD, Pogoda JM. Botulinum toxin type A (BOTOX) for treatment of migraine headaches: An open-label study. Otolaryngol Head Neck Surg 2000;123(6):669–676. 23. Silberstein S, Mathew N, Saper J, Jenkins S. Botulinum toxin type A as a migraine preventive treatment. For the BOTOX Migraine Clinical Research Group. Headache 2000;40(6): 445–450. 24. Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, Jabbari B, Kaufmann HC, Schurch B, Silberstein SD, Simpson DM. Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008;70(19):1707–1714. 25. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg 2005;115(1):1–9. 26. Guyuron B, Rose K. Harvesting fat from the infratemporal fossa. Plast Reconstr Surg 2004;114(1):245–249. 27. Guyuron B, Knize DM. Corrugator supercilii resection through blepharoplasty incision. Plast Reconstr Surg 2001; 107(2):604–607. 28. Guyuron B, Tucker T, Davis J. Surgical treatment of migraine headaches. Plast Reconstr Surg 2002;109(7):2183–2189. 29. Baran CN, Celebioglu S, Sensoz O, Ulusoy G, Civelek B, Ortak T. The behavior of fat grafts in recipient areas with enhanced vascularity. Plast Reconstr Surg 2002;109(5): 1646–1652. 30. Coleman SR. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425. 31. Netter F. Atlas of Human Anatomy. Summit, NJ: CibaGeigy, 1989. 32. Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: Implications for the etiology of migraine headaches. Plast Reconstr Surg 2004;113(2): 693–697; discussion 698–700.

Retropharyngeal Fat Transfer for Congenital Short Palate

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P. H. Dejonckere

47.1  Introduction Velopharyngeal insufficiency (VPI) occurs when the soft palate or “velum” fails to make contact with the back of the throat or “pharynx,” a function necessary for normal speech and swallowing. The subject is unable to close off the oral cavity (mouth) from the nasal cavity (nose). There are many causes of VPI including the following: 1. Cleft palate 2. Submucous cleft palate 3. Congenitally short palate or velum 4. Adenoidectomy, possibly revealing a latent congenitally short palate 5. Motor speech disorders 6. Velo–cardio–facial syndrome Severe cases with perturbation in oral feeding will be recognized at birth. In milder cases, VPI will be diagnosed as soon as the child starts talking in phrases and short sentences (usually by age 2). The treatment requires a coordinated effort between the speech pathol­ogist and cleft palate/craniofacial surgeon (1). In patients, especially children, with mild VPI due to a constitutional short palate (possibly revealed after adenoidectomy) and resistant to speech therapy, transplantation of autologous fat in the dorsal pharyngeal wall to build up a ridge is a relevant surgical solution.

P. H. Dejonckere The Institute of Phoniatrics, ENT-Department, Division of Surgery, University Medical Centre, P.O. Box 85 500, 3508 Utrecht, The Netherlands e-mail: [email protected]

47.2 Symptoms of Velopharyngeal Insufficiency The symptoms include (1) the following: 1. Consonant substitutions Nasal sounds (/m,n/) replace oral sounds (i.e., /p,b,t,d/). 2. Abnormal nasal resonance of the voice There is a permanent “hypernasal” quality to the voice (“hyperrhinophonia”). 3. Audible nasal air emission Turbulent air escapes from the nose (inappropriate nasal air emission) especially during the high-pressure sounds /p,b/ or continuant sounds such as /s,z/. 4. Glottal sound substitutions Sometimes patients, particularly children, develop a different way to produce some speech sounds by compensatory or glottal substitutions (e.g., glottal stops or laryngeal fricatives): they try to “stop” the air or to narrow the airstream at the laryngeal (with the true/false vocal folds) or pharyngeal (e.g., by moving the tongue posteriorly) level, which creates a rough or breathy sound or may sound as if the sound is being omitted. Surgery alone will not improve this type of speech pattern. Nasal regurgitation usually occurs only in severe cases or in case of neurogenic incoordination. Traditional palato- and pharyngoplasty techniques use a pharyngeal flap. Augmentation pharyngoplasty basically aims to move the dorsal pharyngeal wall forward, so that the mobile palate can make contact with the dorsal wall, thereby directing the flow out of the mouth and preventing its escape into the nose. Augmentation pharyngoplasty is a classical surgical procedure for reducing hypernasal speech as a consequence of velopharyngeal

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incompetence (2). However, augmentation pharyngoplasty is only recommended for mild cases of VPI (3). It can also be performed as a complementary procedure after a pharyngoplasty with the creation of a flap. Several kinds of materials have been proposed as posterior wall implant: paraffin (4), silicone (5), homologous cartilage (6), and principally Teflon (polytetrafluorethylene) (7–9). Teflon has been extensively used in the past decennia for vocal fold augmentation in case of unilateral vocal fold paralysis. However, the problem with Teflon is the possible (unpredictable) development of Teflon granulomas (foreign body giant cell reaction) that can occur long after (as many as 25 years) the surgical procedure, even though the functional results (on voice) were satisfactory (10). This was sufficient reason to abandon this material. Mikaelian et  al. (11) and Brandenburg et al. (12) proposed to replace Teflon by autologous fat for injection in the vocal folds. This elicited the idea of also using lipotransplantation for augmentation pharyngoplasty. As early as 1926, von Gaza (13) had already described such a procedure, but using an external cervical approach. Dejonckere and van Wijngaarden (14), and Leuchter et  al. (15) reported favorable functional results, also in the long term.

P. H. Dejonckere

Fig 47.1  Nasopharyngoscopy with a flexible endoscope for functional assessment of the velopharyngeal closure

as its correlation with perception (18, 19). It consists of computing the nasal–oral acoustic ratio. During speech, the acoustic energy emanating from the nose and emanating from the mouth are registered separately and properly filtered. The computer calculates the ratio of the acoustic energy emanating from the nose to the total acoustic energy (emanating from nose and mouth together). This is expressed as a percentage, and has been defined as “nasalance.”

47.3  Preoperative Assessment Basic requirements are perceptual voice and speech evaluation by an experienced team comprising a phonetician and a speech therapist, and a videonasopharyngoscopy (Fig. 47.1). During visual observation, the patient has to perform several tasks including a sustained non-nasal vowel (of comfortable intensity and loudness), fricatives, repeating a short non-nasal sentence, and blowing against a resistance. In case the patient succeeds in some of these tasks (i.e., achieving a complete velopharyngeal closure), specific speech therapy needs to be started first, in order to try to extend the conditions in which a complete closure is obtained. Additional clinical investigations are the classical aerodynamic tests with the mirror and a nose auscultation and contrast videofluoroscopic pharyngography. In both cases, the same phonation and blowing tasks are performed. The objective functional assessment mainly relies upon quantitative computer-assisted acoustic nasometry (Nasometer, Kay Elemetrics): the reliability and validity of this technique have been recognized (16, 17), as well

47.4 Criteria and Indications for Retropharyngeal Fat Injection In the author’s opinion, the criteria for augmentation of the pharyngeal wall with autologous fat are as follows: 1. Slight (to moderate) permanent velopharyngeal gap at nasopharyngoscopy during speech tasks, but (sub) normal muscular activity of tensor and levator veli palatini, with adequate lifting of the soft palate; 2. Distance between velum and dorsal pharyngeal wall not more than 3–4 mm, as measured on lateral RX-pharyngogram; 3. Reduction of speech intelligibility, but absence of severe language acquisition delay or mental impairment; 4. Lack of (sufficient) improvement with speech therapy; 5. Previous velopharyngeal surgery, such as pharyngoplasty with pharyngeal flap, possibly an indication, particularly if the functional results are incomplete.

47  Retropharyngeal Fat Transfer for Congenital Short Palate

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47.5  Surgical Procedure

47.6  Results

The procedure is always performed under general anesthesia with intubation. The fat is harvested from the periumbilical area via a small incision. The surrounding fascia and connective tissue is removed by dissection under the surgical microscope. The remaining fat globules are handled with care and loaded into the Brünings syringe. Fat can also be collected by lipoaspiration. The material is then centrifuged for 3 min at 3,000 rpm in order to eliminate blood. After lifting of the palatum molle, the needle is transorally inserted approximately at the level of the prominence caused by the tubercle of the atlas (Fig. 47.2). The fat is injected submucosally, using the Brünings syringe. The amount of injected fat tissue is variable, usually 2–3 mL in one medial or two lateral sites, depending on the preoperative videonasopharyngoscopic observations and the X-ray contrast pharyngography. If a pharyngoplasty has been previously performed, the fat is positioned more caudally and laterally, in order to optimally narrow the nasopharyngeal ports.

Figure 47.3 shows an enlarged portion of a MRI image scan 5 weeks after injection. Fat signal appears as a light area. Objective (nasometry) and subjective (questionnaires) postoperative assessment demonstrates favorable functional results in 80–90% of patients. The average nasalance percentages appear to be significantly reduced (14, 15) (Fig. 47.4), but in about 50% of

Fig. 47.3  Enlarged portion of an MRT image scan 5 weeks after injection: fat signal appears as a light area

60

NASALANCE % "NORMAL PASSAGE" ±Std. Dev.

55

±Std. Err. Mean

50 45 40 35 30

Fig. 47.2  Transoral injection technique of autologous fat

Pre-op

Post-op 1

Post-op 2

Fig. 47.4  Average nasalance percentages (mean, standard error, and standard deviation) preoperatively, and in the short term (in average 2.2 months) and long term (in average 9.4 months) postoperatively (n = 17)

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the patients a slight form of “nasality” remains audible in running speech. In about 10–15% patients, partial fat resorption induces partial recurrence of some symptoms after 2–3 years. Reinjection is always possible, but resorption is obviously a disadvantage when comparing fat augmentation with pharyngoplasty. Slight or moderate neck pain and oropharyngeal dysphagia may occur for a few days. Other than this, no mention has been made of any long-term adverse effect. No visible migration of injected fat was noticed. One case of obstructive sleep apnea has been reported 6 years after treatment of velopharyngeal incompetence by Teflon injection (20). Resection of the lower threefourth of the Teflon pad, leaving the upper rim to avoid recurrence of the VPI, eliminated the symptoms.

47.7  Conclusions In patients, especially children, with mild VPI due to a constitutional short palate (possibly revealed after adenoidectomy) and resistant to speech therapy, transplantation of autologous fat in the dorsal pharyngeal wall to build up a ridge gives satisfactory functional results, in the short and long terms, as objectively quantified by acoustic nasometry. Further, unlike Teflon, autologous fat tissue will not cause granulomas. This procedure is also suitable after a previous pharyngoplasty with flap.

References   1. Shprintzen RJ, Bardach J. Cleft Palate Speech Management: A Multidisciplinary Approach. Mosby, St Louis, 1995.   2. Parton MJ, Jones AS. Hypernasality following adenoidectomy: A significant and avoidable complication. Clin Otolaryngol 1998;23(1):18–19.   3. Hirschberg J. Velopharyngeal insufficiency. Folia Phoniat (Basel) 1986;38(2–4):221–276.   4. Eckstein HV. Hartparaffininjektionen in die hintere rachenwand bei angeborenen und erworbenen gaumendefekten. Klin Wochenschrift (Berlin) 1922;1:1185.

P. H. Dejonckere   5. Brauer RO. Retropharyngeal implantation of silicone gel pillows for velopharyngeal incompetence. Plast Reconstr Surg 1973;51(3):254–262.   6. Trigos I, Ysunza A, Gonzalez A, Vasquez MC. Surgical treatment of borderline velopharyngeal insufficiency using homologous cartilage implantation with videonasopharyngoscopic monitoring. Cleft Palate J 1988;25(2):167–170.   7. Ward PH, Stoudt R, Jr, Goldman R. Improvement of velopharyngeal insufficiency by teflon injection. Trans Am Acad Ophthalmol Otolaryngol 1967;71(6):923–933.   8. Bluestone CD, Musgrave RH, Mc Williams BJ, Crozier PA. Teflon injection pharyngoplasty. Cleft Palate 1968;5:19–22.   9. Smith JK, McCabe B. Teflon injection in the nasopharynx to improve velopharyngeal closure. Ann Otol Rhinol Laryngol 1977;86(4 Pt 1):559–563. 10. Varvares MA, Montgomery WW, Hillman RE. Teflon granuloma of the larynx: Etiology, pathophysiology and management. Ann Otol Rhinol Laryngol 1995;104(7):511–515. 11. Mikaelian DO, Lowry LD, Sataloff, RT. Lipoinjection for unilateral vocal cord paralysis. Laryngoscope 1991;101(5):465–468. 12. Brandenburg JH, Kirkham W, Koschkee D. Vocal cord augmentation with autogenous fat. Laryngoscope 1992;102(5): 495–500. 13. Gaza WV. Ueber freie fettgeweibstransplantation in den retropharyngealen raum bei gaumenspalte. Arch F Klin Chir 1926;142:590–599. 14. Dejonckere PH, van Wijngaarden HA. Retropharyngeal autologous fat for congenital short palate: A nasometric assessment of functional results. Ann Otol Rhinol Laryngol 2001;110(2):168–172. 15. Leuchter I, Pasche P, Hohlfeld J, Schweitzer V. Treatment of velopharyngeal insufficiency by autologous fat injection. Proceedings 24. Scientific Congress of the German Society of Phoniatrics and Pedaudiology, 28–30.09.2007, Innsbrück. http://www.egms.de/en/meetings/dgpp2007/07dgpp29.shtml 16. Haapanen ML. A simple clinical method of evaluating perceived hypernasality. Folia Phoniatr (Basel) 1991;43(4):122–132. 17. Watterson T, Lewis KE, Deutsch C. Nasalance and nasality in low pressure and high pressure speech. Cleft Palate Craniofac J 1998;35(4):293–298. 18. Keuning KH, Wieneke GH, van Wijngaarden HA, Dejonckere PH. The correlation between nasalance and a differentiated perceptual rating of speech in Dutch patients with velopharyngeal insufficiency. Cleft Palate Craniofac J 2002;39(3):277–284. 19. Keuning KH, Wieneke GH, Dejonckere PH. Correlation between the perceptual rating of speech in Dutch patients with velopharyngeal insufficiency and composite measures derived from mean nasalance scores. Folia Phoniatr Logop 2004;56(3):157–164. 20. Furlow LT, Jr, Block AJ, Williams WN. Obstructive sleep apnea following treatment of velopharyngeal incompetence by teflon injection. Cleft Palate J 1986;23(2):153–158.

Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Total Joint Prostheses to Prevent Heterotopic Bone

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Larry M. Wolford and Daniel Serra Cassano

48.1  Introduction The first report of an autologous fat transplantation appeared in the literature in 1893 (1). Since then, ­autologous fat grafting has been used extensively in the  human body for various applications. These have included esthetic procedures for contour augmentation, particularly in the maxillofacial region, and ablative procedures, as in the treatment of various injuries of the frontal sinus. There have also been reports of its use in the treatment of ankylosis of the temporomandibular joint (TMJ) by Blair (2) in 1913 and by Murphy (3) in 1914. In 1992, Thomas (4) reported the use of autologous fat transplantation as a means of preventing the formation of the heterotopic bone after hip replacement surgery in six patients. Currently, the usual method for prevention of the heterotopic bone in orthopedics is radiation treatment of the region (5–7). The problem of heterotopic calcification is frequently seen following alloplastic materials placed in the TMJ, particularly when alloplasts of Proplast/ Teflon (PT) (Vitek Inc., Houston, TX) or Silastic (DowCorning, Midland, MO) had been previously implanted (8–11) (Fig. 48.1). Heterotopic bone can also result with TMJ involvement from trauma, reactive arthritis, osteoarthritis, sepsis, inflammation, failed previous surgeries, and connective tissue/autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, scleroderma, etc. (12–18). These calcifications can cause continued worsening pain, and a progressive decrease in a range of activities that may lead to bony ankylosis. A variable amount of fibrosis

L. M. Wolford () 3409 Worth Street, Suite 400, Dallas, TX 75246, USA e-mail: [email protected]

and possibly reactive tissues are commonly associated with the heterotopic bone, thereby worsening the effect. No pharmacologic agents have been identified to predictably prevent these unwanted tissues from developing in the TMJ. Durr et al. (19) have reported favorable outcomes in two-thirds of their patients with TMJ

Fig. 48.1  A coronal tomogram of a prosthetically reconstructed TMJ joint, demonstrates heterotopic bone formation on the medial side between the mandibular ramus and base of skull. No fat graft was placed around the prosthesis at surgery

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_48, © Springer-Verlag Berlin Heidelberg 2010

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ankylosis, using postsurgical radiation. However, significant concerns exist relative to the effects of this treatment on nearby structures (i.e., the brain, orbital structures, and parotid gland). In addition to this, the increased vascularity of the TMJ region compared to the hip, and the frequent presence of particulated polymeric materials, may preclude a successful result with this modality. The experiences of other surgeons with the use of radiation therapy in patients with recurrent TMJ ankylosis have not been favorable. Wolford, in 1992, developed the philosophy and technique for placing fat grafts around TMJ total joint prostheses to prevent heterotopic bone formation, decrease fibrosis, improve pain levels, as well as increase jaw function. Wolford and Karras (20) published the first study evaluating fat grafts placed around TMJ total joint prostheses. Fifteen patients (2 males, 13 females) underwent TMJ reconstruction with Techmedica (Techmedica, Inc., Camarillo, CA), a custom-made total joint prostheses (this TMJ prosthesis system is currently manufactured by TMJ Concepts Inc, Ventura, CA). Seven patients had bilateral and eight had unilateral surgeries, for a total of 22 joints. All patients had autologous fat harvested from the abdomen grafted around the articulating portion of the joint prostheses after the fossa and mandibular components had been stabilized. Twenty patients (2 males, 18 females) who received Techmedica total joint prostheses without fat grafts served as controls with 17 bilateral and 3 unilateral cases for a total of 37 joints. In the fat graft group, an average preoperative maximal incisal opening (MIO) was 26.9 mm and at long term follow-up was 38.7 mm; an improvement of 11.8  mm. Contralateral excursive movements aver­ aged 2.3 mm preoperatively and 2.2 mm at long term ­follow-up. In the nonfat grafted group, the average preoperative MIO was 26.8 mm and at long term ­follow-up was 33.1 mm; an improvement of 6.3 mm. Contralateral excursive movements averaged 3.2 mm preoperatively and 1.7 mm at long term follow-up. The differences in the measured function between the two groups were found to be statistically significant (p < 0.01). Although both groups experienced significant decrease in pain,  there was no significant difference noted in the patients’ perception of their level of pain at long term follow-up. There was no radiographic or clinical evidence of heterotopic calcifications or limitation of mobility secondary to fibrosis in any of the fat grafted group, while seven control patients (35%) developed heterotopic bone and required reoperation.

L. M. Wolford and D. S. Cassano Fig. 48.2  The Christensen prosthesis is an off-the-shelf device with three selections for the mandibular component and over 40 selections for the fossa component. The best fitting components are selected to fit the anatomy. These devices have metal-onmetal articulations

This initial study proved that autologous fat transplantation was a useful adjunct to prosthetic TMJ reconstruction. Its use minimizes the occurrence of excessive joint fibrosis and heterotopic calcification, consequently providing an improved range of motion. In another study, Wolford et al. (21) evaluated 115 patients (5 males, 110 females) who had TMJ reconstruction with total joint prostheses and simultaneous fat grafts (88 bilateral and 27 unilateral) for a total of 203 joints. All patients had autologous fat from the abdomen packed around the articulating portion of the joint prostheses after the fossa and mandibular com­ ponents were stabilized. Patients were divided into two groups: Group 1 (n = 76 joints) received Christensen total joint prostheses (TMJ Implants Inc., Golden, CO) (Fig. 48.2) and Group 2 (n = 127 joints) received TMJ Concepts total joint prostheses (TMJ Concepts Inc, Ventura, CA) (Fig. 48.3). The average patient follow-up was 31.2 months (range 12–65 months). In Group 1, MIO increased by 3.5 mm (23.6–27.1 mm), LE decreased by 0.2 mm (1.5– 1.3 mm), and the jaw function improved by 1.9 levels (7.7–5.8), where 0 = normal jaw function and 10 = no jaw function. In Group 2, MIO increased by 6.8 mm (27.6–34.4 mm), LE decreased by 1.4 mm (3.4–2.0 mm), and the jaw function improved by 2.4 levels (7.6–5.2)

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

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patients (1.8%) developed abdominal cysts superficial to the rectus abdominis muscle requiring surgical removal; 8 patients (6.9%) developed seroma formation requiring aspiration while 2 of these 8 patients required temporary drain insertion. This study showed that auto­logous fat transplantation is a useful adjunct to prosthetic TMJ reconstruction to minimize the occurrence of excessive joint fibrosis and heterotopic calcification, consequently providing an improved range of movement and jaw function. The removal of the 25 Christensen and 4 TMJ Concepts prostheses were the result of prosthesis failure (Christensen) and metal hypersensitivity (22–24), but not related to the autogenous fat grafting. There are no other published studies in the literature in reference to fat grafts placed around TMJ total joint prostheses. There are a few reports in the literature in reference to fat grafts to the TMJ area, but without total joint prostheses. Rattan (25) reported a technique of transferring the buccal fat pad into the TMJ as a pedicle or random fat flap. He presented two cases of unilateral ankylosis treated by gap arthroplasty and a buccal fat pad graft with good results in one patient at 15 months and the other at 19 months postsurgery. Dimitroulis (26) evaluated 11 patients with 13 ankylosed TMJs. He treated the patients with gap arthroplasty and the gap was filled with autogenous dermis-fat grafts harvested from the groin. Presurgical incisal opening was 15.6 mm and at the longest followup (average follow-up was 41.5 months) was 35.7 mm. Only one patient reankylosed. This study found the dermis-fat grafts to be successful in treating bony and fibrous ankylosis. Dimitroulis et al. (27) evaluated 15 patients (17 joints) with dermis-fat grafts within the TMJs by MRI. Between 6 months and 2 years postsurgery, fat tissue was identified within and surrounding all of the TMJs.

Fig. 48.3  The TMJ Concepts total joint prosthesis a ­custom-fitted device constructed on a stereolithographic three-dimensional model and designed for each patient’s specific anatomical requirements. The devices have metal-on-polyethylene articulations

(Table 48.1). There was a statistically significant improvement for MIO and patient perception of jaw function in both groups. There was no radiographic or clinical evidence of heterotopic calcifications or limitation of mobility secondary to fibrosis in either group. There were 25 Christensen prostheses (33%) removed because of elevated pain levels due to device failure and/or metal hypersensitivity due to metallosis; no fibrosis or heterotopic bone formation was seen at surgical removal. There were 4 TMJ Concepts prostheses (3%) removed because of metal hypersensitivity. ­Evaluation of the abdominal fat donor sites showed that 10 patients (8.7%) developed complications: 2 obese

Table 48.1  (21) Group 1: Christensen total joint prostheses (n = 76 joints) Group 2: TMJ Concepts total joint prostheses (n = 127 joints) Group

MIO (mm)

LE (mm)

Jaw function Numerical analog score

1 2

T1

T3

T3−T1

T1

T3

T3−T1

0 = normal function: 10 = no function T1 T3 T3−T1

23.6 27.6

27.1* 34.4*

3.5 6.8

1.5 3.4

1.3 2.0

0.2 1.4

7.7 7.6

MIO maximum incisal opening, LE maximum lateral excursion *Statistically significant at p < 0.01

5.8* 5.2*

1.9 2.4

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48.2  Surgical Technique The senior author (LMW) has used two types of TMJ total joint prostheses: the Christensen prostheses and the TMJ Concepts prostheses (22–24). The Christensen TMJ total joint prostheses (Fig. 48.2) are off-the-shelf devices with a choice of three mandibular components and over 40 selections for a fossa component with tryin devices to get the best fit for each patient’s anatomy. The Christensen prostheses are metal-on-metal articulations (Fig. 48.2). The complication rate of these prostheses is significantly higher than with the TMJ Concepts prostheses (22–24).The TMJ Concepts total joint prostheses (10–18) (Fig. 48.3) are patient-fitted devices constructed on three-dimensional models of each patient’s maxillofacial region, including the skull base, maxilla, mandible, and TMJ, using computerassisted design/computer assisted manufacture (CAD/ CAM) principles, to conform to each patient’s specific anatomical requirements. These prostheses have metalon-polyethylene articulations. The prostheses are placed through endaural or preauricular and submandibular incisions (8, 17, 18), after a thorough debridement of the region. The fossa component is positioned through the endaural or preauricular

Fig. 48.4  (a) Fat grafts are harvested from the abdomen through a 4–5-cm length incision generally made in the supra-pubic area. (b) The outer dashed line is the extent of undermining of the skin and beneath the fat pad. The inner solid line denotes the fat graft to be harvested. (c) The abdominal fat graft has been harvested from the abdomen. (d) 3–0 polyglactin sutures are used to close the deep fat layers so no depression in the harvest area will be evident. The skin is closed with subcuticular suturing

incision and is stabilized at the lateral rim of the fossa and the posterior aspect of the zygomatic arch with four 2-mm diameter bone screws. The mandibular component is inserted through the submandibular incision and secured to the mandible usually with six to nine 2-mm diameter screws. Following stabilization of all condylar and fossa components, fat is harvested for grafting around the prostheses. There are numerous areas from which fat can be harvested; abdomen (20, 21), buttock, buccal fat pad (25), breast, thigh, or anywhere else where a patient may have some excess fat. Most commonly we harvest fat grafts for TMJ use from the abdomen. There  is usually abundant fat available there to provide adequate fat volume. Harvesting fat from the abdo­ men can be accomplished from several approaches: Suprapubic (Fig. 48.4), through the naval (Fig. 48.5), from the lateral aspect of the abdomen below the bikini line, or through a pre-existing scar. Enbloc fat harvesting does the best, relative to survival. Liposuction fat tends to do poorly because of significant damage to the fat cells and subsequent resorption problems. For the routine fat graft harvest, the abdomen is prepared and draped in the usual fashion from above the umbilicus to the pubic region. The superior portion of

a

b

c

d

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

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d

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c

e

Fig. 48.5  Abdominal fat can be harvested from the umbilical area. (a) An incision site is outlined around the perimeter of the umbilicus. (b) An incision is made. (c) The skin is undermined maintaining 3–5 mm of fat tissue on the undersurface of the skin. (d) Dissection below the fat tissue, superficial to the rectus

the pubic hair is shaved, if necessary, to place the incision as low as possible on the abdomen for optimal cosmetic result. If an existing scar is present in the lower abdomen, this can be used instead. A 4–5 cm transverse incision is made in the midline through the skin and subcutaneous tissues to expose the abdominal fat pad (Fig. 48.4). The skin is widely undermined superiorly and laterally, taking care to maintain a 3–5 mm layer of fat on the skin side. The initial incision is then deepened into the fat at a variable distance depending on the fat pad thickness and the amount of graft required (usual range per joint was 5–20 mL). The fat is then widely undermined superficial to the rectus abdominis muscle fascia to a similar extent as the overlying skin dissection. The desired amount of graft is then harvested in a single block from the midline region. Twenty to thirty percent more of fat than estimated to fill the dead space in the TMJ region is harvested to allow for shrinkage and errors in estimation. Meticulous hemostasis of the donor site is achieved with electrocautery, and the defect in the fat pad can be closed by advancing the lateral fat flaps toward the midline and suturing with 3–0

f

muscle fascia is completed, the fat excised, and delivered through the incision. (e) The fat is stored on ice until ready for insertion around the joint prostheses. (f) The incision is closed with subcuticular sutures

Fig. 48.6  Fat harvesting technique. (a) The skin is widely undermined, leaving a 3–5 mm layer of fat on the undersurface. The fat pad is then also undermined above the level of the rectus fascia to a similar extent and the graft is taken from the midline region. (b) The lateral fat flaps are then closed in the midline

polyglactin (Fig. 48.6). The skin incision is closed with subcutaneous sutures of 4–0 polydiaxanone, and Steristrips can be placed for re-enforcement.

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Fig. 48.7  A drain may be required to be placed in the fat donor area if adequate hemostasis cannot be achieved at surgery, or a persistent hematoma or seroma develops postsurgery. The drain is inserted and attached to the bulb so that a negative pressure can be applied

In the initial cases, a suction drain (Fig. 48.7) was placed and removed 3–5 days postsurgery, but with careful attention to hemostasis before closure, the requirement for a drain has been significantly reduced, and in fact, rarely necessary. A pressure dressing of fluffed gauze and elastic tape is applied over the donor site and maintained for approximately 3 days before removal, to minimize the incidence of hematoma and seroma formation. The graft is immediately placed through the endaural or preauricular incision to fill the dead space around the articulating portion of the prosthetic components. In bilateral cases, the graft is divided into equal portions and one portion is stored in iced normal saline until placement in the second side. The a

b

Fig. 48.8  Case #1. (a) The TMJ Concepts total joint prosthesis was custom-made for this patient’s specific anatomical requirements. (b) The fossa component of the TMJ Concepts total joint prosthesis was placed through a preauricular incision. The man-

fat is packed into the TMJ region quite firmly, without causing excessive damage to the tissue graft. Incision closure is accomplished in routine layered fashion, usually with 4–0 polydiaxanone for deep sutures and a 5–0 Prolene suture for a subcuticular skin closure. When harvesting fat from the umbilical area, a circular incision is made inside the navel area to gain access to the fat positioned higher on the abdomen (Fig. 48.5). The access is greatly limited making the harvesting more challenging. Also because of the limited access, establishing hemostasis is more difficult. With this approach, fat can be harvested from either or both the lateral sides and inferior to the incision. The incision is closed with 5–0 polydiaxanone suture in an unbroken fashion. Inadequate packing of fat around the prosthesis can result in the development of fibrosis and heterotopic bone formation. In an extremely thin patient who needs a large graft, it may be a challenge procuring an adequate volume of fat from the abdomen. Harvesting from the buttock may provide an adequate source. However, harvesting fat from the buttock usually requires turning the patient toward one side and propping the buttock upward to improve access. The incision is made in the gluteal crease. There is usually more fat located superior to the incision line. Following fat harvest, the ­incision is closed with a continuous or interrupted subcuticular sutures with Steri-strips placed for reinforcement. The access may be somewhat difficult depending c

dibular component was placed through a submandibular incision. (c) The abdominal fat graft was packed into the joint space to prevent recurrence of heterotopic bone formation and fibrosis

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

on how much body rotation can be accomplished. It is best to wait until it is time to harvest the fat before ­placing a supportive roll under the buttock to elevate it. Placing the roll under the hip at the beginning of surgery could result in nerve and soft tissue damage because of the prolonged pressure on the sciatic nerve and soft tissues. When performing TMJ total joint prostheses surgery, antibiotics are routinely administered immediately before the surgery, then every 6 h while the IV is in place. The authors usually use a cephalosporin, but for those hypersensitive to cephalosporins Clindamycin or Levaquin is used. Following hospital discharge, patients are given oral antibiotics for 1–2 weeks postsurgery. a1

b1 Fig. 48.9  Case #1. (a1, a2) A 45-year-old male who had 14 previous failed right TMJ surgeries; the last previous surgery involved right TMJ reconstruction with a total joint prosthesis (Osteomed system) without a fat graft. He had severe TMJ and myofascial pain, headaches and difficulty in eating. (b1, b2) Two years postreconstructive surgery with right TMJ debridement, removal of heterotopic bone and Osteomed prosthesis, TMJ reconstruction with TMJ Concepts custom-fitted total joint prosthesis, and fat graft.

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This regiment minimizes the occurrence of postsurgical infection. Rattan (25) reported the use of a buccal fat graft to the TMJ area. Although it is apparently possible to get the fat back to the joint area, there is a concern if enough fat would be available to pack adequately around the prostheses. Packing the fat tightly around the prostheses yields best results. In patients with a propensity to develop heterotopic bone, placing a fat graft that is not tightly packed to fill all of the voids, could still result in the development of heterotopic bone around the prostheses. Case #1 (Figs. 48.8–48.11): This 45-year-old male was referred to the senior author after undergoing 14 a2

b2

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L. M. Wolford and D. S. Cassano

a1

b1

a2

b2

a3

b3

Fig. 48.10  Case #1. (a1–a3) Preoperative patient with a Class I occlusion on the left side and Class II occlusion on the right side. (b1–b3) The occlusion remained stable 2 years postsurgery

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Fig. 48.11  Case #1. (a) The presurgical panograph X-ray showed massive heterotopic bone formation (outlined by the black arrows) around the Osteomed prosthesis. (b) The heterotopic bone was removed in sections. (c) Ten-year postsurgical radiograph shows the effectiveness of the fat graft for prevention of heterotopic bone development

a

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b

previously failed right TMJ surgeries including procedures using devices that contained PT. He was 2 years post-TMJ reconstruction with an Osteomed total joint prosthesis (Osteomed Inc., Dallas, TX) without the placement of a fat graft around it for that surgery. He had severe TMJ and myofascial pain, headaches, and difficulty to eat. He presented with Class I occlusion on the left side and Class II occlusion on the right side. There was a massive heterotopic bone development and bony ankylosis surrounding the right TMJ, a foreign body giant cell reaction secondary to the previous PT materials, and severe limitation of incisal opening of 20 mm with no translation of the right condyle. The TMJ reconstructive surgery was performed in  one operation including: (a) Unilateral right TMJ debridement and removal of the heterotopic bone formation around the old prosthesis, (b) Removal of the

Osteomed prosthesis, (c) Unilateral right TMJ reconstruction with patient-fitted TMJ Concepts total joint prosthesis, and (d) Unilateral right TMJ fat graft packed around the prosthesis harvested from the abdomen. The patient was evaluated 2 years postsurgery showing good stability, with elimination of the TMJ pain, headaches, myofascial pain, and improved jaw function. The occlusion remained stable. At 10 years postsurgery, his incisal opening was 42 mm with 2–3 mm of translation of the right prosthetic condyle and no radiographic evidence of heterotopic bone formation. Case #2 (Figs. 48.12–48.14): This 12-year-old male developed right TMJ ankylosis at the age of 1 sec­ ondary to sepsis. He had two failed previous surgical attempts for correction by rib grafting. He had only 3 mm of incisal opening and was developing significant dental problems because of inability to receive

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b1

b2

Fig. 48.12  Case #2. (a) Twelve-year-old male developed right TMJ ankylosis at the age of 1 year secondary to TMJ sepsis. He had two failed attempts for correction by rib grafting without the use of fat grafts. He had only a 3-mm incisal opening and was developing significant dental problems as well as marked facial

a

asymmetry and sleep apnea symptoms. (b1, b2) The patient was seen 3 year post right side TMJ reconstruction and mandibular advancement with a TMJ Concepts total joint prosthesis and fat graft. He had an improved facial balance and good jaw function (35 mm opening) without pain

b

Fig. 48.13  Case #2. (a) Three-dimensional CT scan demonstrates the magnitude of the heterotopic bone and joint ankylosis. (b) The heterotopic bone was removed in sections

dental care, had severe facial asymmetry, as well as sleep apnea symptoms. A three-dimensional ­radiograph demonstrates the magnitude of the ankylosis. A TMJ Concepts total joint prosthesis was manufactured to reconstruct the TMJ as well as advance and vertically lengthen the right mandibular ramus. He underwent the following procedures in one stage: (a) Right TMJ

removal of a large mass of heterotopic bone; (b) Recon­ struction of the right TMJ and mandibular advance­ ment with TMJ Concepts ­custom-fitted total joint prostheses; and (c) Fat graft packed around the pros­ theses and area of previous heterotopic bone formation to prevent bone from redeveloping. The patient was evaluated 3 years postsurgery with improved facial

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

a

371

b

c

Fig. 48.14  Case #2. (a) TMJ Concepts total joint prosthesis was custom-made to reconstruct the TMJ as well as advance and vertically lengthen the right mandibular ramus. A fat graft was packed around the prosthesis to prevent heterotopic bone from redevelop-

ing. (b) The lateral cephalogram shows the improved facial balance and normal oropharyngeal airway. (c) The tomogram shows the TMJ Concepts total joint prosthesis with no heterotopic bone formation around the prosthesis at 3 years postsurgery

balance and good jaw function (35 mm opening) without pain. At 3 years postsurgery, there was no radiographic evidence of heterotopic bone formation.

cysts superficial to the abdominal muscle fascia that required excision for elimination. An unsightly scar can occur, but with careful incision closure, this should be of minimal concern. A few patients developed hema­ tomas or seromas in the harvest area (Fig. 48.15). Obtaining good hemostasis at surgery is most important to avoid this problem. Immediately following procurement of the fat graft, the donor site can be packed with gauze for a few minutes. Electrocautery can be used to aide in achieving hemostasis. If hemostasis is not obtainable, then a drain can be inserted and attached to a suction bulb to create negative pressure to prevent hematoma and seroma formation, left in position for approximately 3 days and then pulled out. However,

48.3  Complications Possible complications of abdominal fat graft harvesting include hematoma, seroma, infection, ileus, unaesthetic scar, subcutaneous soft tissue defect, abdominal esthetic concerns, pain and discomfort, and inadvertent peritoneal perforation. At the donor site, there were two extremely obese patients who developed abdominal

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Fig. 48.15  (a) Left lateral abdominal hematoma is associated with fat harvest through the umbilical approach. (b1, b2) A large bore needle (16 gauge) and syringe can be used for aspiration

the authors rarely have to use a drain. Grossly obese patients present a greater risk of donor site morbidity. It may be more difficult to prevent postsurgical bleeding in these patients with a possible resultant hematoma, seroma, or cystic formation. The use of a negative pressure drain for several days immediate postsurgery in this patient type may help prevent this complication. Two additional patients required insertion of a drain on the first and second days postsurgery. Eight other patients did require postsurgical aspiration for the removal of a hematoma or a seroma at the donor site. Aspiration can be achieved by using a large gauge

L. M. Wolford and D. S. Cassano

needle (16 gauge) on a large syringe or low pressure suction for removal. A pressure dressing is then applied. Repeat aspiration may be required. The occurrence of postsurgical hematoma/seroma can usually be avoided by achieving good hemostasis and placing a fluffed gauze dressing, secured with elastic tape or, alternatively, placing a Velcro-secured abdominal binder over the donor area. Additional potential complications include perforation through the abdominis rectus muscle into the abdominal cavity. The authors have never encountered this complication. Infection in the harvest area can occur and would be managed with incision and drainage, culture and sensitivity, irrigations, appropriate antibiotics, etc. Soft tissue defect from the harvest area can be an esthetic concern for some patients. However, careful harvesting, closure of lateral fat pad flaps should minimize this concern. The authors have never encountered significant postsurgical ileus. At the recipient site complications can also occur. Infections can occur which involve the prosthesis and fat graft (Fig. 48.16). The occurrence of an infection is very unusual, but with a greater risk in patients with immuno-dysfunctional problems. If an infection does occur, aggressive management will be required to salvage the prosthesis including: incision and drainage, removal of the fat graft if involved, and placement of irrigating catheters and drains. Multiple daily irrigations with antibiotic solutions work well and usually within 3–5 days, the drains and irrigating catheters can be advanced and removed. The authors have had about 10 patients who developed an infection involving the prosthesis and fat graft since 1989. The infections usually occur within the first month postsurgery. All but two of the prostheses have been salvaged with this regiment. Both patients who required prosthesis removal were informed early in the infectious process that immediate surgical intervention was recommended to salvage the prostheses. Both patients refused the recommendation for immediate surgical treatment, but both had draining fistulas so they had no significant pain. The first patient had a draining fistula from the right external auditory canal and did not return for treatment until 6 months postonset of infection. The prosthesis was removed and joint debrided. A new prosthesis was inserted 3 months later with a fat graft placed around the articulating portion of the prosthesis, and at 9 years postreplacement, the patient has had no further problems. The second

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

a

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c

b

Fig. 48.16  This 25-year-old female with juvenile rheumatoid arthritis and significant immunodysfunction had her TMJs reconstructed with TMJ Concepts total joint prosthesis and fat grafts. (a) One month postsurgery she developed a unilateral right side infection associated with the total joint prosthesis. (b) The patient was prepared for surgery and had spontaneous drainage from the original submandibular incision area. (c) The joint

was debrided, but prosthesis maintained. An irrigating catheter was placed above the endaural incision into the articulating area of the joint and another placed along the ramus component. A drain was placed through the submandibular incision. Daily multiple irrigations were performed for 5 days, when the catheters and drain were removed. This prosthesis was salvaged

patient had an immunodeficiency condition and developed a right submandibular draining fistula associated with the right total joint prosthesis at 1 month postsurgery. Although repeated recommendations for surgical intervention were made, she sought nonsurgical management for 5 years with numerous antibiotics that was unsuccessful before returning for surgical treatment.

The prosthesis was removed and IV antibiotics were used for 2 months. The prosthesis was successfully replaced 3 months later with another fat graft placed around the prosthesis. Case # 3 (Figs. 48.17–48.19): This 52-year-old female was 4 years post-trauma that involved multiple mandibular fractures including bilateral subcondylar fractures.

374 Fig. 48.17  Case #3. (a1, a2) A 52-year-old female is seen 4 years post-trauma with bilateral temporomandibular joint severe arthritis and displaced condyles. The mandible is significantly retruded with a high occlusal plane angle and associated facial morphology. (b1, b2) One year postsurgery following bilateral TMJ reconstruction and mandibular advancement with custom-made TMJ total joint prostheses (TMJ Concepts system®), bilateral TMJ fat grafts, bilateral coronoidectomies, and simultaneous maxillary osteotomies

L. M. Wolford and D. S. Cassano

a1

a2

b1

b2

She presented with bilateral TMJ severe arthritis, displaced condyles, and a class II skeletal and occlusal dentofacial deformity. She had severe TMJ pain, headaches, myofascial pain, difficulty in eating and chewing, as well as severe sleep apnea related to the retruded mandible and associated with severely reduced oropharyngeal airway. In addition, she had immunodysfunctional problems and chronic sinusitis. Following orthodontic preparation, surgery was performed in one operation including: (a) Bilateral TMJ reconstruction and mandib­

ular counter-clockwise advan­cement (28 mm at pogonion) with custom made TMJ total joint prostheses (TMJ Concepts system®), (b) Bilateral coronoidectomies, (c) Bilateral TMJ fat grafts placement (harvest from the abdomen), (d) Left mandibular body osteotomy, and (e) Multiple maxillary osteotomies to down graft the posterior aspect and upright the incisors. At 6 weeks postsurgery, she developed bilateral infections around the prostheses with intraoral draining fistulas. She was taken back to surgery for joint and mandibular debridement,

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

a1

b1

a2

b2

a3

b3

375

Fig. 48.18  Case #3. (a1–a3) Presurgical occlusion demonstrates anterior open bite, Class II occlusal relationship, and posterior crossbite. (b1–b3) The occlusion remained stable 1-year postsurgery

closure of the intraoral fistulas, and placement of bilateral extra-oral irrigating catheters and drains. She was placed on IV Clindamycin. At 3 days postsurgery, the drains and irrigating catheters were advanced and at day 5 removed. She was maintained on PO Clindamycin following hospital discharge for 1 month. The patient was

evaluated 1 year postsurgery showing good stability, with elimination of TMJ pain, headaches, myofascial pain, improved jaw function and facial esthetics, and increased oropharyngeal airway, eliminating the sleep apnea. At 4 years postsurgery, no reccurrence of infection has been seen.

376 Fig. 48.19  Case #3. (a) Pretreatment cephalometric analysis shows a retruded mandible, anterior open bite, steep occlusal and mandibular plane angles, over-angulated lower incisors, severe decreased oropharyngeal airway and significant degenerative changes of the condyles. (b) The STO (prediction tracing) demonstrates the TMJ and orthognathic procedures required to achieve a good functional and esthetic result including bilateral TMJ reconstruction and mandibular advancement with custom made TMJ total joint prostheses (TMJ Concepts/Techmedica system®), bilateral coronoidectomies, and maxillary osteotomies for counterclockwise rotation of the maxillo-mandibular complex and occlusal plane angle. (c) Cephalometric analysis at 1-year postsurgery demonstrates good facial balance. (d) Superimposition of the immediate postsurgery (red lines) and 1-year follow-up (black lines) cephalometric tracings demonstrate the treatment stability achieved for this patient

L. M. Wolford and D. S. Cassano

a

b

c

d

Case # 4 (Figs. 48.20–48.22): This 14-year-old female presented with juvenile rheumatoid arthritis, bilateral TMJ involvement with significant condylar resorption, class II skeletal and occlusal dentofacial deformity, an anterior open bite, and decreased oropharyngeal airway with sleep apnea symptoms, but no TMJ symptoms, pain, or headaches. Following orthodontic preparation, surgery was performed which consisted of:  (a) bilateral TMJ reconstruction and mandibular ­counter-clockwise advancement with custom made TMJ total joint prostheses (TMJ Concepts system®), (b) bilateral TMJ fat grafts placement (harvest from abdomen), (c) bilateral coronoidectomies, (d) multiple max­ illary osteotomies to down graft the posterior aspect

and upright the incisors, and (e) chin augmentation with an HTR implant (Walter Lorenz CO. Jacksonville, FL). Pogonion advanced 25 mm. The patient was evaluated 1 year postsurgery showing good stability, free from TMJ pain, headaches and myofascial pain; as well  as improved jaw function, facial esthetics, and increased oropharyngeal airway. Patients with inflammatory diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, lupus, scleroderma, reactive arthritis, etc., have greater susceptibility to TMJ fibrosis and ankylosis. In patients with inflammatory disease processes, the fat grafts are essential to prevent fibrosis and reactive bone formation as well as to maximize the functional and comfort outcomes.

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Fig. 48.20  Case #4. (a1, a2) A 14-year-old girl had bilateral TMJ juvenile rheumatoid arthritis, significantly retruded mandible, high occlusal plane angle and associated facial morphology. (b1, b2) One year postsurgery following bilateral TMJ reconstruction and mandibular advancement with custom-made TMJ total joint prostheses (TMJ Concepts system®), bilateral TMJ fat grafts, bilateral coronoidectomies, simultaneous maxillary osteotomies and chin augmentation demonstrating a good stable, functional and esthetic outcome

377

a1

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b1

b2

48.4 Prevention of Fibrosis and Heterotopic Bone The formation of extensive fibrosis and heterotopic bone has been problematic after total joint reconstruction of the TMJ, as well as from other types of TMJ arthrotomies. In the TMJ this is particularly true for

multiple operated joints and joints with previously failed alloplastic implants, as well as following prosthetic and autologous joint reconstruction (20, 21, 28). Fibrosis is related to scar tissue deposition, especially in multiple operated joints or failed alloplastic reconstruction where a persistent inflammatory response may be present. Heterotopic bone may be deposited in a similar reaction in joints with inflammatory conditions

378

L. M. Wolford and D. S. Cassano

a1

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a2

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Fig. 48.21  Case #4. (a1–a3) Presurgical occlusion demonstrated an anterior open bite and Class II end-on cuspid relationship. (b1–b3) The occlusion remained stable 1-year postsurgery

and after alloplastic implant failure. Additionally, the presence of dead space after extensive joint debridement or total joint prosthesis placement leads to blood clot formation in the joint area, with subsequent organization. Pluripotential cells may then migrate into the area and be induced to differentiate into fibroblasts and osteoblasts, with deposition of collagen and bone

respectively. In excessively fibrotic joints, there is a decrease in vascularity and thereby a decrease in oxygen tension in the surrounding tissues. This can lead to  the transformation of fibrous tissue into cartilage and bone (29). In addition, heterotopic bone can also result with TMJ involvement from trauma, reactive arthritis, osteo­arthritis, sepsis, inflammation, and

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Fig. 48.22  Case #4. (a) Pretreatment cephalometric analysis shows a retruded maxilla and mandible, anterior open bite, steep occlusal and mandibular plane angles, over-angulated lower incisors, severe decreased oropharyngeal airway and significant degenerative changes of the condyles (juvenile rheumatoid arthritis). (b) The STO (prediction tracing) demonstrates the TMJ and orthognathic procedures required to achieve a good functional and esthetic result including bilateral TMJ reconstruction and mandibular advancement with custom-made TMJ total joint prostheses (TMJ Concepts system®), bilateral TMJ fat grafts (harvest fat from the abdomen) bilateral coronoidectomies, maxillary osteotomies for counterclockwise rotation of the maxillo-mandibular complex, and chin augmentation. (c) Cephalometric analysis at 1-year postsurgery demonstrates good facial balance. (d) Superimposition of the immediate postsurgery (red lines) and 1-year follow-up (black lines) cephalometric tracings demonstrate the treatment stability achieved for this patient

379

a

b

c

d

connective tissue/ autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, scleroderma, and so on. In the orthopedic experience, various pharmacologic agents, most notably indomethacin and etidronate, have been used with varying success (30, 31). Pharmacologic therapy has been suggested for use after prosthetic TMJ reconstruction, but no substantial data exist regarding its effectiveness (8). In the senior authors (LMW) experience with these medications, the results have been very disappointing.

Radiation treatment of the operated area within 4 days of prosthetic hip reconstruction is now a common practice and appears to offer an effective means of preventing heterotopic bone formation in orthopedics. However, local radiation of the TMJ raises concerns regarding potential adverse effects on adjacent vital structures, (i.e., eyes and associated structures, brain, middle ear, parotid gland), and it may be ineffective due to the substantially greater vascularity of the maxillofacial region. However, Durr et al. (19) reported on 10 patients (15 TMJs) with bony ankylosis surgically

380

managed with either costochondral grafts, gap arthroplasty, or debridement of heterotopic bone and treated early postoperatively with radiation, 10 Gy in five fractions. With a mean of 19 months follow-up, 10 of 15 TMJs did not show heterotopic bone development while 5 patients (33%) had recurrence of heterotopic bone. An additional complication identified was parotitis in three patients (30%). The placement of fat grafts around the articulating area of the TMJ provides significantly better results than radiation in preventing fibrosis and heterotopic bone formation (20, 21, 26, 27). The rationale for placing autologous fat grafts around the TMJ total joint prostheses is to obliterate the dead space present around the joint prosthesis, thus preventing the formation and subsequent organization of a blood clot. Creating this physical barrier, serves to minimize the presence of pluripotential cells, and prevents the formation of extensive fibrosis and heterotopic calcification. It may also isolate any residual reactive tissue from previous alloplastic failure to the periphery of the region, minimizing its formation around the joint components. The net result, as evidenced by the data collected, is a decrease and perhaps elimination of the incidence of heterotopic bone formation and improved jaw function (20, 21). Fat grafts, however, should not be used as a disc replacement in loaded joints. In our procedure of fat graft­ ing around the prostheses, the graft is not functioning as an articular disc, but only as a filling material to eliminate the dead space. Kohn et al. (32) presented an animal study where meniscectomies were performed and fat grafts placed as an articular disc replacement. Osteoarthritis was evident in all treated joints within 6 months. The authors state that fat is not suitable as a meniscal substitute. Dimitroulis (26) evaluated 11 patients with 13 ankylosed TMJs that he treated with gap arthroplasty and the gap was filled with autogenous dermis-fat grafts harvested from the groin. Presurgical incisal opening was 15.6 mm and at longest follow-up (average followup was 41.5 months) was 35.7 mm. Only one patient reankylosed. These patients were not reconstructed with TMJ total joint prostheses, or any form of hard tissue TMJ reconstruction. The patients had improved jaw function, but there was no evaluation as to occlusal and skeletal outcomes. This study did find the dermisfat grafts to be successful in treating bony and fibrous ankylosis. Dimitroulis et al. (27) evaluated 15 patients (17 joints) by MRI where dermis-fat grafts had been

L. M. Wolford and D. S. Cassano

placed within the TMJs. At 6 months to 2 years postsurgery, fat tissue was identified within or surrounding all of the TMJs. Merikanto et al. (33) studied the effects of creating cranial defects with placement of fat grafts into the defects. The control defects were not filled. The fat grafted cranial defects showed no bone regeneration while the control defects showed a complete bone fill with lamellar bone. Histologic evaluation of the fat grafted defects showed living fat cells filling the defect. Osteogenesis was inhibited in the fat grafted defects. Saunders et al. (34) demonstrated in mice that free fat grafts go through a period of initial breakdown of fat cells, followed by revascularization, resulting in ­normal appearing fat, although a smaller volume than originally grafted. In three human subjects who received fat grafts to the lumbar region at surgery, at up to 22 months later at reoperation, there was normal fat tissue although a reduced volume compared to the amount originally grafted, and no evidence of replacement by scar tissue. Yamaguchi et al. (35) demonstrated the importance of early and adequate revascularization of autogenous fat grafts for maintenance of graft volume and for the production and interaction of adipocyte-derived angiogenic peptides such as vascular endothelial growth factor (VEGF) and leptin, important for graft survival and volume maintenance. Trevor et al. (36) showed there was no demonstrable difference in treatment outcomes following placement of a free fat graft vs. a pedicle fat graft in the surgical sites of dorsal laminectomy and duratomy. They concluded that there was no advantage of the use of a pedicle fat graft over a free graft. Qi et al. (37) demonstrated that at early stages following free fat grafting, the fat showed ischemia. The adipocytes released lipid and dedifferentiated to preadipocytes. After revascularization, the preadipocytes began to absorb lipid and became mature adipocytes. The fat grafts were almost normal at 6 months. The ultimate fate of the transplanted fat around the TMJ is unknown. Studies of fat transplantation to other anatomic areas show a variable amount of resorption, with a decrease in volume ranging from 20 to 75% (38, 39). As an adjunct to prosthetic joint reconstruction, the ultimate resorption of a portion of the graft may not be detrimental to the result. If the formation of the initial hematoma, fibrosis, and reactive tissue can be prevented, there may be reduced incidence of complications. Clinically, the fat grafts appeared viable with some samples showing strands of collagen present in it, but

48  Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ)

Fig. 48.23  Histological examination of a fat graft biopsy taken 4 years after implantation around a TMJ Concepts total joint prosthesis shows viable fat still present without evidence of inflammation, heterotopic bone formation, or significant fibrosis

no evidence of an inflammatory process. The consistency of the tissue around the prosthesis was significantly softer than seen in the nonfat grafted patients. Histologically, viable fat was observed (Fig. 48.23). The technique of graft procurement is straight forward, with minimal potential for complications. The fat grafts are harvested just prior to graft placement, requiring only about 15 min of additional surgical time. However, some surgeons may prefer to have two surgical teams working concurrently so the operation is not prolonged. It is not recommended to harvest the fat grafts prior to beginning the TMJ reconstruction as this would require the grafts to be “on the table” for an extended time period, likely to result in significant loss of graft viability. It will usually take a minimum of 4 h to prepare the TMJs and place the prostheses in bilateral cases, before the fat grafts can be placed. Therefore, procuring the fat graft just prior to placement will maximize graft viability; an important factor for graft survival. If the fat graft placement is delayed (i.e., opposite side in bilateral cases) then the graft is stored on ice until ready for insertion. This improves graft viability. The most common donor site for harvesting is the abdomen, where there is usually abundant fat for most cases. The most common approaches the authors use include: the supra-pubic incision, the umbilical or  trans-naval incision, or approach through a pre-­ existing scar (C-section, hysterectomy, appendectomy,

381

abdominoplasty) or other previous abdominal surgery scar. However, the fat can be harvested from almost any fat source including buttock, thigh, buccal fat pad, breast, etc. Autologous fat grafting is a very useful adjunct to prosthetic reconstruction of the TMJ and may prove to be similarly beneficial in autologous reconstruction. Graft procurement is quick and easy, with minimal morbidity. The results of our studies (20, 21) demonstrate the efficacy of TMJ reconstruction with total joint prosthesis and simultaneous autologous fat grafts to the articulating area of the TMJ joints. A statistically significant improvement for fat grafted patients was found regarding MIO and the patient’s perception of the jaw function. The most common complication found in the donor area was seroma or hematoma, which was usually easily treated with aspiration and pressure dressing. TMJ reconstruction with TMJ Concepts total joint prostheses and autogenous fat grafts provides a highly predictable treatment method for patients with nonsalvageable TMJ pathology.

References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   2. Blair VP. Operative treatment of ankylosis of the mandible. Trans South Surg Assoc 1913;28:435.   3. Murphy JB. Arthroplasty for intra-articular bony and fibrous ankylosis of the temporomandibular articulation. J Am Med Assoc 1914;62:1783.   4. Thomas BJ. Heterotopic bone formation after total hip arthroplasty. Orth Clin North Am 1992;23(2):347–358.   5. Fingeroth RJ, Ahmed AQ. Single dose 6 Gy prophylaxis for heterotopic ossification after total hip arthroplasty. Clin Orthop Relat Res 1995;(317):131–140.   6. DeFlitch CJ, Stryker JA. Postoperative hip irradiation in prevention of heterotopic ossification: Causes of treatment failure. Radiology 1993;188(1):265–270.   7. Maloney WJ, Jasty M, Willett C, Mulroy RD, Jr., Harris WH. Prophylaxis for heterotopic bone formation after total hip arthroplasty using low-dose radiation in high-risk patients. Clin Orthop Relat Res 1992;(280):230–234.   8. Wolford LM, Cottrell DA, Henry CH. Temporomandibular joint reconstruction of the complex patient with the techmedica custom-made total joint prosthesis. J Oral Maxillofac Surg 1994;52(1):2–10.   9. Wolford LM, Henry CH, Nikaein A, Newman JT, Namey TC. The temporomandibular joint alloplastic implant problem. In: Sessle BJ, Bryant PS, Dionne RA (Eds), Temporo­ mandibular Disorders and Related Pain Conditions, IASP Press, Seattle, WA 1995, pp. 443–447.

382 10. Henry CH, Wolford LM. Treatment outcomes for TMJ reconstruction after Proplast-Teflon implant failure. J Oral Maxillofac Surg 1993;51(4):352–358. 11. Wolford LM. Temporomandibular joint devices: Treatment factors and outcomes. Oral Surg Oral Med Oral Path Oral Radiol Endol 1997;83(1):143–149. 12. Mercuri LG, Wolford LM, Sanders B, White RD, Hurder A, Henderson W. Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report. J Oral Maxillofac Surg 1995;53(2):106–115. 13. Mercuri LG, Wolford LM, Sanders B, White RD, GiobbieHurder A. Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 2002;60(12):1440–1448. 14. Wolford LM. Concomitant temporomandibular joint and orthognathic surgery. J Oral Maxillofac Surg 2003;61: 1198–1204. 15. Wolford LM, Pinto LP, Cardenas LE, Molina OR. Outcomes of treatment with custom-made temporomandibular joint total joint prostheses and maxillomandibular counter-clockwise rotation. Baylor Univ Med Cent Proc 2008;21:18–24. 16. Wolford LM. Clinical indications for simultaneous TMJ and orthognathic surgery. Cranio 2007;25(4):273–282. 17. Wolford LM, Pitta MC, Reiche-Fischel O, Franco PF. TMJ Concepts/Techmedica custom made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg 2003;32(3):268–274. 18. Wolford LM, Mehra P. Custom-made total joint prostheses for temporomandibular joint reconstruction. Baylor Univ Med Cent Proc 2000;13:135–138. 19. Durr ED, Turlington EG, Foote RL. Radiation treatment of heterotopic bone formation in the temporomandibular joint articulation. Int J Radiat Oncol Biol Phys 1993;27(4): 863–869. 20. Wolford LM, Karras SC. Autologous fat transplantation around temporomandibular joint total joint prostheses: Preliminary treatment outcomes. J Oral Maxillofac Surg 1997;55(3):245–251. 21. Wolford LM, Morales-Ryan CA, Garcia-Morales P, Cassano DS. Autologous fat grafts placed around temporomandibular joint (TMJ) total joint prostheses to prevent heterotopic bone. Baylor Univ Med Center Proc 2008;21:248–254. 22. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of 2 temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg 2003;61(6):685–690. 23. Wolford LM. Further comparison of temporomandibular joint prosthesis systems. J Oral Maxillofac Surg 2004;62: 264–269. 24. Wolford L. Factors to consider in joint prosthesis systems. Baylor Univ Med Cent Proc 2006;19:232–238.

L. M. Wolford and D. S. Cassano 25. Rattan V. A simple technique for use of buccal pad of fat in temporomandibular joint reconstruction. J Oral Maxillofac Surg 2006;64(9):1447–1451. 26. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33(8):755–760. 27. Dimitroulis G, Trost N, Morrison W. The radiological fate of dermis-fat grafts in the human temporomandibular joint using magnetic resonance imaging. Int J Oral Maxillofac Surg 2008;37(3):249–254. 28. MacIntosh RB. Costochondral and dermal grafts in temporomandibular joint reconstruction. Oral Maxillofac Clin North Am 1989;1:363. 29. Hall BK. Cartilage. Biomedical Aspects. New York, Academic Press 1988, pp. 322–323. 30. Francis MD, Russell RCG, Fleisch H. Diphosphonates inhibit formation of calcium phosphate crystals in vitro and pathologic calcification in vivo. Science 1969;165(899): 1264–1266. 31. Ritter MA, Gioe TJ. The effect of indomethacin on paraarticular ectopic ossification following total hip arthroplasty. Clin Orthop 1982;(167):113–117. 32. Kohn D, Rudert M, Wirth CJ, Plitz W, Reiss G, Maschek H. Medial meniscus replacement by a fat pad autograft. An experimental study in sheep. Int Orthop 1997;21(4): 232–238. 33. Merikanto JE, Alhopuro S, Ritsila VA. Free fat transplant prevents osseous reunion of skull defects. A new approach in the treatment of craniosynostosis. Scan J Plast Reconstr Surg 1987;21(2):183–188. 34. Saunders MC, Keller JT, Dunsker SB, Mayfield FH. Survival of autogenous fat grafts in humans and in mice. Connect Tissue Res 1981;8(2):85–91. 35. Yamaguchi M, Matsumoto F, Bujo H, Skibasaki M, Takahashi K, Yashimoto S, Kchinose M, Saito Y. Revascularization determines volume retention and gene expression by fat grafts in mice. Exp Biol Med 2005;230(10): 742–748. 36. Trevor PB, Martin RA, Saunders GK, Trotter EJ. Healing characteristics of free and pedicle fat grafts after dorsal laminectomy and duratomy in dogs. Vet Surg 1991;20(5): 282–290. 37. Qi Z, Li E, Wang H. Experimental study on free grafting of fat particles. Zhonghua Zheng Xing Shal Shang Wai Ke Za Zhi 1997;13(1):54–56. 38. Carpaneda CA, Ribeiro MT. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17(1):43–47. 39. Horl HW, Feller AM, Biemer E. Technique for liposuction fat reimplantation and long-term volume evaluation by magnetic resonance imaging. Ann Plast Surg 1991;26(3): 248–258.

Autologous Fat Grafts for Skull Base Repair After Craniotomies1

49

Jose E. Barrera, Sam P. Most, and Griffith R. Harsh IV

49.1  Introduction

49.2  Characteristics of Fat Tissue

Fat grafts are free, nonvascularized pieces of fat tissue transferred into a defect in the body. Autologous fat grafting is a valuable technique in reconstructing the base of the skull. It is used to fill relatively small, welldefined cavities formed by the loss of the bulk of soft tissue. Goals include restoring a more cosmetic contour, protecting superficial tissues from irregular projections of the underlying bone, providing a contrast with recurrent tumor on imaging studies, and preventing leakage of cerebrospinal fluid (CSF). Examples range from the small grafts used to fill the porus acousticus (i.e. following removal of its posterior wall in retrosigmoid resection of an acoustic neuroma, or filling the sella face after a transphenoidal removal of a pituitary adenoma) to the large grafts used to fill the temporal bone defect of a combined subtemporaltranslabrynthine removal of a petrous meningioma or the clival defect following resection of a chordoma.

Fat is a well-vascularized tissue with high metabolic activity. Fat has both structural and metabolic functions: it provides a support framework protecting the body and is a reservoir for the storage of energy. Since the number of fat cells varies little after adolescent growth, change in the volume of fat reflects change in the mean fat cell volume. The lipid content of fat cells can also change. Cells removed by liposuction or other surgical procedures are not replaced by new fat cells. Reduction in total body fat causes shrinkage of  adipocytes. Subsequent increase in body fat may prompt re-expansion of shrunken adipocytes and redifferentiation of fat cells with subsequent increase of volume (1, 2). Fat cells, which have thin cell membranes, are connected to other fat cells by a fibrous network. Without intercellular supporting fibers, fat cells tend to collapse. Connective tissue demarcates interconnected clusters of fat cells into lobules of fat. When harvesting fat for transplantation, this connective tissue should be preserved; it will maintain the integrity of the transplant and its utility as a tissue replacement at the recipient site (2). Histological analysis of fat grafts has identified two critical pathophysiologic features of fat transplantation: blood supply and cell population. All grafts undergo imbibition, inosculation, and neovascularization. First, transplanted fat cells imbibe nutrients from the recipient bed. Next, capillary buds sprout into the fat graft (inosculation). Finally, over a period of days to weeks, angiogenesis, the ingrowth of new blood vessels from surrounding tissue, revascularizes the graft.

1 The authors have no financial interest in any commercial product mentioned in this paper and have received no financial support for this study.

J. 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 e-mail: [email protected]

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Peer’s “host cell replacement theory” (3) postulates that histiocytes, which phagocytize fat freed as transplanted adipocytes, disintegrate and they thus become adipocytes. More credibly, Gampper’s “cell survival theory” argues that transplanted adipocytes survive, as neovascularization restores circulation to the grafted fat tissue. In a manner similar to the response generated by a skin graft, host cells, such as polymorphonuclear leukocytes (PMNs), plasma cells, lymphocytes, and eosinophils, infiltrate the graft in the first 4 days after implantation. By the fourth day, neovascularization is evident. Histiocytes act only to remove fat from cells that either are disrupted by transplantation or die before circulation is restored (2). Biopsies of fat grafts show zones of cytosteatonecrosis, lipophagic granulomas, lymphocytes, adipocytes, giant multinucleated cells, and new vessels 3 months after transplantation (4). Between 6–8 months, grafts are infiltrated heavily by PMNs in a fibrotic matrix, and in 1 year a substantial connective tissue and fibrotic reaction is present. Some fat is still identifiable but the inflammatory reaction is predominant and is thus postulated to make the dominant contribution to filling in the tissue defect.

Fig. 49.1  Fat graft harvest sites

J. E. Barrera et al.

The amount of fat surviving and the duration of that survival are important determinants of the success of fat grafting. Although MRI is able to distinguish fat from most other tissues, few clinical imaging studies have been performed.

49.3  Technique Three aspects of the procedure warrant mention: (a) harvesting the graft, (b) transferring the graft, and (c) placing the graft. Fat harvest can be performed during any interval of the procedure in which it will not disturb any microsurgery being performed. Almost any site can be a donor; the abdomen and lateral iliac region are easily accessible and therefore preferred. Fat is most commonly harvested from the anterior abdominal wall. An incision below the umbilicus or in the left lower quadrant is relatively covert and will not be misidentified as an appendectomy scar. An incision two fingerbreadths beneath the anterior superior iliac crest is a good alternative, particularly in thin women (Fig. 49.1) (5).

49  Autologous Fat Grafts for Skull Base Repair After Craniotomies

Careful harvest, gentle cleansing, atraumatic handling, and avoidance of dessication of the graft are essential to preserving its structural integrity and viability. A dry, blood-stained, fragmented piece of fat can fill a defect initially, but it will rapidly degenerate and be absorbed. Subcutaneous dissection should be circumferential about the targeted graft. Scissors are preferred to electrocautery to avoid heat and dessication damage to the graft. Since blood hastens degradation, the graft should be gently rinsed with isosmotic fluid. The graft is placed in a receptacle filled with bacitracin saline solution (Fig. 49.2) (5).

The fat graft is placed directly into the craniotomy defect. Strips of fat are layered successively into the defect. Using a retractor to facilitate infilling, strips of fat are stacked on top of each other until the craniotomy defect is obliterated. The strips are wedged tightly side to side, both to fill all the dead space and to prevent development of a CSF fistula. Excessive external to internal pressure is avoided lest it drive the fat intracranially to occlude the subarachnoid space, stretch cranial nerves or compress the brainstem (Figs. 49.3 and 49.4) (5). In prevention or repair of a CSF fistula at the skull base, a structure with greater firmness may be needed.

Fig. 49.2  Fat graft preparation

a

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b

Fig. 49.3  Fat graft placement into craniotomy defect. (a) Surgical mastoid view. (b) Axial view

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a

b

Fig. 49.4  Using a retractor to facilitate infilling, strips of fat are stacked on top of each other until the craniotomy defect is obliterated. (a) Surgical mastoid view. (b) Axial view

Supple fat can be supplemented with firmer mucosa, fascia, perichondrium, cartilage or bone. Autologous material may be harvested from the same or a different surgical field. One study employing fascia lata, middle turbinate mucosa, nasal perichondrium and fat for ethmoidal defects and fascia lata, nasal cartilage and abdominal fat for sphenoid defects reported an 87.5% (14 of 16) success rate using these techniques (6).

J. E. Barrera et al.

49.4 Advantages, Disadvantages, and Complications Advantages of fat grafts include the ease of both harvest and implantation and low donor site morbidity. Disadvantages of fat grafting include a volume loss of up to 50% over a period of time. Such atrophy can open a successfully occluded fistula. Large pieces of devascularized fat undergo partial or complete necrosis before revascularization can occur, particularly in the hypovascular recipient surgical bed often found after radiation or surgery. This limits the size of defect which can be filled by a fat graft. For this reason, vascularized grafts, either local pedicled (e.g., septal mucosal grafts based on the posterior nasal artery, frontal pericranial flaps or lateral temporalis muscle and fascia rotation flaps) or microvascular free tissue transfer (e.g., radial forearm or rectus abdominis transplantations), are preferred for larger defects in the dependent areas (7). Complications other than recurrent CSF fistula associated with fat grafting include bleeding, infection, and wound dehiscence at either donor or recipient sites. Poor antibiotic penetration into and healing about an infected avascular fat graft often requires wound exploration and debridement, including removal and replacement of the graft. Otherwise, persistent wound infection can seed meningitis. Fortunately, lipoid meningitis, a noninfectious inflammatory reaction to lipid particles dispersed into the subarachnoid space from a degenerating graft, and its consequence, communicating hydrocephalus, are rare. The patient returns with a severe headache and/or CSF leakage. Computed tomography demonstrates communicating hydrocephalus and fat droplets widely dispersed throughout the ventricles and subarachnoid space (8).

49.5  Conclusions Fat grafting is a highly useful technique for the repair of small surgical defects of the skull base. Careful surgical technique is important to implanting a viable graft. Fat can be supplemented with other autologous tissues, preferably vascularized, to close large defects at significant risk for CSF fistula formation.

49  Autologous Fat Grafts for Skull Base Repair After Craniotomies

References 1. Imola MJ, Schramm V. Skull base reconstruction. Emedicine. com 2008. 2. Gampper, TJ. Fat grafting. Emedicine.com 2008. 3. Peer LA. Transplantation of Tissue. Baltimore, Lippincott Williams & Wilkins, 1959. 4. Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg 1993;17(2):113–115.

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5. Jackler RK. Atlas of Skull Base Surgery and Neurotology. New York, Thieme Medical Publishers, 2009. 6. Gendeh BS, Mazita A, Selladurai BM, Jegan T, Jeevanen J, Misiran K. Endonasal endoscopic repair of anterior skullbase fistulas: The Kuala Lumpur experience. J Laryngol Otol 2005;119(11):866–874. 7. Schuller DE, Goodman JA, Miller CA. Reconstruction of the skull base. Laryngoscope 1984;94(10):1359–1364. 8. Hwang PH, Jackler RK. Lipoid meningitis due to aseptic necrosis of free fat graft placed during neurotologic surgery. Laryngoscope 1996;106(12 Pt 1):1482–1486.

Part Fat Processing and Survival

V

Fat Processing Techniques in Autologous Fat Transfer

50

Nancy Kim and John G. Rose Jr.

50.1  Introduction Autologous fat transfer was first described over 100 years ago, by Neuber (1), who utilized excised fat to fill scar depressions. By the early 1900s, there were reports of successful subcutaneous fat grafting for soft tissue augmentation in the face (2, 3). It was not until the 1980s, however, that layered micro grafts became practical for use as a soft tissue filler, enabled largely by advances in liposuction techniques, which made harvesting much more feasible (4–6). Fournier (7–12) and later Coleman (13–15), developed the basic techniques of manual aspiration and microlipoinjection, which is still in practice today. Commercially-available fillers, including modified hyaluronic acid compounds, have become popular for cosmetic modification of rhytids, correction of agerelated volume loss, scar modification, and treatment of facial hemi atrophy (16–22). As they are non-autologous, they are subject to low but significant complication rates due to allergy, extrusion, infectious disease transmission, and foreign body reaction. A majority of these materials is also relatively costly and have a short life within the body, which is to say that they last only for a few months. Autologous fat, on the other hand, is readily available, relatively inexpensive, easy to harvest, and autogenic, without the associated risks of allogenic fillers and implants. Fat, because it involves the transfer of living adipocytes, is also theoretically much more long-lasting and potentially a permanent filler

N. Kim () Oculoplastics Service, Department of Ophthalmology, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, F3-332, Madison, WI 53703, USA e-mail: [email protected]

depending on a number of factors related to harvesting and processing of the tissue, reinjection techniques, and vascularity of the recipient bed. The major disadvantage of fat transfer is the high variability in resorption of the grafts in both the short and long term (6–12). An estimate of resorption rates by volume as high as 70% have been reported in some series (7, 12–14). Anticipation of volume loss necessitates initial overcorrection, and loss of transferred adipocytes requires reinjection. A great deal of the scientific literature regarding autologous fat transfer has focused, therefore, on optimizing graft viability at each step of the process: choosing candidates for surgery, choice of potential donor site, recipient site preparation, fat harvesting, fat processing, and methods and sites of reinjection. With regard to donor site selection, several reports assessed fat cells harvested from multiple donor sites and compared their viability. For example, Rohrich et al. (23) compared harvests from the abdomen, flank, thigh, and medial knee. All produced a statistically equivalent number of viable cells. Similarly, von Heimburg et al. (24) compared preadipocytes removed from the abdomen, breast, and buttocks. They showed comparable viability of fat cells taken from all these regions using both excisional and liposuction techniques. From these data, it seems likely that donor site choice plays a minimal role in graft survival. Choosing a site, therefore, should be based on ease and safety of access and patient preference. Similar to donor site considerations, manipulations of specific harvest methods have been shown to have minimal impact on the ultimate survival and longevity of transferred fat. Although there were some questions raised early in the development of the tumescent technique by Klein, (25–27) on the possible detrimental metabolic and inflammatory effects of using

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epinephrine-containing, regional local anesthesia on living fat cells, these effects were found to be reversible and persistent only in the direct presence of lidocaine (28). Early fat transfer procedures relied on direct excisional harvest of fat lobules rather than liposuction. When fat transfer is performed in this manner, the size of fat lobules may correlate with survival during the early postoperative period, with larger particles more prone to central necrosis (29, 30) because of the ischemia that occurs before vascularization can extend from the recipient bed to the core of the graft. Surface adipocytes obtain sufficient nutrition via osmosis from the surrounding recipient bed and interstitium, while vascular ingrowth from the bed into the graft occurs. These effects are only important in cases in which segmental excisional fat harvest is utilized, instead of the much more common, current technique of liposuction. Studies investigating excisional harvesting vs. liposuction found no differential effect on adipocyte viability at moderate levels of aspiration. Utilizing an assay of glycerol-2-phosphate dehydrogenase (G3PDH) as a marker for fat cell injury, Lalikos et  al. (31) demonstrated no significant difference in the degree of damage to adipocytes harvested using manual liposuction vs. lobular excision. Comparisons of liposuction conducted using mechanical suction vs. handheld syringe aspiration similarly have shown no difference in injury to fat cells during harvesting, so long as the maximum vacuum utilized is comparable. Histologic studies of human fat transfer (29) have shown that distension and deformation of adipocyte cell membrane occurs approximately at the relative vacuum levels greater than −0.5 atm while higher levels, which are producible with mechanical suction, cause rupture of the membrane and vaporization of fat cells. Syringe extraction normally produces levels less than −0.6 atm. Coleman (13–15) and Fournier (7–12) showed that relatively high level, wall suction based aspiration vs. manual aspiration decreased viable concentrations as well.

50.2  Fat Processing Techniques With regard to uptake and survival of transferred fat, it is clear that there is little data to suggest that the choice of the donor site or specific means of graft harvest makes a significant difference in optimizing engraftment. The

N. Kim and J. G. Rose

way in which fat is processed following harvest and prior to injection, however, has been found to reliably affect the proportion of viable adipocytes available for injection. The unprocessed samples contain three major components – intact fat cells, liquefied fat, and serosanguinous fluid – which must be separated to maximize the density of cells in the final transplant. Separation to remove the fractions which are inert and subject to early reabsorption (13, 32, 33) not only gives the surgeon a better estimate of the actual volume of viable fat being transferred, but also eliminates debris and free lipid which may invoke an inflammatory reaction in the region of the graft which may reduce long term uptake. The amount of fat engrafted is thus optimized to decrease the likelihood that further injections will be necessary at a later date to achieve the desired degree of augmentation: It is the number of viable fat cells at the time of transfer which is the critical determinant of long term graft volume. Common methods of separation currently in use involve centrifugation (13–15, 32, 34–37) at various rates and durations, or spontaneous sedimentation. The advantage of centrifuging is that fat cells can be prepared quickly and immediately after harvest, for use at target sites, while sedimentation primarily relies on gravity to separate the fractions and can take up to 30–60 min. Processing by sedimentation is thus more practical if adjunct procedures are performed in the same session; the fat can sediment while those procedures are performed. Performing further decantation of sedimented tissue to facilitate separation of adipocytes from liquefied fat and serosanguinous fluid can accelerate this process but can be somewhat labor intensive depending upon the amount of fat to be processed. Early studies comparing the concentration of viable fat cells present in centrifuged vs. sedimented samples demonstrated similar numbers of intact adipocytes. Brandow and Newman (38) showed that centrifugation of harvested fat did not reduce the microscopic structural integrity of adipocytes as compared to control samples. Boschert et al. (39) confirmed a reliably high concentration of fat cells following centrifugation and demonstrated that the highest concentration of intact adipocytes can reliably be found in the bottom-most layer of centrifuged specimens (a 250% increase relative to control samples). These authors also showed that free lipid and damaged adipocytes, due to lower relative density, were effectively sequestered in the more superficial layers. In this study, however, the rate

50  Fat Processing Techniques in Autologous Fat Transfer

at which the specimens were spun was significantly lower than the rates commonly reported by other investigators for processing of autologous fat grafts and may have thus underestimated the degree to which cells might be damaged by centrifuging. In an animal study of fat implantation into the nude mouse, Ramon et al. (40) showed a trend suggesting improved graft retention 4 months following surgery for animals receiving fat samples which had been decanted on a sterile towel compared to those receiving samples centrifuged at 1,500 revolutions per minute (rpm) for 5 min. A third method of separating blood, free lipid, and necrotic debris from viable fat cells involves washing of the sample following centrifugation (41) (Fig. 50.1) or sedimentation (26, 29, 32, 33, 35) or in lieu of either of these processing methods (42). Some practitioners reported good results using sterile water for washing, without significant lysis despite exposure to a hypotonic environment (42) while others recommended use

Fig. 50.1  The left syringe contains liposuction aspirate prior to processing, with adipocytes in a suspension of serosanguinous fluid and lipid. The right syringe, after centrifugation, is separated into a serosanguinous layer at the bottom of the syringe (lower arrow), with adipocytes above and a thin layer of lipid at the top (upper arrow)

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of 5% glucose solution (12) or normal saline (29, 30) Others, such as Baran et  al. (43) found that washing lobular fat specimens in normal saline decreased graft survival relative to unwashed samples. Chajchir et al. (41) have suggested that washing removes fibrin from the fat sample, which may be important in stabilizing adipocytes within the wound bed. In a recent review by Sommer and Sattler (44), the number of viable adipocytes or longevity of grafts were not clearly correlated with particular fat processing methods, including centrifugation at variable levels of force and duration, washing or sedimentation. The cell density and outcome analyses among the studies included in this review varied in terms of histologic technique (with several omitting histology entirely) and length of clinical follow-up periods. For this reason, direct comparison between the included studies was not possible, precluding any conclusions regarding the advantages or disadvantages of the processing methods used. To directly address the potential effects of all three separation techniques on adipocyte survival in both a quantitative and qualitative manner, Rose et  al. (45) performed a histologic evaluation of intact cells in liposuction samples processed, utilizing centrifugation with washing, centrifugation without washing, and sedimentation. Low volume, periumbilical fat samples were taken from 22 healthy patients using a handheld syringe and Coleman liposuction cannula under tumescent anesthesia. Samples were then processed by one of the three techniques: centrifugation at 3,000 rpm for 3 min, comparable to rates/durations commonly reported in the fat transfer literature, sedimentation without decantation, or a combination of centrifugation at the above rate/duration with subsequent washing with normal saline. Specimens for histologic analyses were drawn from processed fat left over after implantation was complete, preserved in formalin and were sent for standardized paraffin processing and staining. Isolated lobules were then analyzed to determine the number of intact adipocytes present per high power field; the number of nucleated, intact adipocytes per high power field; and nucleated adipocyte cross-sectional area. The assumption in this study and its predecessors was that the intact cells represent viable cells. A count of nucleated, intact cells was included as a corollary measure based on the same assumption. Qualitative descriptions of adipocyte morphology were also obtained. The results of this study showed significant differences between sedimentation and centrifugation.

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was found for counts of both intact and intact nucleated fat cells. These higher cell counts were likewise reflected in measures of adipocyte morphology including mean cross-sectional area which was significantly larger in the sedimented specimens. Based on the assumption that there is a positive correlation between the number of viable adipocytes and increased graft survival, this study provides strong evidence that sedimentation yields the greatest potential for optimizing retained graft volume and survival (Figs. 50.2 and 50.3).

50.3  Future Issues for Fat Processing

Fig. 50.2  400× photomicrograph of PAS-stained adipocytes after processing by sedimentation, demonstrating relatively intact, nucleated adipocytes with minor trauma and overall normal morphology

Fig. 50.3  400× photomicrograph of PAS-stained adipocytes after processing by centrifugation and washing, demonstrating a reduced number of intact, nucleated adipocytes with more extensive trauma and reduced cell size

Sedimentation yielded almost double the mean concentration of intact cells (27.1 cells per high power field) relative to centrifugation with or without washing (14.2 cells per high power field, 11.8 cells per high power field, respectively). This increase in adipocyte survival

Issues that remain to be addressed with regard to fat processing techniques include long-term follow-up of graft survival and the volume augmentation provided by engraftment. There are few studies on the histology of transferred adipocytes in humans. In an investigation of autologous fat transfer to abdominal subcutaneous fat in patients about to undergo abdominoplasty, Carpaneda and Ribeiro (30) found that as little as 40% of the original graft is viable 1 mm from the graft edges at, up to 60 days after placement. Animal models of fat transfer also demonstrate variable rates of resorption and have shown that transplanted cells are histologically indistinguishable from native adipocytes (46). Thus, an important area which remains is the development of in-vivo adipocyte markers which could be used to follow fat cells separated by sedimentation vs. centrifugation or washing to determine whether long term viability after reinjection is affected by a processing method independent of cell concentration. Alternatively, serial, noninvasive measures such as radio imaging to follow three-dimensional volume augmentation of recipient sites might prove to be helpful in determining if particular processing methods produce different outcomes in the long-term. Other issues which remain to be systematically investigated include the possible interaction between the recipient site and the processing method. It may be that the survival of adipocytes delivered to relatively vascular targets where nutritive support is excellent, may do well regardless of the processing method. Cells placed within areas of comparative ischemia, such as areas of atrophy or scarring which are metabolically more demanding environments for cells, may show the effects of prior cell processing and subtle injury.

50  Fat Processing Techniques in Autologous Fat Transfer

In addition to removal of inert fractions of serosanguinous fluid and liquefied lipid from adipocytes, there is preliminary evidence that pretreating graft samples during processing may increase implant retention. Insulin irrigation of samples, for instance, has been shown to increase adipocyte membrane stabilization and enhance fat cell survival by increasing intracellular glycogen and lipid formation (47, 48) but these results have somewhat been controversial. Other potential methods to improve graft take under investigation include the addition of bovine fibroblastic growth factor to the processed fat. In a rodent model, Eppley et al. (49), demonstrated that treated grafts retained their preoperative graft weight at 1 year following implantation, significantly longer than in animals receiving control grafts. Other substances under scrutiny which show early promise in reducing necrosis within grafts include IL-8 (50) via its action in promoting angiogenesis, cellular proliferation, and cytokine and growth factor synthesis (51).

References   1. Neuber GA. Fettransplantation. Vehr Dtsch Ges Chir 1893; 22:66.   2. Lexer E. Frei fettransplantation. Dtsch Med Wochenschr 1910; 36:640.   3. Bruning P. Cited by Broeckaert TJ. Contribution a l’etude des greffes adipeuses. Bull Acad R Med Belgique 1919;28: 440.   4. Illouz YG. De l’utilization de la graisse aspire pour combler les defects cutanes. Rev Chir Esth Langue Franc 1985; 10:13.   5. Illouz YG. The fat cell “graft”. A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123.   6. Fournier PF, Otteni F. Lipodissection in body sculpturing: The dry procedure. Plast Reconstr Surg 1983;72(5):598–609.   7. Fournier PF. Who should do syringe liposculpturing? J Dermatol Surg Oncol 1988;14(10):1055–1056.   8. Fournier PF. Why the syringe and not the suction machine? J Dermatol Surg Oncol 1988;14(10):1062–1107.   9. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin 1990;8(3):523–537. 10. Fournier PF. Reduction syringe liposculpturing. Dermatol Clin 1990;8(3):539–551. 11. Fournier PF. A simplified procedure for locking the plunger during syringe-assisted liposculpturing. Plast Reconstr Surg 1996;98(3):569–570. 12. Fournier P. Fat grafting: My technique. Dermatol Surg 2000; 26:1117. 13. Coleman SR. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19(5): 421–425.

395 14. Coleman S. Facial recontouring with lipostructure. Facial Cosmet Surg 1997;24(2):347–367. 15. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg 2001;28(1):111–119. 16. Olenius M. The first clinical study using a new biodegradable implant for the treatment of lips, wrinkles, and folds. Aesthetic Plast Surg 1998;22(2):97–101. 17. Duranti F, Slati G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid for soft tissue augmentation: A clinical and histological study. Dermatol Surg 1998;24(12): 1317–1325. 18. Broder KW, Cohen SR. An overview of permanent and semipermanent fillers. Plast Reconstr Surg 2006;118(3 Suppl): 7S–14S. 19. Jacovella PF, Peiretti CB, Cunille D, Salzamendi M, Schechtel SA. Long-lasting results with hydroxylapatite (Radiesse) facial filler. Plast Reconstr Surg 2006;118(3 Suppl): 15S–21S. 20. Lemperle G, Gauthier-Hazan N, Lemperle M. PMMAmicrospheres (Artecoll) for long-lasting correction of wrinkles: Refinements and statistical results. Aesthetic Plast Surg 1998;22(5):356–365. 21. Bucky LP, Kanchwala SK. The role of autologous fat and alternative filler in the aging face. Plast Reconstr Surg 2007; 120(6 Suppl):89S–97S. 22. Burgess CM. Treatment of facial asymmetry with poly-­ L-lactic acid: A case study. Aesthetic Plast Surg 2008;32(3): 552–554. 23. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: A quantitative analysis of the role of centrifugations and harvest site. Plast Reconstr Surg 2004; 114(1):391–395. 24. Von Heimburg D, Hemmerich K, Haydarlioglu S, Staiger H, Pallua N. Comparison of viable cell yield from excised versus aspirated adipose tissue. Cells Tissues Organs 2004;178(2): 87–92. 25. Klein JA. The tumescent technique: Anesthesia and modified liposuction technique. Dermatol Clin 1990;8(3): 425–437. 26. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg 1993; 92(6):1085–1098. 27. Klein JA. Anesthetic formulation of tumescent solutions. Dermatol Clin 1999;17(4):751–759. 28. Moore JH, Jr, Kolaczynski JW, Morales LM, Considine RV, Pietrzkowski Z, Noto PF, Caro JF. Viability of fat obtained by syringe suction lipectomy: Effects of local anesthesia with lidocaine. Aesthetic Plast Surg 1995;19(4):335–339. 29. Niechajev I, Sevcuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 30. Carpaneda CA, Ribeiro MT. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 1993;17(1):43–47. 31. Lalikos JF, Li YQ, Roth TP, Doyle JW, Matory WE, Lawrence WT. Biochemical assessment of cellular damage after adipocyte harvest. J Surg Res 1997;70(1):95–100. 32. Amar R. Adipocyte microinfiltration in the face or tissue reconstruction with fat tissue graft. Ann Chir Plast Esthet 1999;44(6):593–608. 33. Fagrell D, Enestrom S, Berggren A, Kniola B. Fat cylinder transplantation: An experimental comparative study of tree

396 different kinds of fat transplants. Plast Reconstr Surg 1996;98(1):90–96. 34. Locke MB, de Chalain TM. Current practice in autologous fat transplantation: Suggested clinical guidelines based on a review of recent literature. Ann Plast Surg 2008;60(1): 98–102. 35. Toledo LS. Syringe liposculpture: A two-year experience. Aesthetic Plast Surg 1991;15(4):321–326. 36. Asken S. Facial liposuction and microlipoinjection. J Dermatol Surg Oncol 1988;14(3):297–305. 37. Fulton JE, Suarez M, Silverton K, Bames T. Small volume fat transfer. Dermatol Surg 1998;24(8):857–865. 38. Brandow K, Newman J. Facial multilayered micro lipoaugmentation. Int J Aesthetic Restor Surg 1996;4:95–110. 39. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis of lipocyte viability after liposuction. Plast Reconstr Surg 2002;109(2):761–765. 40. Ramon Y, Shoshani O, Peled IJ, Gilhar A, Carmi N, Fodor L, Risin Y, Ulmann Y. Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 2005;115(1):197–201. 41. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesthetic Plast Surg 1986;10(2): 115–117. 42. Rubin A, Hoefflin S. Fat purification: Survival of the fittest. Plast Reconstr Surg 2002;109(4):1463–1464. 43. Baran CN, Celebioglu S, Sensoz O, Ulusoy G, Civelek B, Ortak T. The behavior of fat grafts in recipient areas with enhanced vascularity. Plast Reconstr Surg 2002;109(5): 1646–1651.

N. Kim and J. G. Rose 44. Sommer B, Sattler G. Current concepts of fat graft survival: Histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166. 45. Rose JG Jr, Lucarelli MJ, Lemke BN, Dortzbach RK, Boxrud CA, Obagi S, Patel S. Histologic comparison of autologous fat processing methods. Ophthal Plast Reconstr Surg 2006; 22(3):195–200. 46. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P. Long-term survival of free fat grafts in muscle: An experimental study in rats. Aesthetic Plast Surg 1996;20(5):403–408. 47. Asaadi M, Haramis HT. Successful autologous fat injection at 5-year follow-up. Plast Reconstr Surg 1993;91(4):755–756. 48. Yuksel E, Weinfeld AB, Cleek R, Wamsley S, Jensen J, Boutros S, Waugh JM, Shenaq SM, Spira M. Increased free fat graft survival with the long-term, local delivery of insulin, insulin-like growth factor-1, and basic fibroblast growth factor by PLGA/PEG microspheres. Plast Reconstr Surg 2000;105(5):1712–1729. 49. Eppley BL, Sidner RA, Platis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6):1022–1030. 50. Shoshani O, Livne E, Armoni M, Shupak A, Berger J, Ramon Y, Fodor L, Gilhar A, Peled IJ, Ulmann Y. The effect of interleukin-8 on the viability of injected adipose tissue in nude mice. Plast Reconstr Surg 2005;115(3):853–859. 51. Tezono K, Sarker KP, Kikuchi H, Nasu M, Kitajima I, Maruyama I. Bioactivity of the vascular endothelial growth factor trapped in fibrin clots: Production of IL-6 and IL-8 in monocytes by fibrin clots. Haemostasis 2001;31(2):71–79.

Injection Gun Used as a Precision Device for Fat Transfer

51

Joseph Niamtu

51.1  Introduction One of the biggest advances in the field of cosmetic surgery has been the resurgence of lipotransfer (1–8). For years, cosmetic facial surgeons made patients’ faces look tighter but not necessarily younger. This was a result of pulling skin and soft tissue without volume restoration. Volume restoration can include many techniques including fillers, alloplastic implants, lifting techniques, and lipotransfer. This author has used (and still uses) all these techniques in his armamentarium of cosmetic procedures (9, 10). Some patients will request a specific procedure and at other times the surgeon will choose a specific modality based on the specific rejuvenation required. Many specialists, (dermatologists in particular) have led the way to easy and improved methods to transfer fat from a distant site to the head and neck. We have learned a lot about the success and failure of transferred adiposities but there is still a division among practitioners as to whether injected fat will endure after reinjection. In the author’s experience, about two-third of the injected volume is resorbed and reinjection (or reinjections) is required to maintain augmentation. Other colleagues dispute this and claim retention rates with a single injection session. Maybe their technique is superior to mine or their patients have lower expectations but I have been utilizing fat transfer for 6 years and the patients expect dramatic results. There has been no difference in using centrifuging vs. not centrifuging and emulsifying vs. not emulsifying. There are more fillers available to choose from, and the longevity of these fillers have increased dramatically. J. Niamtu 11319 Polo Pl., Midlothian, VA 23113-1434, USA e-mail: [email protected]

There is no doubt that fat is a valuable filler and fulfills many of the criteria of “the perfect filler.” Its use throughout the body (and head and neck in my case) is well documented and there are a plethora of injection instruments available to simplify the harvest and transfer of the autogenous fat. There are some cases in which it is simply “handy” to use fat. The surgeon performs 2–3 facelifts per week, and it is very easy to harvest periumbilical fat and reinject it in the nasolabial folds during this procedure. I rarely reinject these patients, but the primary injection compliments my facelift procedure and the patients always notice the improvement. I also favor fat injection in facial reconstruction cases, where large volume augmentation is required. These cases would be impractical for fillers. There are several things about fat transfer that have to be considered. Requiring multiple injections over an extended period of time to maintain augmentation is a drawback. The main drawback, however, is the need to over correct the augmentation. To augment a patient’s lips, an increased amount of fat has to be injected to compensate for the resorption and patients will not tolerate the several weeks of over correction while waiting for the swelling to resolve. Freezing and storing fat brings too many related hassles such as not wanting to be in the tissue bank business and deal with banking issues of backup power sources for the storage freezer, etc. It is simpler to reharvest at each session.

51.2  Technique The author prefers the periumbilical region due to ease of access and abundance of donor fat. Most of the patients are under intravenous sedation or general anesthesia and sterile conditions are essential.

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398 Fig. 51.1  (a) Tumescent injection of the harvest site. (b) Harvesting cannula. (c) Fat being harvested from the periumbilical approach. (d) Harvested fat

J. Niamtu

a

b

d

c

The abdomen is prepped with Techni-Care (CareTech Labs, St. Louis, MO) with great care and use cotton tipped applicators in the depth of the umbilicus. Several milliliters of 2% lidocaine with 1:100,000 epinephrine is injected circumferentially around the umbilicus. An adequate standard tumescent solution is injected in a radius around the umbilicus commensurate with the anticipated harvest amount. A stab incision is made with a number 11 scalpel blade in the 6 o’clock position on the umbilicus. Fat is harvested by hand with a simple harvest cannula and a 10-mL syringe (Fig. 51.1). Depending upon the volume required, fat is harvested from the 3 o’clock to the 9 o’clock position around the umbilicus. If more fat is needed, a stab incision at the 12 o’clock position is made for superior umbilical access. After the fat is harvested, it is poured on to a dry 4 × 4 gauze and the liquid portions allowed to soak in (Fig. 51.2). The author has used the standard centrifuge

Fig. 51.2  The harvested fat is placed on a 4 × 4 gauze pad to drain as an alternative to centrifuging

51  Injection Gun Used as a Precision Device for Fat Transfer

method but found no negative effects when the technique was abandoned. The syringe barrel with the plunger removed is used to scrape the fat back into the syringe. A female to female Leur-loc adapter that is connected from the full syringe to an empty syringe is then used to push the fat from one syringe to the other, pushing the syringe plungers hard and fast until the fat becomes creamy and homogenized. This creamy fat is easily injected and as stated earlier this technique seems to persist the same as centrifuged fat. The fat is then drawn up into appropriate syringes for injection. For very large defects or augmentations a 5 or 10-mL syringe may be used although more delicate areas such as the tear trough warrant the use of 1-mL syringes. Multiplanar injection is an absolute necessity for adipocyte survival. The fat is injected into multiple levels from the periosteum to the dermis and especially in the muscular layers when present. For tear trough fat filling, begin deep on the periperiosteal layer and also inject somewhat more superficially with great care to stay deep in the orbicularis oculi layer. For lip injections, inject into the dead center of the lip. The labial artery is generally in the posterior one-third of the lip and with a blunt cannula, damage to the structure is rare. Injection in the periorbital region is done with 1-mL syringes on a small blunt cannula so as not to generate excessive syringe pressure. Since intravascular injection always looms as a potential complication, it is important to inject small volumes with low plunger pressure and to inject upon withdrawal. Various sized cannulas are used to inject fat when treating multiple areas.

Fig. 51.3  Injection apparatus with a loaded syringe. The syringe plunger is removed and the rubber cap is placed on the injection gun trigger

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51.3 Precision Injection with Gun Injection Device Anyone who has experience with fat injection is well aware of the problems associated using needles and cannulas. One of the biggest problems is clogging. In the presence of a clog, the surgeon is often tempted to increase syringe pressure to free the clog and this can lead to a large bolus of fat being inadvertently injected in the wrong place. The main advantage of the gun injection device is the ability to disperse or deposit very small strands of fat precisely (11). Anyone who has used calking gun or cake decorating gun can appreciate how small “clicks” of the gun allow small deposition with finite control. The fat injection gun device takes some getting used to for those surgeons used to free hand syringe techniques but the appreciation is quickly found. The basic technique involves the normal harvest preparation and technique. Once the fat is drawn into the syringes, the syringe plunger is removed and the rubber stopper is pulled off and inserted on the plunger of the injection gun (Fig. 51.3). The syringe is loaded into the gun and the trigger is pulled to engage the syringe. The syringe is then backloaded by using a Leur-Loc female to female connector to push the fat from the harvest syringe into the injection device. By releasing the gun plunger lock, the fat can be expressed from the normal syringe into the fat injection gun. This maneuver makes the loading easier. The loaded injection gun is then ready for

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J. Niamtu

Fig. 51.4  The injection device loaded with fat ready for use

transfer (Fig. 51.4). The appropriate cannula or needle is then attached to the syringe and is purged by pulling the trigger. The apparatus is available with hardware to adapt 10 and 3-mL syringes and the appropriate metal plunger must be used with that specific syringe size. It can be somewhat cumbersome changing injection gun plunger sizes, so all the areas requiring a given syringe size are done at once. If the larger syringes are to be a

used it is easier to do all the same areas requiring that size. The bottom line is to minimize continual changing of the injection gun plunger. The beauty of this device is that each click of the trigger will deposit a controlled bolus of fat and it makes precision filling possible. The author prefers to pull the trigger while withdrawing the cannula. If larger areas are treated the cannula stays in the same place while the trigger is pulled numerous times (Fig. 51.5). d

b e

c

Fig. 51.5  (a) Injection device injecting fat into the perioral region. (b) Injection device injecting fat into the nasolabial folds. (c) Injection device injecting fat into the chin. (d) Injection device injecting fat into the lips. (e) Injection device injecting fat into the cheek

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Disadvantages of the fat gun include the need for additional equipment and the need to change the gun plunger for different syringe sizes.

  2. Niamtu J. Facial liposuction: A fine balance. Plast Surg Prod 2007;17(7):20–24.   3. Obagi S. Autologous fat augmentation: A perfect fit in new and emerging technologies. Facial Plast Surg Clin N Am 2007;15(2):221–228.   4. Niamtu J 3rd. Simple technique for lip and nasolabial fold anesthesia for injectable fillers. Dermatol Surg 2005;31(10): 1330–1332.   5. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg 2007;120(6 Suppl):89S–97S.   6. Donofrio LM. Structural autologous lipoaugmentation: A panfacial technique. Dermatol Surg 2000;26(12):1129–1134.   7. Niamtu J. Clinical technique for fat transfer. Cosmet Facial Surg Oral Maxillofac Surg Clin N Am 2000;12(4):641–647.   8. Niamtu J. Liposculpture and lower facial rejuvenation. Plast Surg Prod 2000:28–32.   9. Niamtu J. Accurate and anatomic midface filler injection by using cheek implants as an injection template. Dermatol Surg 2008;34(1):93–96. 10. Niamtu J. Rejuvenation of the lip and perioral areas. In: Bell WH, Guerrero CA (eds), Distraction Osteogenesis of the Facial Skeleton, BC Decker, Ontario, Canada, 2007. 11. Niamtu J. Fat transfer gun used as a precision injection device for injectable soft tissue fillers. J Oral Maxillofac Surg 2002;60(7):838–839.

51.4  Conclusions Fat injection is a popular option for soft tissue augmentation. Many techniques and devices exist for both harvest and transfer. The fat injection gun is a precise means of accurate deposition of fat in the soft tissues, offers greater control than free hand injection, and is a valuable tool in the armamentarium of the surgeon practicing lipotransfer. This device can also be used with any injectable fillers, especially the more viscous or particulate substances.

References   1. Obagi S. Autologous fat augmentation for addressing facial volume loss. Oral Maxillofac Surg Clin N Am 2005;17(1): 99–109.

Tissue Processing Considerations for Autologous Fat Grafting

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Adam J. Katz and Peter B. Arnold

52.1  Introduction Autologous fat transfer is not a new technique, having been described for aesthetic use in the late 1800s by Neuber (1); even so, the science of fat grafting was not pursued in any meaningful way until the 1980s. The use of autologous fat has many benefits for the correction of contour differences. It is a plentiful, nonimmunogenic, and easily manipulated substance. The purpose of fat transplantation for most indications is correction of a contour defect with predictable and long-term volume maintenance. Issues related to graft viability, predictable and reproducible volume maintenance, and evidence-based methodology have received a great deal of attention in the recent past. Many authors and surgeons have strict protocols for the harvest, treatment, and injection of fat – so many, in fact, that there may be as many techniques as there are surgeons performing them. There is little objective scientific data to support any one technique. As a result, there are many different techniques, each with proponents ready to disparage other approaches. The extent of variability in fat grafting methodology is readily apparent in the literature. In a recent study by Kaufman et al. (2), a 30-question survey relating to autologous fat transfer was submitted to 650 randomly selected plastic surgeons. Although the great majority of respondents concurred on the need for overcorrection, the use of anesthetic agents, and harvest sites, there was almost no consensus as to most

A. J. Katz () Department of Plastic and Maxillofacial Surgery, University of Virginia, P.O. Box 800376, Charlottesville, VA 22908-0376, USA e-mail: [email protected]

other aspects of autologous fat grafting (2). While outside the scope of this chapter, it is important to understand the rationale (if any) for various techniques in order to grasp the state of the art and, ultimately, devise a reliable method of autologous fat transfer based on objective scientific data. Several studies have attempted to show how manipulating harvested fat in particular ways may increase graft viability (3–7). These include concentration of fat cells using an “open” method, by placing the aspirate onto a cotton towel (5) and varying the speed of centrifugation (3), as well as methods that combine washing and centrifugation (7). Each of these studies has merit – and some extensive data – yet there is no clear evidence that unequivocally delineates which techniques are necessary and/or beneficial for assuring or enhancing graft survival. There are an equal number of “how we do it” reports by individuals or groups, with each asserting the benefits of a particular technique for manipulating harvested tissue (8–11). Part of the difficulty in deriving evidence-based conclusions from these multiple studies, however, relates to a lack of clear, objective, and reproducible outcome parameters and analytical techniques in the field. At present, there is no technique available that enables the accurate in vivo quantification of the number of grafted cells that survive transplantation. The reader is directed to the excellent review of fatgraft survival from Sommer and Sattler (12) for further information as to how each variable of autologous fat transfer – from harvest to longevity analysis – is addressed in the literature. The authors conclude that long-term survival and volume maintenance of fatgrafts is determined by the amount of fibrosis induced, in addition to the number of viable fat cells transferred. Additionally, they propose that the survival of the transferred fat cells depends more on the anatomic site into which they are transferred – and the mobility and

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vascularity of the transfer site – than on harvesting techniques, tissue processing, and reinjection methods (12). This is an interesting and worthwhile concept. Appropriate recipient site/bed preparation is known to be critical to the success of skin grafting; yet little or no research has addressed this corollary for fat grafting. In short, there remains a need for standardized methodology related to adipose tissue harvest, refinement, preparation, and delivery. While the significance of particular autologous fat transfer variables are debatable, there is little argument that the ultimate fundamental objective of the procedure is to preserve the integrity of the cellular components of the graft before, during, and after transplantation, and to facilitate graft revascularization as quickly and effectively as possible. Ideal specifications for a standardized device/­ system for autologous fat grafting would include

A. J. Katz and P. B. Arnold

(13–15). Each has its advantages, but none optimizes and standardizes the entire process. The particulars of fat grafting will eventually be worked out, as most agree that autologous fat is the ideal filler for contour deformity. The eventual development and consensus endorsement of an effective, user-friendly device/system for tissue processing will a

• • • • •

Closed, sterile system Simple to use in the operating-room setting Quick and efficient tissue handling and transfer Ability to process a wide range of tissue volumes Effectively remove free oil and fatty acids, which can damage cell membranes • Remove water-phase components such as blood components and tumescent solution • Concentrate tissue fragments without destroying cellular components • Adaptable and permissive to a range of “graft enhance­ment” strategies, such as the ability to introduce growth factors While a single device does not yet exist (as far as we are aware), various attempts have been made to streamline the harvesting and processing procedures in autologous fat grafting (Fig. 52.1). The LipiVage™ system from Genesis Biosystems is a disposable filtration system that concentrates fat after harvesting without the need for centrifugation or decanting. Fat is harvested at low suction levels and the oils and fluids are separated. The fat is washed by the passing of tumescent solution through one of the chambers, and the option of rinsing the harvested fat with growth factors, insulin, etc., is available. Following harvest and rinsing, the fat is ready to be injected into the target tissue. Other devices and/or techniques have been described to simplify the harvesting, processing, and/or injection of liposuctioned fat, including the “no touch” tourniquet technique of harvesting (9), the “bag within a bag” device for refinement of liposuctioned fat (10), and the “Coleman Technique”

b

Fig. 52.1  Shows a prototype device of a filter ‘bag’ within an outer non-porous container, with an inlet port and an outlet port. The inner filter bag traps the adipose tissue fragments while letting the liquid phase effluent drain through the dependent port. Figure (a) shows the entrapment and refinement of adipose tissue (the inlet port is clamped at the top); figure (b) shows the device empty, but hooked in-line with an aspiration system

52  Tissue Processing Considerations for Autologous Fat Grafting

be a basic and important first step toward the standardization of autologous fat grafting. Such a device/system will ultimately provide the necessary foundation for efforts to transform the art of fat transfer into the science of tissue transplantation.

References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   2. Kaufman MR, Bradley JP, Dickinson B, Heller JB, Wasson K, O’Hara C, Huang C, Gabbay J, Ghadjar K, Miller TA. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results. Plast Reconstr Surg 2007;119(1):323–331.   3. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, Yoshimura K. Influences of centrifugation on cells and tissues in liposuction aspirates: optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg 2008; 121(3):1033–1041;discussion 1042–1043.   4. Piasecki JH, Gutowski KA, Lahvis GP, Moreno KI. An experimental model for improving fat graft viability and purity. Plast Reconstr Surg 2007;119(5):1571–1583.   5. Ramon Y, Shoshani O, Peled IJ, Gilhar A, Cami N, Fodor L, Risin Y, Ulmann Y. Enhancing the take of injected adipose

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tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 2005;115(1):197–201;discussion 202–203.   6. Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of harvest and transfer methods on adipocyte viability and review of the literature. Dermatol Surg 2001;27(9):819–826.   7. Smith P, Adams WP, Jr, Lipschitz AH, Chau B, Sorokin E, Rohrich RJ, Brown SA. Autologous human fat grafting: effect of harvesting and preparation techniques on adipocyte graft survival. Plast Reconstr Surg 2006;117(6): 1836–1844.   8. Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast Reconstr Surg 2007;120(1): 295–302.   9. Karacalar A, Orak I, Kaplan S, Yildirim S. No-touch technique for autologous fat harvesting. Aesthetic Plast Surg 2004;28(3):158–164. 10. Katz AJ, Hedrick MH, Llull R, Futrell JW. A novel device for the simple and efficient refinement of liposuctioned tissue. Plast Reconstr Surg 2001;107(2):595–597. 11. Kuran I, Tumerdem B. A new simple method used to prepare fat for injection. Aesthetic Plast Surg 2005;29(1):18–22; discussion 23. 12. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166. 13. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367. 14. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119. 15. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 2006;118(3 Suppl):108S–120S.

Fat Grafting Review and Fate of the Subperiostal Fat Graft

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Defne Önel, Ufuk Emekli, M. Orhan Çizmeci, Funda Aköz, and Bilge Bilgiç

53.1  Introduction Many materials have been used for soft tissue augmentation and contouring. In the earliest years of the nineteenth century, hydrocarbons, especially paraffin was widely used to correct contour defects like facial deformities (1, 2). However wide use of paraffin brought many complications and a search for new substances began. Rubber and purified latex became popular as injectable fillers in the 1920s (2). Nowadays, solid autologous tissues like cartilage and bone grafts or Alloplastic materials like tantalum mesh are used for skeletal recontouring (3–5). For soft tissue augmentation, fat, fascia or dermal grafts, and free vascularized flaps are the alternatives (4, 6). Several investigators have reported that the weight and volume of the free fat graft reduces by 40–50% (7). These unsatisfactory results led the surgeons to perform various experimental studies to find the reason and a solution to this problem. There are several questions to be answered: (a) Which harvesting technique gives least trauma to the fat cells? (b) Does local anesthesia have a negative effect on the fat cell survival? (c) What is the ideal fat transplantation technique? (d) What can be done to minimize trauma, air exposure, and contamination while applying the cleaning process? (e) What is the relationship between longevity of augmentation and fat cell survival? (1). Fat grafting in traumatized facial tissues using lipoinjection can cause bulging and depressed areas

D. Önel () Plastic and Reconstructive Surgery Department, Medical Park Hospital, Fevzi Pasa cad. Sarachane Parkı Yani Fatih, Istanbul, Turkey e-mail: [email protected]

because all the fat tissue is not vascularized and the necrotic sites heal with fibrosis. As the scarred skin overlying the bone is thin, the irregularities after the fat injection can cause unpleasant results. Placing the fat grafts under the periosteum can be a solution to this problem. In the experimental study we compare subperiosteal fat grafting with supraperiosteal fat grafting.

53.2  Materials and Methods Forty-eight Sprague-Dawley male rats weighing 200– 378 g were used. The animals were anesthetized with intraperitoneal ketamine (100 mg/kg) and xylazine (10 mg/kg). Each rat was caged separately and fed ad libitum. Cephalothin (30 mg/kg) was given intramuscularly 30 min before fat excision and the weight of each rat was noted. Fat tissue was excised surgically from the shaved right inguinal region. The excised fat was washed with saline and kept in saline solution till the transplantation. The en bloc fat tissue was cut down to approximately 1 mg piece (Fig. 53.1). The weight of each graft was recorded. In the experimental group an incision of approximately 1 cm long was made in the scalp between the ears. The skin flap was elevated with the pericranium. The fat graft was placed between the bone and periosteum. The subperiosteal pocket was closed by placing 6/0 Prolene sutures between the periosteum and neck muscles. Afterwards skin 4 closure was performed with 5/0 Prolene. In the control group, the same skin incision was performed. A pocket was performed between the periosteum and the skin. After the fat graft was placed into this pocket, the skin closure was performed with 5/0 Prolene.

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a

b

c

Fig. 53.1  Fat grafts in saline solution ready for transplantation

Both experimental and the control groups contained 24 rats. The fat grafts were removed both from the experimental and the control groups on the 10th, 30th, and 60th days after transplantation, thus forming six subgroups, each containing eight rats (Fig. 53.2). Each graft was weighed and histopathologic examination was performed.

53.3  Results Graft weight change after transplantation: Graft weights for the first 10 days increased in both groups due to the inflammatory reaction. The mean fat

Fig. 53.2  (a) Fat graft harvest under the periosteum. (b) Extracted supraperiosteal fat graft after 1 month. (c) Extracted subperiosteal fat graft after 1 month

graft weight increase rate in the experimental group was 61.6% and the mean body weight increase rate was 4.7%. The results were similar in the control group. The mean fat graft weight increase rate was 58.3%.and the mean body weight increase rate was 4.9% (Table 53.1). In the first month, we observed important amount of weight decrease in both of the groups. The mean fat graft weight decrease rates in the experimental group and in the control group were 49.6% and 52%, respectively (Table 53.2). This

53  Fat Grafting Review and Fate of the Subperiostal Fat Graft

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Table 53.1  Rat body and fat graft weight change on the tenth day of grafting

Table 53.3  Rat body and fat graft weight change in the second month of grafting

Rat

Rat

1 2 3 4 5 6 7 8

Experimental group

Control group

Body weight change rate

Fat graft weight increase rate

Body weight change rate

Fat graft weight increase rate

  3.2   5.8   7.1   3.2   6.6  0 10.8   3.2

150.6 104.1   37   60.3    4.1   43.3   33   34

0 8.3 3.8 7.1 7.1 5 3.4 3.3

   5.1   20.9   13.3   17.9   80.2 177.4   88.4   89.3

1 2 3 4 5 6 7 8

Table 53.2  Rat body and fat graft weight change in the first month of grafting Rat

1 2 3 4 5 6 7 8

Experimental group

Control group

Fat graft Body weight weight change rate decrease rate

Body weight change rate

Fat graft weight decrease rate

4.5 2.2 4.7 6 0 0 2.3 9

  4.3 11.7   4.4   4.1  4 −4.5   4.5   4.3

59.5 38.5 58.9 28.7 53.2 55.4 59 62.8

73.8 53.3 45 41.1 47.4 57.2 31.7 47.4

graft weight change percent

150

Control group Body weight change rate

Fat graft weight decrease rate

  2.2 −2.2   3.7   2.1   9.5  0   1.6 −6.9

  2.2 −2.2  0   4.3 −3.5   6.9   2.1   3.3

70.3 63.8 83.2 70.8 73.4 70.6 73.9 63.3

64.9 70.8 60 75.8 66.2 80.4 65.4 82.9

difference was not significant according to the Student’s t-test in any confidence level (p < 0.40) (Fig. 53.3). By the second month the decrease in the fat graft weight became more dramatic. Both groups lost approximately 70% of their initial weight, although their body weight did not decrease (Table 53.3).

53.4 Histopathologic Examination Findings

control group experiments group

100 50 0 -50 -100

control group experiments group

Experimental group Fat graft Body weight weight change rate decrease rate

0

10

30

60

0

58.3

-49.6125

-70.775

0

61.6

-52

-71.1625

day

Fig. 53.3  Each data point reported in the graph is the mean of 8 fat graft weight change percentage. Error bars on each data point represent 95% confidence intervals

All tissues were fixed in 10% formalin and embedded in paraffin after processing. Sections of 4–5 mm were stained with hematoxylin-eosin. The histopathologic evaluation was made semi-quantitatively. The following parameters were evaluated: necrosis, vascularization, fibroblastic proliferation, acute and chronic inflammation, and macrophage infiltration. The values of these parameters were designated mild (+), moderate (++), and severe (+++) (Fig. 53.4). On the tenth day, necrosis was more prominent in the control (supraperiosteal) group as against the experimental (subperiosteal) group (Table 53.4). On the 30th day, subperiosteal tissues revealed no necrosis, while supraperiosteal grafts contained some necrosis but less than the grafts removed on the tenth day (Table 53.5). After 2 months, no necrosis was observed in both the supraperiosteal and subperiosteal groups (Table 53.6). Acute inflammation was a feature of the first groups  on the tenth day but not severe in both of them (Table 53.4). After 2 months, necrosis and acute inflammation were absent. Chronic inflammation was mild (Table 53.6).

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Table 53.4  Results of the histopathologic examination on the tenth day of grafting Control group Necrosis Vascularization Fibroblastic proliferation Acute inflammation Chronic inflammation Macrophage infiltration

Experiment group

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

++ ++ ++ − ++ ++

++ + + − ++ ++

+ ++ + + ++ ++

+ + + + ++ ++

+ ++ ++ − ++ ++

+ + ++ − ++ ++

+ + + + ++ ++

+ ++ + − ++ ++

+ + + + ++ ++

+ + + + ++ ++

++ + + + ++ ++

+ + + − ++ ++

+ + + − ++ ++

+ ++ ++ + ++ ++

+ + + + ++ ++

+ ++ ++ − ++ ++

+ mild, ++ moderate, +++ severe

Table 53.5  Results of the histopathologic examination in the first month of grafting Control group Necrosis Vascularization Fibroblastic Proliferation Acute Inflammation Chronic Inflammation Macrophage Infiltration

Experiment group

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

+ ++ + − ++ +++

+ + ++ − ++ ++

− + ++ − ++ +++

+ + ++ + ++ +++

− + + + ++ ++

+ + − − ++ ++

− + − − ++ ++

− + + + ++ ++

− + ++ − ++ ++

− + ++ − ++ +

− + ++ − ++ ++

− + ++ − + ++

− + + − ++ ++

− + +++ − + ++

− + ++ − + +

− + + − + ++

+ mild, ++ moderate, +++ severe

Table 53.6  Results of the histolpathologic examination in the second month of grafting Control group Necrosis Vascularization Fibroblastic proliferation Acute inflammation Chronic inflammation Macrophage infiltration

Experiment group

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

− + + − − −

− + + − + −

− + + − + +

− + − − − +

− + + − − +

− ++ + − − −

− + − − + −

− + + − + +

− ++ + − − +

− + + − + −

− + − − − −

− + + − + −

− + + − + +

− + + − + +

− + − − − +

− + − − − −

+ mild, ++ moderate, +++ severe

As an observation, there was no great histopathologic difference between the supraperiosteal and subperiosteal grafts. The inflammation and necrosis which were observed on the tenth day of grafting decreased in the second month of grafting. There was no significant difference observed between supraperiosteal and subperiosteal groups with respect to necrosis, inflammation, vascularization, and fibrosis (p < 0.05).

53.5  Discussion Fat grafting was first attempted by Neuber in 1893 (8) and was widely applied by Lexer (9). In 1911, Bruning

(10) was the first to inject autologous fat into the subcutaneous tissue for the purpose of soft tissue augmentation. In the 1980s, liposuction became a widely used operation. Thereafter, suctioned semi-liquid fat tissue became the most commonly used soft tissue filler. Illouz (11) and Fournier (12) developed an easy approach to fat transfer which they called microlipoinjection. Fat grafts can be used both for aesthetic needs and for reconstruction of posttraumatic and postsurgical deformities. Acne and chicken pox scars are the common scars requiring surgical treatment. Most facial scars contain both depressed and bulging areas. Therefore, scar revision is performed in combination with liposuction of the bulging areas and lipoinjection of depressed areas.

53  Fat Grafting Review and Fate of the Subperiostal Fat Graft

411

a

b

c

d

Fig. 53.4  (a) Supraperiosteal fat graft in the first month of transplantation. Fat tissue, microcysts, prominent fibrous and inflammatory infiltration can be seen (HE × 125). (b) Subperiosteal fat graft in the first month of transplantation. Mixed inflammatory cells, fat tissue, and mild fibroblastic proliferation can be seen

(HE × 125). (c) Supraperiosteal fat graft in the second month of transplantation. Mature fat tissue and fibrous tissue with minimal inflammation are observed (HE × 125). (d) Subperiosteal fat graft in the second month of transplantation. Minimal chronic inflammation, fibrous, and fat tissue are observed (HE × 125)

Thickening the aged thin soft tissues by fat grafting enhances the aspect of the face when applied to elderly people. Better results can be obtained by combining fat grafting with rhytidoplasty and with resurfacing techniques such as chemical peeling and dermabrasion (4). Introduction of fat graft to compensate the atrophy/ ptosis of fat and the depletion of bone mass increases the longevity of the suspension techniques and gives a more youthful appearance to the skin. Although there are a number of studies which show that fat grafting has unsatisfactory results, this fact

has not prevented it from being widely used (13–15). There is plenty of autologous substance available. Hence, it is not hard to believe that it is the ideal soft tissue filler to establish normal facial and body contour. Numerous clinical and experimental studies have been carried out to provide long-lasting durability. Fat harvesting and transplantation techniques have been compared. Moreover, the effect of centrifugation or addition of insulin, vitamin, or growth ­factors on fat graft survival have been evaluated (16–19).

412

Longevity of the correction with fat transplantation depends principally on the tissue, the mobility and vascularity of the recipient site. Guerrerosantos (4) performed 3,423 surgical procedures by using fat grafts in 16 years and he prefers to inject the fat into the muscle or at least under the superficial musculoaponeurotic system or over the periosteum of the facial bones. Hence, there is no need for overcorrection which has been recommended by other surgeons (20). Fat grafts are believed to receive nourishment from the interstitial fluid for the first 4 days after transplantation. During this period, till the revascularization is completed, the supply of oxygen and nutrition may not be sufficient for the graft to survive. Placing the fat grafts in well vascularized anatomic layers such as muscle, fascia or periosteum has been recommended (20). In one of the experimental studies, in order to overcome the ischemic period, fat graft was transported by a fascia flap after the vascularization period (fat prefabrication) (7). Multilayering and small amounts of injection are recommended for fat grafting of the facial tissues. The deepest layer of injection was the supraperiosteal level. Ellenbogen (21) injected fat over the sternum of a lady with mild pectus excavatum. He suggested that fat injected over the bone, seems to persist, although it is not a fat environment. The other interesting finding was that the injected fat over bone felt like harder tissue and not like fat. Sometimes achieving a smooth surface and an adequate augmentation with fat grafting in injured facial tissues can be difficult. If the skin overlying the fat graft is thin, this can result in bulging and depressed areas. Thus, when fat grafting posttraumatic injuries, placing the grafts under the periosteum not only provide a well vascularized medium for the fat tissue, but also prevent surface irregularities. New studies about tissue engineering have focused on cell-based therapies involving multipotential stromal cells. For example, the chondrogenic potential of adipose tissue-derived stromal cells were examined. Stromal cells were isolated from human subcutaneous adipose tissue obtained by liposuction and were expanded and grown in vitro with or without chondrogenic media in alginate culture. Alginate cell constructs grown in chondrogenic media for 2 weeks in vitro were then implanted subcutaneously in nude mice for 4 and 12 weeks. Immunohistochemical analysis of these samples showed significant production of

D. Önel et al.

cartilage matrix molecules (22). Stem cells from fat are clearly multipotential, with the capacity to differentiate into a wide variety of cell types, including fat, bone, and cartilage. Thus supplying any tissue texture that is needed both for trauma reconstruction and aesthetic needs can be achieved by fat cell engineering (23, 24). In this study, we placed the fat grafts under the periosteum in the experimental group and compared the results with the control group where the fat grafts were placed over the periosteum. The weight changes and histopathologic findings after transplantation were similar in both of the groups. Although the mean weight loss rate on the 30th day of transplantation was a little higher in the experimental group, it was not significant according to the Student’s t-test (p < 0.40). Thus, subperiosteal fat grafting can achieve similar amount of augmentation with supraperiosteal fat grafting. In order to overcome the risk of irregularities after the supraperiosteal grafting over the bone regions with thin and traumatized skin, subperiosteal fat grafting can be preferred. When the fat graft is placed under a smooth sheet, the grafted area will have a smooth surface.

References   1. Sommer B, Sattler G. Current concepts of fat graft survival: Histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166.   2. Coleman SR. Structural fat grafts. The ideal filler? Clin Plast Surg 2001;28(1):111–119.   3. Converse JM, Wood-Smith D. Horizontal osteotomy of the mandible. Plast Reconstr Surg 1964;34:464–471.   4. Guerrerosantos J. Long-term outcome of autologous fat transplantation in aesthetic facial recontouring. Clin Plast Surg 2000;27(4):515–543.   5. Jackson IT, Munro IR, Salyer KE, Whitaker LA (Eds). Atlas of Craniomaxillofacial Surgery, St. Louis, CV Mosby, 2000, pp. 1982.   6. Smahel J. Adipose tissue in plastic surgery. Ann Plast Surg 1986;16(5):444–453.   7. Tezel E, Numanog˘lu A, Bayramiçli M, Sav A. Fat prefabrication using a fascial flap in the rat model. Br J Plast Surg 2000;53(2):155–160.   8. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   9. Lexer E. Freie fettransplantation. Deutsch Med Wochenschr 1910;36:640. 10. Bruning P. Cited by Broeckaert, TJ, Steinhaus, J. Contribution e l’etude des greffes adipueses. Bull Acad Roy Med Belgique 1914;28:440.

53  Fat Grafting Review and Fate of the Subperiostal Fat Graft 11. Illouz YG. The fat cell graft. A new technique to fill depressions. Plast Reconstr Surg 1986;78:122. 12. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin 1990;8(3):523–537. 13. Kononas TC, Bucky LP, Hurley C, May JW. The fate of suctioned and surgically removed fat after reimplantation for soft tissue augmentation: A volumetric and histologic study in the rabbit. Plast Reconstr Surg 1993;91(5):763–768. 14. Niechajev I, Sevcuk O. Long-term results of fat transplantation: Clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506. 15. Von Heimburg D, Lemperle G, Dippe B, Krüger S. Free transplantation of fat autografts expanded by tissue expanders in rats. Br J Plast Surg 1994;47(7):470–476. 16. Fagrell D, Eneström S, Berggren A, Kniola B. Fat cylinder transplantation: An experimental comparative study of three different kinds of fat transplants. Plast Reconstr Surg 1996;98(1):90–96. 17. Har-Shai Y, Lindenhaum ES, Gamliel-Lazarovich A, Beach D, Hirshowitz B. An integrated approach for increasing the

413 survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg 1999;104(4):945–954. 18. Markey AC, Glogau R. Autologous fat grafting: Comparison of techniques. Dermatol Surg 2000;26(12):1135–1139. 19. Nishimura T, Hashimoto H, Nakanishi I, Furukawa M. Microvascular angiogenesis and apoptosis in the survival of free fat grafts. Laryngoscope 2000;110(8):1333–1338. 20. Chajchir A, Benzaquen I, Wexler E. Suction curettage lipectomy. Aesthetic Plast Surg 1983;7(4):195–203. 21. Ellenbogen R. Fat transfer: Current use in practice. Clin Plast Surg 2000;27(4):545–546. 22. Franklin D, Rice H, Awad H, Guilak F, Erickson G, Gimble J. Chondrogenic potential of fat derived stromal cells. Biochem Biophys Res Comm 2002;290:763–769. 23. Wickham MQ, Erickson G, Gimble J, Vail T, Guilak F. Multipotent stromal cells derived from infrapatellar fat pat of the knee. Clin Orthop 2003;(412):196–212. 24. Gimble J, Guilak F. Adipose-derived adult stem cells: Isolation, characterization, and differentiation potential. Cytotherapy 2003;5(5):362–369.

Part Complications

VI

Complications of Fat Transfer

54

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

54.1  Introduction Fat transfer is a procedure that is more than a century old and has been extensively used in cosmetic and reconstructive surgery in the last three decades as a result of the introduction of liposuction. Physicians performing fat transfer must understand clearly the ­relevant anatomy, pathophysiology, and complications resulting from fat transfer use, their prevention, and treatment.

54.2  Complications There are many possible complications of fat transfer (Table 54.1). 1. Absorption Absorption of fat takes place as a result of using damaged fat, bloody fat, infection, not following the correct technique, using machine with pressure above 25 in. of Hg for fat aspiration, using fat from fibrous areas for transfer like the upper abdomen, upper back, and subscapular fat. The percentage of absorption varies from 0 to 70% (1, 2). Generally the authors recommend 30–50% over-correction because of this. To achieve optimal results, it is necessary to manipulate fat very gently, placing it in small segments, in different layers,

H. A. Khawaja () Cosmetic Surgery and Skin Center, 53A, Block B II, Gulberg III, 53660, Lahore, Pakistan e-mail: [email protected]

and in the subcutaneous tissue to prolong adipocyte survival. It should be injected beneath the gland and under and into the pectoralis major muscle in female breasts and in the direction of gluteus maximus muscle in the buttocks. If tunnels are made with a blunt cannula into the donor area before injecting fat,, fat will not be squeezed into the area, and this prolongs survival. Fat should be injected while the operator is retrieving, not advancing the cannula, to avoid retrograde trauma. Heavy physical exercise should be avoided by patients who have undergone a large volume fat transfer, and facial expressions should be minimized for 1 week postoperatively in those undergoing facial fat transfer. Table 54.2 shows the degree of persistence of fat according to facial and body locations. 2. Infection Primary infection can be avoided by following strict sterile aseptic operating room technique, perioperative broad spectrum injectable antibiotics, and starting oral broad spectrum antibiotics 1 day before surgery and continuing for 7–10 days postoperatively. Preoperative tests should be done - especially complete blood count, fasting blood sugar, hepatitis B and C screening, and test for HIV. Blood borne secondary infection (bacteremia/septicemia) can settle in fat causing abscess formation. Any focus of infection in the body (e.g., tonsil or boil) should be treated accordingly. Recently, surgeons have been concerned about the occurrence of mycobacterial infections related to fat transfer. These problems took place as a result of poor asepsis of surgical instruments. Sterilization with liquids must be condemned. Metallic instruments have to be autoclaved and rubber tubes need gas sterilization. The best treatment is combination of antibiotics.

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_54, © Springer-Verlag Berlin Heidelberg 2010

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Table 54.1  Complications of fat transfer Absorption

Pressure and avascular necrosis

Infection Embolism Cysts, pseudocysts, liponecrotic cysts Blindness Lipomatous formation, and lipomatosis Ossification Traumatic fat necrosis (breast) Vascular and nerve injuries Cavernous sinus thrombosis Remote lipomas

Skin necrosis, sinus formation Hematoma, seroma, bloody fat Skin pigmentation Pseudo-tumor Calcification Masses Asymmetry Penile and urethral distortion Volumetric hypertrophy Calculi in the urinary tract

Table 54.2  Fat persistence according to site Site Nasolabial folds Malar areas Cheeks Marionette lines Glabellar frown lines Transverse forehead lines Lips Breasts Dorsum of hands Buttocks Calves Tissue defects Male external genitals Female external genitals

Longer

Shorter

Variable

* * * * * * * * * * * * * *

and extensive mechanical obstruction (after a massive embolus) can occur. Platelets in the thrombus or embolus liberate 5-hydroxytryptamine or thromboxane, which cause spasm of pulmonary vessels (4). The precise cause of death in many cases of this condition is not understood. Fat transferred to the calves should probably not exceed 60–100 mL on each side. Extremely careful antiseptic technique should be followed in these areas. Compression should not be applied to the calves postoperatively. In order to avoid embolism, fat should not be injected in a centripetal direction (toward the eye) in the periorbital area. In the dorsum of hands, injection should be opposite to the direction of venous blood flow and should be slow to avoid large spurts of fat. The fat transfer cannula should always be blunt, and approximately the size of a 14-gauge needle. The accidental opening of a large vein, such as the jugular, may allow air to be pulled in. If air is not taken out of the syringes, it can be injected subcutaneously, giving a bubbly appearance to the subcutaneous tissue. In humans, the lethal amount of air injected into the vascular system is less than 9 mL/kg. The effects are very similar to massive pulmonary embolism. The characteristic churning noise that may be heard without the aid of a stethoscope serves to differentiate the two conditions clinically (4). Careful preoperative marking of important blood vessels is very important. As a preventive measure, all patients should be referred to the cardiologist (regardless of the age) for a complete cardiac and vascular check up. Epinephrine should be used for the procedure, and sharp instruments should never be used for transfer.

54.2.1  Viral Infection/Warty Over-Growth 4. Blindness The authors have noticed warty overgrowths at the cannula entry points in some cases. Cautery of the wart is the only treatment that is required. 3. Embolism Excessive augmentation of the calves by fat can compress the greater or lesser saphenous vein or the vein linking the two systems resulting in the formation of a  thrombus. A propagated clot of phlebothrombosis can likewise produce pulmonary thromboembolism (3). Septic pulmonary emboli can be produced if ­infection takes place. Pulmonary infarction, progressive pulmonary hypertension (after recurrent episodes),

Blindness can take place as a result of centripetal (needle pointing toward the eyeball) injection of fat around the orbit. If blunt instruments are not used for fat transfer around the orbit, penetrating injury to the eyeball can occur. Capsular penetration and deposition of hematoma, seroma, or fat deposits around the central retinal artery can lead to central retinal arterial thrombosis. Injection of fat into the glabellar frown lines has resulted in the onset of pain and loss of vision in one eye while receiving the injection (5–7). There was central retinal arterial thrombosis, probably secondary to fat particle embolism. The authors recommend placement of centrifugal injections around the eyeball, use of a small blunt

54  Complications of Fat Transfer

cannula, and preinjection marking of important blood vessels and nerves in this area to avoid this complication. Coleman (8) has suggested limiting bolus size, not using a sharp needle, limiting syringe size, and not using a ratchet gun in order to avoid arterial emboli. However, venous fat emboli can occur from the glabellar area rather than from injection into the arterial system and would result in the same blindness. Syringe pressure alone can cause the entry of fat into the vascular system. There have been reports not only of blindness but also cerebral ischemia and brain damage following injection of fat into the glabellar area (9–13). The author (MAS) has encountered a case of a female patient born in 1982 with severe cleft palate and cleft lip. Multiple procedures for repair were performed from age 3½ months to age 9. At age 15 she had advancement of the lower lateral cartilages for a deformed nasal tip and at age 22 she had open nasal tip rhinoplasty. At age 24 she had injection under pressure of 0.5 mL of fat to her right nasal tip using an 18-gauge needle. Three to four minutes after the injection the patient lost vision in her right eye and her right pupil was dilated and there was numbness and weakness of the left arm and hand. She was noted to have left homonymous hemianopsia and developed ptosis and superior rectus muscle palsy indicating left third nerve palsy. Fat venous emboli were seen in the central retinal veins. The origin of the emboli was most likely from pressure injection of the fat that entered torn veins in the field of needle insertion and not from direct injection into a vein since aspiration prior to the injection of fat did not produce blood and the injection was given in a retrograde manner while withdrawing the needle. There is an intimate connection of the venous supply of the nose to the retina via the ophthalmic veins and to the sagital sinus system which resulted in the visual and neurologic damage. 5. Cysts, pseudocysts, and lipo necrotic cysts Cysts are usually small and self limited, especially on the face and dorsum of hands and male and female genitals. Moderate sized cysts can occur on the face, breasts, and calves in cases of moderate amount of fat transfer. Moderate to large sized cysts can occur in cases of large fat transfer, especially in the breasts. Intralesional triamcinolone injections can be used for smaller cysts if they persist. Moderate and large sized cysts can be aspirated using a 2-mm cannula

419

Bambi cannula. Post treatment compression is used to obliterate the cyst wall in cases of superficial cysts. Johnson (14) showed that 1, 3, and 5 mL fat injections resulted in small cysts but 10 mL injections resulted in macro cysts. Oil cysts occur through confluence of necrotic fat cells and have a lining of macrophages. Resorption may take years, thus, giving a false impression of a successful transplantation. Too much injection of fat in one area has to be avoided to prevent oil cyst formation. For small volume fat transfer, Fischer’s (15) technique of rice grain-size facial fat transfer can be used, even for extra-facial areas. Castello et al. (16) reported a case of a large painful masswhich was a large cyst with calcified capsule on mammogram that appeared 10 months after injection. This was excised. Mandrekas et al. (17) had a patient in which 40 mL of fat was injected into a defect in the left groin. Three months postoperatively there was a mass in the groin at the site of the fat transfer. The mass was excised and on histology had mature fat cells and occasional fatty globules. Millard (18) reported lipo-necrotic cysts after augmentation mammaplasty with fat injections in a 26-year-old female which were later excised. Montanana Vizcaino et al. (19) reported a lipo-necrotic cyst after autologous fat transplantation. Har-Shai et al. (20) described a large lipo-necrotic pseudocyst formation after cheek augmentation by fat injection. 6. Calcifications Calcifications can take place in localized areas of fat deposits or in cysts. In the female breasts, calcifications could be misdiagnosed as possible breast cancer. The timing of their appearance, their position, and character will indicate the cause. The size and form of these are quite different in the two entities, and they should not  be confused by an experienced mammographer. Microcalcifications from fat necrosis are periparenchymal and do not exhibit multidensity, rod-like, punctated, or branching spicules (21). Microcalcifications take place following breast augmentation with implants, open and closed capsulotomy, and breast reduction. Calcifications that remain stable can be observed. Delayed calcifications occurring months after the injection, can be sampled by stereotactic core needle biopsy. Open biopsy is unnecessary, if the core shows benign tissue. Pulgam et  al. (22) reported one case with bilat­ eral  palpable masses in the breasts after fat transfer.

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On mammography there were calcified and noncalcified masses and on ultrasound, hypo-echoic masses were noted that had mild to moderate acoustic enhancement and dense acoustic shadowing was seen. They also described one patient with fat injection for a defect in the breast after lumpectomy and irradiation who developed a 2.5-cm palpable mass with eggshell peripheral calcification and calcifications within the oil cyst consistent with fat necrosis. 7. Ossification Calcification in fat deposits and cysts can proceed to ossification, especially if a hormonal abnormality exists. Trauma to fat cells is also a predisposing factor. In cases of cancellous type ossification, liposuction of the deposits usually results in a cure; however, in cases of cortical type ossification, surgical removal is the procedure of choice. In some of these cases, benign ossific deposits should only be observed if they are symptomless. 8. Traumatic fat necrosis (breast) Traumatic fat necrosis usually occurs in the breast but can occur in any other area of fat transfer. Following a blow or even indirect trauma (e.g., contraction of the pectoralis major muscle) an often painless lump appears (23). The swelling is usually attached to the skin and nipple retraction can also take place, which may be misdiagnosed as carcinoma. However, history of fat transfer and injury should alert the clinician. On incising the lump, a chalky white area of necrotic fat is found. Fat injections should be placed beneath the gland and into and below the muscle in female breasts. 9. Skin necrosis/sinus formation Over-augmentation can lead to this complication. Ten to twenty milliliters of fat is recommended for injection into the malar areas, lips, cheeks, and chin; 150– 350 mL for each side in female breasts; 100–150 mL per side of the buttocks in the direction of gluteus maximus muscle; 60–80 mL in male external genitals; 120 mL for female external genitals at three points: pubic area and two labia majora; 20–30 mL for each side in the dorsum of hands; and 60–100 mL for each side of calves (24). Excessive compression can lead to fat and skin necrosis with sinus formation (Fig. 54.1). Intra-arterial injection of fat can result in tissue necrosis (7).

Fig. 54.1  Sinus tract at cannula site

10. Compression atrophy (pressure necrosis), and avascular necrosis Compression atrophy can take place in cases where mega fat transfer has been performed and excessive compression is applied to the area. It can also take place in areas where liposuction has been carried out and excessive compression is applied to the area. The lower abdomen is more vulnerable to pressure necrosis after liposuction and excessive compression to this area should be avoided postoperatively. Pressure necrosis as a result of over-augmentation of fat or excessive compressive garments can lead to avascular necrosis (arterial/venous thrombosis) with its subsequent sequelae of infarction of important anatomical structures and motor nerve paresis or paralysis. It is best to limit over-correction of fat up to 30–50%. 11. Asymmetry Asymmetry can take place in the nasolabial folds, malar areas, cheeks and chin, female breasts, buttocks, calves, and male and female external genitals. Asymmetry can  be from incorrect technique, fat absorption, fat hypertrophy or atrophy, or incorrect application of external pressure garments. Lipo-aspiration is required for hypertrophy and atrophy, and additional fat transfer is required for absorption. Correct fat transfer technique and application of external garments is also an important factor in preventing asymmetry.

54  Complications of Fat Transfer

12. Bloody fat, hematomas, and seromas Patients are asked to refrain from aspirin, beta-blockers, vitamin E preparations, nonsteroidal anti-inflammatory drugs, and from smoking for at least 10 days before surgery. Coagulation tests are performed preoperatively. In the donor area, super-tumescence should be used with chilled Klein’s solution. In the receptor area, 1% lidocaine plus 1: 400,000 epinephrine should be used only in the incision sites with intravenous sedation (Midazolam plus Fentanil) if necessary. Hematomas or seromas can take place if sharp instruments are used for fat transfer, postoperative cooling is not done, in cases of arterial or venous damage, in patients taking a variety of allopathic, homeopathic, or herbal drugs, and in patients with liver disorder, blood dyscrasia, or vascular disorder. Aspiration and compression of hematomas and seromas can be carried out. Aspiration and injection of room air can resolve chronic seromas (25). 13. Iatrogenic injuries Facial nerve branches (temporal, zygomatic, buccal, marginal mandibular, and cervical), dorsal nerves in the penis, and nerves in other areas can get damaged during fat transfer. The area at greatest risk of damage is the temporal branch which can be easily avoided by drawing a mark from the ear lobe to the lateral edge of eyebrow and from the tragus to a point just above and behind the highest forehead crease. The approximate path of the ramus to the frontalis muscle can be made by drawing a line from 0.5 cm below the tragus to a point 1.5 cm above the lateral eyebrow. It is most vulnerable as it crosses the midzygomatic arch (26). To avoid the temporal nerve, procedures should be superficial to the superficial temporal fascia. Over the buccal fat pad, the zygomatic and buccal branches are covered only by their fascia and the variable risorius muscle. Dissection in this area may damage the nerve branches producing variable weakness of the affected muscles. The marginal mandibular nerve at the jawline near the facial artery and vein is covered only by the skin and platysma muscle, which in some patients may be thinned or atrophic. Temporal and marginal mandibular nerves are at highest risk because they have the least number of arborizations and cross-connections with themselves or adjoining nerves and have long solitary thinned rami to their muscular destinations. Three types of nerve injuries can be sustained: neuropraxia, axontmesis, and neurotmesis. Fat transfer can

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compress the nerve producing neuropraxia. A wait and watch policy should be adopted. Because there is temporary physiological disruption in the nerve impulses, complete recovery takes place with the passage of time. If calcification takes place along the nerve, exploration should be done. Sharp instruments should not be used for transfer, and preoperative nerve mapping should be carried out to avoid these injuries. In cases of axontmesis and neurotmesis, electromyographic and nerve conduction studies should be carried out. In cases of complete transaction, nerve ends should be sought and end-to-end anastomosis carried out using epineural fine, nonabsorbable sutures. Preoperative per­cutaneous marking of the facial nerve and its branches is important in preventing damage (27). The facial artery enters the face by winding round the base of the mandible and piercing the deep cervical fascia at the anteroinferior angle of the masseter muscle. It can be palpated here. First it runs upward and forward to a point half an inch lateral to the angle of mouth. Then it ascends by the side of the nose (angular artery) up to the medial angle of the eye where it terminates by supplying the lacrimal sac and anastomosis with the dorsal nasal branch of the ophthalmic artery. The extreme tortuosity of the artery prevents its walls from being unduly stretched during movements of the mandible, lips, and cheeks. It lies between the superficial and deep muscles of the face. The large anterior branches (superior and inferior labial, lateral nasal) anastomose with similar branches of the opposite side, and with the mental artery. In the lips, anastomoses are large so that cut arteries spurt from both ends. The transverse facial artery (branch of the superficial temporal), after emerging from the parotid gland, runs forward over the masseter between the parotid duct and zygomatic arch, accompanied by the upper buccal branch of the facial nerve. It supplies the parotid gland and its duct, the masseter, and the overlying skin, and ends by anastomosing with neighboring arteries (28). The veins of the face accompany the arteries, and drain into the common facial and retromandibular veins. They communicate with the cavernous sinus. The veins on each side form a W shaped arrangement. Each corner of the W is prolonged upwards into the scalp, and downwards into the neck. The facial vein is the largest vein of the face. It begins at the angular vein at the medial angle of the eye and is formed by the  union of supratrochlear and supraorbital veins. The angular vein continues as the facial vein, running

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downward and backward behind the facial artery with a straighter course. It crosses the anteroinferior angle of the masseter, pierces the deep fascia, crosses the submandibular gland, and joins the anterior division of the retromandibular vein (below the angle of the mandible) to form the common facial vein which drains into the internal jugular vein. Careful arterial and venous marking preoperatively in their entire course is very important to prevent ­vascular damage. Small blunt tipped cannulas should be used for transfer. Needles should not be used for transfer. The facial vein communicates with the cavernous sinus through deep connections. The first is between the supraorbital and superior ophthalmic veins. The second is with the pterygoid plexus through the deep facial vein, which passes backward over the buccinator. Infections from the face can spread in a retrograde direction, and cause thrombosis of the cavernous sinus. This is especially likely to occur in the presence of infection in the upper lip, lower part of the nose, and adjoining nasolabial triangle. This area is therefore called the “Danger Area of Face” (28). A characteristic picture results with blockage of the venous drainage of the orbit causing edema of the conjunctiva and eyelids, marked exophthalmos, and transmitted pulsations from the internal carotid artery. Pressure on the contained cranial nerves results in ophthalmoplegia. Examination of the fundus shows papilledema, venous engorgement, and retinal hemorrhages resulting from the acutely obstructed venous drainage (28). Very careful antiseptic technique should be followed in this area. 14. Lipomatous (hypertrophy) formation, symmetrical/asymmetrical lipomatosis Lipomatous formation can take place after fat transfer. Cases can occur in the glabella, lower lip, face, dorsum of hands, and penis (Fig. 54.2) (29–31). This occurs usually after several months to years after initial fat transfer. Symmetrical and asymmetrical lipomatosis can take place in the breasts, gluteal region, and penis (Fig. 54.3). Fat hypertrophy/hyperplasia has been postulated as a cause of this lipomatous formation and lipomatosis, though the exact mechanism remains unknown. Postulated and predisposing causes include trauma to the fat cells, presence of adipocyte precursor cells in the donor area, abnormal blood supply or an aberrant development of blood vessels, neurogenic

H. A. Khawaja et al.

Fig. 54.2  Lipomatous (hypertrophy) formation after fat transfer above the left nasolabial fold and viral wart at the cannula entry point on the right cheek

Fig. 54.3  Lipomatosis (hypertrophy) in the penis after fat transfer

factors, rachet effect, dominant gene factor, hereditary, race, gender, corticosteroids, insulin, leptin and ob gene, neuropeptide, and a central lipostat (control mechanism) regulating fat deposition and homeostasis. Lipoaspiration using syringe or suction machine usually results in a cure. In smaller cases, triamcinolone acetonide can be injected. (a)  Symmetrical volumetric hypertrophy The authors have had symmetrical volumetric hypertrophy of fat in the face of a patient who received fat injections twice in the malar areas and cheeks. Fat hypertrophied symmetrically in the form of layers above the SMAS. Fulton (32) reported the problem of breast enlargement following fat transfer to the breast. He attributed this enlargement to the liposuction as reported by Bissacia and Scarborough (33).

54  Complications of Fat Transfer

(b)  Masses Breast masses appear as a result of incorrect fat injection technique when fat is injected subcutaneously, and not deep between the gland and the muscle. These can also result, when fat injection is more than the recommended amounts (Fig. 54.4). Periorbital masses can also form as a result of fat injections exceeding the recommended amounts (Fig. 54.5).The authors have seen metacarpal masses (lipomas) in some patients where more than 5 mL of fat is injected per metacarpal. These are more prominent at the metacarpophalengeal joint junctions. Masses are usually self limiting. If a mass does not disappear after a while, triamcinolone acetonide can be injected which will result in its dissolution. (c)  Remote lipomas Liquid fat can be displaced and form lipoma elsewhere, especially if fat transfer has been combined with another procedure in which undermining has been used. However, other remote lipomas after fat transfer are hard to explain.

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15. Penile/urethral distortion/calculi in the urinary tract Penile and urethral distortion can take place if proper technique is not followed while injecting fat, and if more than 100 mL of fat is injected in the penis (Fig.  54.6). In some areas, fat can accentuate giving the appearance of a lipomatous formation. Excess fat deposition along the urethral side and ventral base can lead to compression of urethra. The urethral distortion can lead to urinary symptoms like frequency of micturation, hesitancy, dribbling, distortion of the urinary stream, poor urinary flow and can predispose to primary urethral or urinary tract stone formation and stasis which can lead to primary urethral or retrograde infection in the urinary tract. 16. Pseudotumor Pseudotumor as a result of edema, bruising, and irregularity of the transfer area can take place. Adequate surgical technique and postoperative cooling of the transplanted area prevents this.

Fig. 54.4  Breast masses bilaterally close to cannula entry points as a result of subcutaneous insertion of fat

Fig. 54.5  Periorbital fatty mass as a result of fat injection which was more than the recommended amount

Fig. 54.6  Penile deviation as a result of uneven injection of fat

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17. Skin pigmentation Hyperpigmentation of skin takes place if fat leaks out of the entry points as a result of suture(s) opening postoperatively. This pigmentation is more marked in darker complexioned people. This hyperpigmentation is treated with hydroquinone and sunscreens. It is usually self-limiting. 18. Fat migration Excessive injection of fat in a single area, muscle action massaging the fat, external pressure from dressings or sleeping on the area of fat injection, and/or fat transfer to an area with loose skin and minimal fibrous tissue can result in fat migration. The forehead is particularly prone to fat migration especially if fat is injected under the forehead lines and is pressed to smooth out the result. Some physicians use botulinum toxin injection to paralyze muscle action in the area of fat injection.

54.3  Conclusions Fat transplantation is an important component of facial and body rejuvenation. In some cases, it has to be repeated once or twice to achieve better results. It is safe in experienced hands. However, a number of complications can take place as a result of fat transfer. Some of these complications are lethal. Therefore physicians performing fat transfer must understand in detail the relevant fat transfer anatomy, pathophysiology, and complications resulting from the techniques used and their prevention and treatment. They must receive specific training programs by experienced ­physicians before performing fat transfer independently. Physicians performing fat transfer should be competent in preventing and treating fat transfer complications.

References   1. Bircoll M. A nine years experience with autologous fat transplantation. Am J Cosmet Surg 1992;9:55–59.   2. Shiffman MA (ed). Principles of autologous fat transplantation. In: Autologous Fat Transplantation. New York, Marcel Dekker, 2001, pp. 5–22.

H. A. Khawaja et al.   3. Alexander RW. Guidelines for autologous fat transfer. In:  Shiffman MA (ed), Autologous Fat Transplantation. New York, Marcel Dekker, 2001, pp. 23–30.   4. Walter JB, Israel MS. General Pathology, 6th edition. Edinburgh, Churchill Livingstone, 1987, pp. 538–542.   5. Coiffman F. Lipoinjection complications. In: Hinderer U (ed), Plastic Surgery 1992. Vol II. Amsterdam: Excerpta Medica, 1992:759–760.   6. Teimourian B. Blindness following fat injection. Plast Reconstr Surg 1988;82(2):361.   7. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107(1):85–87.   8. Coleman SR (ed). Problems, complications, and postprocedure care. In: Structural Fat Grafting. St. Louis, MO, Quality Medical Publishing, 2004, pp. 75–102.   9. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24(4):615–616. 10. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face. J Neurol 1998;245(1):53–54. 11. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and small case series: Ocular and cerebral ischemia following facial injection of autologous fat. Arch Ophthalmol 2001; 119(5):777–778. 12. Thaunat O, Thaler F, Loirat P, Decrois JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 2004;113(7):2235–2236. 13. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 2003;61(8):1151–1152. 14. Johnson G. Autologous fat graft by injection: Ten years experience. Am J Cosmet Surg 1992;9:61–65. 15. Fischer G. Fat transfer with rice grain-size parcels. In:  Shiffman MA (ed), Autologous Fat Transplantation. New York, Marcel Dekker, 2001, pp. 55–63. 16. Castello JR, Barros J, Vazquez R. Giant liponecrotic pseudocyst after breast augmentation by fat injection. Plast Reconstr Surg 1999;103(1):291–293. 17. Mandrekas AD, Zambacos GJ, Kittas C. Cyst formation after fat injection. Plast Reconstr Surg 1998;102(5):1708–1709. 18. Millard GF. Liponecrotic cyst after augmentation mammaplasty with fat injections. Aesth Plast Surg 1994;18(4): 405–406. 19. Montanana Vizcaino J, Baena Montilla P, Benito Ruiz J. Complications of autografting fat obtained by liposuction. Plast Reconstr Surg 1990;85(4):638–689. 20. Har-Shai Y, Lindenbaum E, Ben-Itzhak O, Hirschowitz B. Large liponecrotic pseudocyst formation following cheek augmentation by fat injection. Aesthetic Plast Surg 1996; 20(5):417–419. 21. Bircoll M. Autologous fat transplantation: An evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation. Am J Cosmet Surg 1988; 5:283–288. 22. Pulgam SR, Poulton T, Mamounas EP. Long term clinical and radiologic results with autologous fat transplantation for

54  Complications of Fat Transfer breast augmentation: Case reports and review of literature. Breast J 2006;12(1):63–65. 23. Mann CV, Russell RCG. Bailey and Loves Short Practice of Surgery, 21st edition. London, Chapman and Hall, 1992, pp. 793–794. 24. Hernandez-Perez E. Practice perspectives: Fat injection in different parts of the body. Dermatol Nurs 1998;10:135–138. 25. Shiffman, MA.Seromas in cosmetic surgery. Int J Cosmet Surg Aesthetic Derm 2002;4(4):293. 26. Salasche SJ, Bernstein G. Surgical Anatomy of the Skin, 1st edition. Connecticut, Appleton and Lange, 1988, pp. 89–139. 27. Park JI. Preoperative percutaneous facial nerve mapping. Plast Reconstr Surg 1998;101(2):269–277. 28. Chaurasia BD. Human Anatomy Regional and Applied, 2nd edition. Delhi, Jain Bhawan, 1992, pp. 39–49.

425 29. Khawaja HA, Hernandez-Perez E. Lipomatose formation after fat transfer-a report of 2 cases. Int J Cosmet Surg 1998–1999;6(2):144–145. 30. Miller JJ, Popp JC. Fat hypertrophy after autologous fat  transfer. Ophthal Plast Reconstr Surg 2008;18(3): 228–231. 31 Guaraldi G, Fazio ODE, Orlando MD, Murri R, Wu A, Guaraldi P, Esposito R. Facial hypertrophy in HIV-infected subjects who undergo autologous fat tissue transplantation. Clin Infect Dis 2005;40(2):e13–e15. 32. Fulton JE. Breast contouring with “gelled” autologous fat: A  10-year update. Int J Cosmet Surg Derm 2003;5(2): 155–163. 33. Bissacia E, Scarborough DA. Breast enlargement after liposuction. Am J Cosmet Surg 1990;7(2):97–98.

Facial Fat Hypertrophy in Patients Who Receive Autologous Fat Tissue Transfer

55

Giovanni Guaraldi, Pier Luigi Bonucci, and Domenico De Fazio

55.1  Introduction Lipodystrophy (LD), referring to morphologic changes and metabolic alterations, affecting HIV-1-infected patients, was first described in 1998 (1–5). The main clinical features are peripheral fat loss or lipoatrophy of the face, limbs, and buttocks and central fat accumulation within the abdomen, breast, and the dorso-cervical spine both of which may be present in the same individual (6, 7). Facial lipoatrophy is undoubtedly the most frequent and distressing sign of this clinical syndrome. Given the dysmorphic changes due to LD, there can be a substantial impact on the patient’s body image, with erosion of self esteem, loss of antiretroviral drug adherence, and disclosure of HIV condition (8). In order to modify progression of the metabolic and morphologic aspects of this condition, a multidisciplinary approach consisting of antiretroviral switching, life style changes (mainly diet or physical activities) as well as lipid lowering agents or antidiabetic drugs can be utilized (9–12). With regard to the most stigmatizing condition of LD, facial lipoatrophy, the only clinically appreciable intervention is plastic surgery. Surgeons can perform autologous fat transplant (AFT) from a subcutaneous abdominal graft or injections of absorbable or nonabsorbable fillers into the lipoatrophic areas of the face. It is surprising how very few studies have assessed the safety, efficacy, and durability of these interventions

and only two studies have compared different surgical approaches (13–14). At the Metabolic Clinic of the University of Modena and Reggio Emilia, an extensive surgery experience for HIV-related facial lipoatrophy has been gathered from 2001 to 2007. About 397 AFT, 2,505 injection of reabsorbable fillers and 2,649 nonreabsorbable fillers have been performed so far. In the absence of long-term follow-up of patients treated with facial fillers, the authors believe that AFT should be the preferred option for the treatment of facial lipoatrophy when an appropriate graft site is available. Nevertheless, this major surgery technique may have minor and major complications. Minor complications include pain, edema, and superficial bleeding. Major complications may be represented by disfiguring facial fat graft hypertrophy. Four cases of facial fat graft hypertrophy occurred at the beginning of the surgeons’ clinical experience when areas of fat hypertrophy (mainly buffalo hump) were used for graft donor site. These subjects developed facial fat hypertrophy at the same time as recurrence of fat hypertrophy in the harvest site. Patients described them selves as “hamster” because of the swollen checks and this clinical picture has been published as “Hamster syndrome” (15). This phenomenon have no more been observed with clinical relevance since the use of fat hypertrophy for the harvest site has been avoided.

55.2  Patients and Methods G. 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 e-mail: [email protected]

At the Metabolic Clinic, from 2001 to 2002, 41 people with LD and facial lipoatrophy underwent AFT to treat facial fat wasting. Surgery was performed using Coleman’s technique (16) employing an harvest of intact

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_55, © Springer-Verlag Berlin Heidelberg 2010

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fat tissue parcels, with nonviable components removed, and avoiding mechanical trauma, exposure to infectious agents, and direct contact with air to allow the graft to remain metabolically active. Small cannulas were used to implant the graft to provide nutrition and to anchor the fat. The graft source was the subcutaneous abdominal region in 27, dorsocervical fat pad (i.e., buffalo hump) in 14, breast in 2, and pubic region in 2. Few patients had multiple donor sites for graft source.

55.3  Results Patients’ baseline characteristics were 32.1% female, mean age 43 + 6 years, 21% CDC group C, mean CD4 nadir 191 + 151 cells/mL, CD4 at surgery 582 + 248 cells/mL, median HIV-VL at surgery 9,621 + 24,867 copies/mL, mean HAART exposure 65 + 17 months, mean D4T exposure was 44 + 19 months. Surgery resulted in a safe, effective, and durable aesthetic result in all patients with a mean check subcutaneous thickness increase of 5.5 mm (SD 2.4). After a median of 17.5 months post surgery, four patients developed renewed fat accumulation of fat tissue harvest from a single site, the dorsocervical fat pad in

three and the abdomen in one patient. Four of these patients developed simultaneous facial graft hypertrophy. In three cases the graft source had been the dorsocervical fat pad and in one the subcutaneous abdominal fat tissue. Patients were said to look like “hamsters.” In the follow-up period, the four patients had D4T switched to ABC or TDF and PI to an NNRTI or multiple NRTIs. None of them used steroids. Mean increase of body weight was 2 kg. Progressive facial cheek lipohypertrophy after surgery was documented by ultrasound performed by the same operator with a high frequency transducer (LOGIQ 3-GE Medical System, transducer: 7.5 MHz). The subcutaneous thickness increase from surgery to the 24 month evaluation was 14.6 mm, SD 2.1; p = 0.07) in the four patients. Figure 55.1 represents the graphic of the cheeks subcutaneous thickness increase in the four patients compared to the cohort and the morphological appearance of patient 1. Patient 1 had 3-years follow-up only as he died due to non Hodgkin lymphoma. He had no surgery correction. The other three patients are all alive in good health and all had at least one surgery correction with facial liposuction. Patient 4 had two face liposuction performed. Figure 55.2 depicts picture follow-up of all the patients.

Cheek subcutaneous thickness

Fig. 55.1  Subcutaneous cheek thickness increase, as measured by ultrasound in the cohort and in the four patients with facial fat hypertrophy (graph). Facial fat graft hypertrophy (photos in graph) and simultaneous fat hypertrophy of the dorsocervical fat pad (bottom line photos)

Check subcutaneous thickness (mm)

25

20

15

Patient 1 Patient 2 Patient 3 Patient 4

10

5

0

Presurgery

4-12 months of follow up

9-24 months of follow up

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

T0

1y

2y

3y

429 4y

5y

6y

PT1

PT2

* PT3

* PT4

*

*

* = liposuction of the face Fig. 55.2  Follow up of the four patients who developed facial hypertrophy

55.4  Discussion The reasons for fat depletion and accumulation in HIVinfected patients receiving antiretroviral therapy remain unexplained. Microscopic features in patients with lipoatrophy show adipocyte remodeling that involves the combination of apoptosis, defective lipogenesis, and increased metabolic activity in different areas (17). Antiretroviral drugs may impair lipid metabolism enzymes with resulting hyperlipidemia, insulin resistance, and adipocytes apoptosis because of the high homology between the low density lipoprotein-receptorrelated protein (LRP) and the cytoplasmic retinoic acid binding protein type I (CRABP-1). Several of the commonly used nucleoside analogs inhibit mitochondrial enzymes (g-polymerase), producing a progressive loss of mtDNA with impairment of oxidative phosphorylation pathway. Antiretroviral drugs may cause downregulation of TNF-a homeostasis, altering transcriptional regulation, glucose, fatty acid metabolism and hormone receptor signaling. Hypertrophy of the subcutaneous denervated fat transplanted in the cheeks clearly suggests that the

abnormal distribution of adipose tissue in HIV-infected patients can not be entirely explained as “a selective neuropathy mediated via the CNS” but that some other circulating or humoral factor, as yet unknown, should be taken into account in order to explain the pathogenesis of HIV-associated adipose redistribution syndrome (18). Our observations do not provide a support for any pathogenetic mechanism. It is unlikely to depend only on paracrine factors, such as cytokine signals. In fact, paracrine factors were present where the alteration appeared, but relapse occurred in a different area. Gullar et al. (19), have recently shown that “Buffalo hump” adipose tissue shows specific disturbances in gene expression with respect to subcutaneous fat from HIV-1-infected/HAART-treated patients. Mitochondrial alterations cannot explain the differential behavior of “buffalo hump” with respect to adipose depots prone to lipoatrophy. The absence of a local inflammatory status in the “buffalo hump” may explain in part the differential behavior of this adipose tissue. An altered gene expression (high expression of PCNA) supports the notion of a transformed phenotype in adipose cells in the “buffalo hump” indicating an intrinsic enhancement in cell proliferation. Auto-

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transplantation of the adipose tissue from “buffalo humps” to facial lipoatrophic areas in reconstructive surgery may result in an enlargement of adipose tissue cheeks, a former lipoatrophic area. This indicates that cells in the “buffalo hump” may have acquired a high proliferative capacity that remains even when they are placed in a lipoatrophic environment. Altered gene expression may be remarkably variable among different “buffalo hump” samples, however, thus suggesting a distinct extent of acquisition of the proliferative status. This may explain why adipose tissue cheek enlargement after autotransplantation occurs only in a sub-set of patients.

55.5  Conclusions A clinical implication is that when AFT is chosen for face atrophy treatment, the preferred subcutaneous adipose graft site should be abdomen or groin. Acknowledgement  We thank A Grisotti, M Callegari, M De Lorenzi, I Pecorari and M Blini for their active contribution in the surgery activities; G. Orlando, N. Squillace, G Nardini and B Beghetto for their assistance in the project.

References   1. Carr A, Samaras K, Burton S, Freund I, Chisholm DJ, Cooper DA. A syndrome of peripheral lipodystrophy, hyperlipidemia and insulin resistance due to HIV protease inhibitors. AIDS 1998;12(7):F51–F58.   2. Lo JC, Mulligan K, Tai VW, Algren H, Schambelan M. “Buffalo hump” in men with HIV-1 infection. Lancet 1998;351(9106):867–870.   3. Stricker R, Goldberg B, Martinez E. Fat accumulation and HIV protease inhibitors. Lancet 1998;352(9137):1392.   4. Saint-Marc T, Partisani M, Poizot-Martin I, Bruno F, Rouviere O, Lang JM, Gastaut JA, Touraine JL. A syndrome of peripheral fat wasting (lipodystrophy) in patients receiving long term nucleoside-analogue therapy. AIDS 1999;13(13): 1659–1667.   5. Miller K, Jones E, Yanovski J, Shankar R, Feuerstien I, Falloon J. Visceral abdominal-fat accumulation associated with use of indinavir. Lancet 1998;351(9106):871–875.   6. Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: Contribution to protease inhibitor related lipodystrophy syndrome. AIDS 2000; 14(3):F25–F32.

G. Guaraldi et al.   7. Saint-Marc T, Partisani M, Poizot-Martin I, Rouviere O, Bruno F, Avellaneda R, Lang JM, Gastaut JA, Touraine JL. Fat distribution evaluated by computed tomography and metabolic abnormalities in patients undergoing antiretroviral therapy: Preliminary results of the LIPOCO study. AIDS 2000;14(1):37–49.   8. Guaraldi G, Murri R, Orlando G, Sterrantino G, Borderi M, Grosso C, Cattelan AM, Nardini G, Beghetto B, Antinori A, Esposito R, Wu AW. Morphologic alterations in HIV infected people with lipodystrophy are associated with good adherence to HAART. HIV Clin Trials 2003;4(2):99–106.   9. Guaraldi G, De Fazio D, Orlando G, Murri R, Grisotti A, Nardini G, Callegari M, De Lorenzi I, Prinzivalli G, Pecorari M, Beghetto B, Covezzi R, Amorico G, Esposito R, Wu A. Autologous fat transfer for treating facial wasting in HIV body fat redistribution. 10th Conference on retroviruses and opportunistic infection. 10–14 February 2003, Boston, MA. 10. Guaraldi G, De Fazio D, Rondina R, Orlando G, Murri R, Grisotti A, Nardini G, Callegari M, De Lorenzi I, Blini M, Pecorari M, Beghetto B, Covezzi R, Esposito R, Wu A. Autologous fat transfer for treating facial wasting in HIV related lipodystrophy: Experience of 53 treated patients. 5th International workshop on Adverse Drug Reactions in HIV. 8–11 July 2003, Paris, France, Abstract book, p.L56 No 80. 11. Valantin MA, Aubron-Oliviera C, Ghosn J, Laglenne E, Pauchard M, Schien H, Bousquet R, Philippe Katz, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: Results of the open label study VEGA. AIDS 2003;17(17):2471–2477. 12. Moyle GJ, Lysakova L, Brown S, Sibtain N, Healy N, Priest C, Mandalia S, Barton SE. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Med 2004;5(2):82–87. 13. Guaraldi G, Orlando G, De Fazio D, De Lorenzi I, Rottino A, De Santis G, Pedone A, Spaggiari A, Baccarani A, Borghi V, Esposito R. Comparison of three different interventions for the correction of HIV-associated facial lipoatrophy: A prospective study. Antivir Ther 2005;10(6):753–759. 14. Negredo E, Higueras C, Adell X, Martinez, JC, Puig J, Fumaz CR, Muñoz-Moreno JA, Perez-Alvarez N, Videl S, Estany C, Cinquegrana D, Gonzalez-Mestre V, Clotet B. Reconstructive treatment for antiretroviral-associated facial lipoatrophy: A prospective study comparing autologous fat and synthetic substances. AIDS Patient Care STDS 2006; 20(12):829–837. 15. Guaraldi G, De Fazio D, Orlando G, Murri R, Wu A, Guaraldi P, Esposito R. Facial lipohypertrophy in HIV-infected subjects who underwent autologous fat tissue transplantation. Clin Infect Dis 2005;40(2):e13–e15. 16. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg 2001;28(1):111–119. 17. Lloreta J, Domingo P, Pujol RM, Arroyo JA, Baixeras N, Matias-Guiu X, Gilaberte M, Sambeat MA, Serrano S. Ultrastructural feature of highly active antiretroviral therapy-associated partial lipodystrophy. Virchows Arch 2002; 441(6):599–604. 18. Fliers E, Sauerwein HP, Romijn JA, Reiss P, van der Valk M, Kalsbeek A, Kreier F, Buijs RM. HIV-associated adipose

55  Facial Fat Hypertrophy in Patients Who Receive Autologous Fat Tissue Transfer redistribution syndrome as a selective autonomic neuropathy. Lancet 2003;362(9397):1758–1760. 19. Guallar JP, Gallego-Escuredo JM, Domingo JC, Alegre M, Fontdevila J, Martínez E, Hammond EL, Domingo P, Giralt

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M, Villarroya F. Differential gene expression indicates that “buffalo hump” is a distinct adipose tissue disturbance in  HIV-1-associated lipodystrophy. AIDS 2008;22(5): 575–584.

Lid Deformity Secondary to Fat Transfer

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Brian D. Cohen and Jason A. Spector

56.1  Introduction In the lower eyelid, the tear trough can be thought of as a triangle, bordered by the levator labii alaeque nasi muscle medially, the orbicularis oculi muscle laterally, and the levator labii superiorus muscle inferiorly (Fig. 56.1). This concavity may become accentuated with age as the suborbicularis oculi and malar fat pads atrophy, or can become more apparent after aggressive “defatting” of the lower lid. There are several techniques that can be used to correct the tear trough deformity by addition or replacement of volume. Of all the fillers currently available in

the United States, autologous fat is one option that has the potential to produce a permanent correction. Fat grafting not only corrects the tear trough deformity, but also helps restore the youthful appearance of the malar eminence by repositioning the transition zone between the eyelid and the malar region upward (1, 2). By augmenting volume, autologous fat transplantation (AFT) ameliorates the appearance of dark circles by smoothing the lower lid topography, which reduces shadows, and by decreasing the appearance of blood vessels directly under the skin (1). This useful technique in the armamentarium of plastic surgeons can provide the patient and surgeon with excellent aesthetic results, but like all cosmetic interventions, it can have unintended sequelae and should be performed with caution (3).

56.2  Contour Deformity

Fig. 56.1  Anatomy of the tear trough

B. 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 e-mail: [email protected]

The most common complication of autologous fat transfer to the lower eyelids is the creation of contour deformities in the form of visible lumps or bulges. Improper placement of any filler, in terms of location, quantity and texture, may result in significant deformity (3, 4). Although this may be a temporary problem (months) with most available fillers, the potential longevity of autogenous fat can make this a permanent problem. These contour deformities may be more apparent with a change in gaze or when a person smiles (Fig. 56.2). As the best treatment is prevention, any AFT to the lower lid should be performed using minute aliquots of fat (0.05–0.1 mL) per injection. Once present, however, there are many different approaches to the treatment of excess grafted fat in the lower eyelid including massage, steroid injections, suction assisted lipectomy (SAL) and direct excision (5). For small irregularities,

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a

b

Fig. 56.2  Bilateral lower lid deformities caused by autologous fat transplantation. (a) At rest. (b) While smiling. (c) At upward gaze. Note the irregular topography (L > R) exacerbated by

a

c

smiling. The protuberant lower lid fat causes an unaesthetic shadowing, and the lower lid skin itself appears to be hyperpigmented secondary to the underlying injected fat

b

Fig. 56.3  Through a subciliary incision, a skin flap was elevated and healthy appearing yellow fat was noted to lie nonanatomically (a) between the lower lid skin and the orbicularis, within the muscle. (b) as well as deep to the muscle

the first line of treatment should be to massage the irregularity between a fingertip and the underlying bone. Coleman recommends this be done four to six times per day for approximately 30 s, although there are no (non-anecdotal) data to demonstrate the efficacy of this technique. Another minimally invasive option involves intralesional injection of steroids (triamcinolone 5 mg/mL). Although steroids may successfully induce fat atrophy when locally injected, imprecise application can produce further complications including excessive atrophy of the fat grafts, thinning of the overlying eyelid skin, hyper or hypopigmentation and visible crystals (5). If a “lump” deformity is present at 3 months post AFT it will probably not respond to massage or steroid treatment and will likely require direct excision. For larger amounts of excessive fat in the lower lid, some have advocated SAL. However, there remains a paucity of peer-reviewed data to support the safety and

reliability of this technique when applied to the lower lid. Alternatively, excess fat can be excised directly via a subciliary incision (Figs. 56.3 and 56.4). Although direct excision may allow for complete removal of all fat lying in non-anatomical locations, this method should be used with caution since it may cause scarring of the anterior and middle lamellae resulting in ectropion. If such an aggressive approach is to be undertaken, the patient should be counseled preoperatively regarding potential complications, particularly the risk of ectropion. In the only peer reviewed series published, Kranendonk and Obagi (1) have shown their experiences using autologous fat transfer to the periorbital region. Although they report on 250 patients in their series, no details are provided as to exactly how many patients underwent AFT to the upper and/or lower eyelids. They reported performing corrective procedures on only two patients (less than 1%) who developed

56  Lid Deformity Secondary to Fat Transfer

a

b

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c

Fig. 56.4  Postoperative appearance of patient at 1 year. (a) At rest. (b) While smiling. (c) At upward gaze. The lower lid contour, hyperpigmentation, and shadowing are significantly

improved (Photos reprinted with kind permission of Springer Science and Business Media)

local “nodules” after fat transfer to the lower eyelids. One of these patients received a local steroid injection and the other patient opted to have the fat directly excised through a blepharoplasty incision. Few other details were given regarding this cohort of patients and no follow-up was provided.

improve by injecting more than the required volume of fat, anticipating that some of the fat graft will resorb. However, placing more than the required amount of fat should not be attempted in the periorbital region as even a small degree of overcorrection can be obvious. Another less common complication of periorbital AFT can result from hypertrophy of previously placed grafts (14, 15). Previous case reports using fat harvested from the abdomen have demonstrated growth of transferred fat as the patient gained weight (14, 15). As with all invasive procedures, infection is possible though the only published series reports a rate of less than 1%. Those authors did not routinely administer prophylactic antibiotics. Other consequences of AFT include fat resorption and possibly fat necrosis, which can lead to fibrosis, nodularity or a fatty pseudocyst (16).

56.3  Fat Embolization As documented by several case reports (6–11), the most serious and catastrophic complication associated with AFT to the face is embolization of the injected fat (5, 7, 12). The arterial supply to the periorbital region is through branches of the internal carotid system and thus injection of fat into this area may be associated with a greater risk of cerebrovascular or ocular ischemic event than other regions of the face supplied by the external carotid system (13). Although it is unclear how much intraarterial fat is enough to produce an embolic event, it is safe to assume that even minute quantities of fat inadvertently delivered intraarterially may have deleterious consequences. Prudent measures to reduce the likelihood of this dreaded complication include the use of a blunt cannula to avoid vascular penetration (1, 5, 12, 13), injection of the fat while the tip is in motion and moving in a retrograde fashion, as well as using smaller syringes that require less pressure to inject.

56.4  Miscellaneous When performing AFT, many plastic surgeons purposely overcorrect the contour they are attempting to

56.5  Conclusions Autologous fat transfer to the lower eyelid can be a very gratifying procedure as it can produce permanent correction of tear trough and contour deformities. As with any invasive procedure, AFT can result in significant local and systemic complications of which the practitioner should be cognizant prior to incorporating this technique into his practice. Although AFT to the periorbital region appears to be safe and is gaining popularity, there remains a paucity of peer-reviewed published data to corroborate this fact and until more data are available individual practitioners should exercise appropriate caution.

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References   1. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg 2007;33(5):572–578.   2. Trepsat F. Periorbital rejuvenation combining fat grafting and blepharoplasties. Aesthetic Plast Surg 2003;27(4):243–253.   3. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg 2008;32(3):411–414.   4. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367.   5. Coleman SR. Lower lid deformity secondary to autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg 2008;32(3):415–417.   6. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361.   7. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107(1):85–87.   8. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993; 24(4):615–616.

B. D. Cohen and J. A. Spector   9. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face. J Neurol 1998;245(1):53–54. 10. Thaunat O, Thaler F, Loirat P, Decrois JP, Boulin A. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 2004;113(7):2235–2236. 11. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 2003;61(8):1151–1152. 12. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesth Surg J 2002;22:555. 13. Feinendegen DL, Baumgartner RW, Vuadens P, Schroth G, Mattle HP, Regli F, Tschopp H. Autologous fat injection for soft tissue augmentation in the face: a safe procedure? Aesthetic Plast Surg 1998;22(3):163–167. 14. Miller JJ, Popp JC. Fat hypertrophy after autologous fat transfer. Ophthal Plast Reconstr Surg 2002;18(3):228–231. 15. Latoni JD, Marshall DM, Wolfe SA. Overgrowth of fat autotransplanted for correction of localized steroid-induced atrophy. Plast Reconstr Surg 2000;106(7):1566–1569. 16. Har-Shai Y, Lindenbaum E, Ben-Itzhak O, Hirshowitz B. Large liponecrotic pseudocyst formation following cheek augmentation by fat injection. Aesthetic Plast Surg 1996; 20(5):417–419.

Part Miscellaneous

VII

The Viability of Human Adipocytes After Liposuction Harvest

57

John K. Jones

57.1  Introduction Autologous adipose tissue has long been touted as a tissue source for soft-tissue volume augmentation in aesthetic and reconstructive surgery (1–7). The notion of grafting or transferring autologous adipose tissue is an attractive one because of the relative ease of harvest, low morbidity of harvest, and the volume of potential donor sites. The ability to avoid allogeneic or alloplastic materials and their potential infectious, antigenic, and immunologic responses is also of great benefit.

57.2  Historical Perspective In 1893, Neuber (1) reported on the use of surgically excised small block grafts with no overfilling. Although initially encouraged by the results, he was later disappointed by the significant resorption he observed. Lexer (2), in 1910, modified Neuber’s technique by using single large block grafts and reported excellent shortand long-term results. In an attempt to reproduce these outcomes, other surgeons used his techniques but were unable to duplicate his outcomes and instead noted significant resorption. In 1911, Bruning (3) used a syringe to inject small cubes of surgically harvested adipose. He also reported excellent initial results followed by disappointing resorption. Over the years many modifications of these techniques were tried but unfortunately

J. K. Jones 6818 Austin Center Blvd, Suite 204, Austin, TX 78731-3100, USA e-mail: [email protected]

were also characterized by lack of predictability due to resorption (8, 9). These early attempts at adipose grafting lacked a solid scientific basis. Some level of clinical success as possible based on clinical reports, but the fundamental tenets of free adipose transfer had not yet been established or tested. In an attempt to explain the results seen with adipose grafting, Neuhof (4), in 1923, proposed the “host replacement theory.” According to his theory, surgically transplanted adipose tissue does not survive but is gradually replaced by the host tissue, primarily in the form of fibrous connective tissue. His theory was opposed by Hausberger (5) and Gurney (6) with their “cell survivor theory.” They proposed that at least some of the adipocytes survived transplantation, but as the cells initially de-differentiated into a precursor cell, they called it a preadipocyte. They further proposed that these preadipocytes were capable of differentiation into mature adipocytes with appropriate stimulation. Despite the lack of basic scientific evidence to support adipose grafting the practice continued. A review of the literature on human free-adipose transfer reveals a plethora of techniques for both harvesting and transplantation. As with other surgical endeavors, the number of techniques and the predictability of outcome have a reciprocal relationship. In other words, if a simple, safe, predictable, and reproducible technique was readily available, the literature would not be replete with multiple techniques. Despite the lack of a scientific basis and unpredictable results, the notion of free adipose transfer for soft-tissue augmentation was too tempting to be abandoned. Prior to the early 1970s, compilation of available information suggested graft survival rates of 0–50%. These estimates were based on clinical outcome assessments, which are inherently subjective, thus

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little objective quantitative and qualitative information could be gained. Available laboratory studies using various animal species involved harvesting the material by various methods followed by surgical transfer or injection into areas typically devoid of adipose tissue to allow for objective outcome measures. When these areas were subsequently harvested and examined some information could be gained as to the viability of the grafts (10–12). Thus clinically apparent survival (subjective clinical outcomes) or sustained presence in  a grafted site (animal studies) was the only evidence we had for the viability of transplanted adipose tissue. It was not until the advent of cell and tissue culture techniques that some of the fundamental questions regarding human adipose tissue as a potential free graft tissue could be investigated. In 1971, Smith (7) described “fibroblast-like cells” grown in a tissue culture of human adipose tissue. In these early cell cultures, the cells were grown on a liquid medium. Mature adipocytes were observed to change phenotype to a fibroblast-like cell that was called a preadipocyte. In 1973, Poznanski et al. (13) were able to prove in vitro to isolate, identify, and culture preadipocytes. In a series of experiments, Van et al. (12–14) were able to prove in vitro to in vivo differentiation of preadipocytes to adipocytes. These investigators proved that adipose tissue could be surgically excised and remain viable, as demonstrated by growth in culture. They also showed that the cells could survive transplantation, thus satisfying the basic tenets for viable freeadipose transplantation.

Fig. 57.1  Macroscopic appearance of harvested adipose tissue on the day of harvest and transfer into cell culture. Note percentage of three-dimensional matrix covered by adipose tissue

J. K. Jones

57.3 Liposuction and Free Adipose Transfer At roughly the same time that cell culture techniques and basic science research satisfied the basic biologic tenets regarding free adipose transfer, liposuction techniques which were being developed. The development of adipose removal techniques by suction or aspiration stimulated a resurgence of interest in free adipose transfer for augmentation because of the relative ease and low morbidity of the harvest procedure. Pre­sumably the biologic basis for the transplantation of aspirated adipose was provided in the available literature concerning free-adipose transfer. To make this extrapolation was risky since nearly all of the available literature concerned adipose tissue that was harvested by gentle surgical excision and not by aspiration or suction. Empirically the aspiration process was potentially much more traumatic to the harvested tissue than gentle surgical excision. In 1997, Jones and Lyles (17) reported on the viability of human adipocytes after closed syringe liposuction harvest. Our study involved the harvesting of  human adipose tissue utilizing a tumescent technique and closed syringe liposuction instrumentation. After harvesting, the tissue was washed three times with normal saline and gentle agitation in the syringe. The tissue was then transferred to a cell culture ­system utilizing a three-dimensional matrix material (Fig. 57.1). Macroscopic observation revealed maintenance of mature adipose tissue in each culture ­without de-differentiation into a precursor phenotype

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Fig. 57.2  Macroscopic appearance of adipose tissue growing in cell culture media at 2 weeks after harvest. Notice macroscopic appearance and percentage of three-dimensional matrix block coverage

Fig. 57.3  Macroscopic appearance at 2 months. Note complete coverage of three-dimensional matrix and extension onto fluid media indicating continued growth and maintenance of mature phenotype

(Fig.  57.2). There was very little evidence of ongoing cell damage or demise. The cultures were observed to  enlarge and store lipid available in the media while  maintaining a mature phenotype (Fig. 57.3). Microscopic observation revealed maintenance of mature adipose tissue phenotype and very little evidence of cellular damage or debris (Fig. 57.4). Indeed the adipose tissue was observed to migrate into the matrix as mature adipocytes.

Fig. 57.4  Microscopic appearance at 4 weeks indicating maintenance of mature adipocyte phenotype

57.4 Viability of Human Adipocytes After Aspiration Harvest Jones and Lyles (15) were able to prove that, at least with their harvesting technique, mature adipocytes could be aspirated with a high degree of viability. This catalyzed the resurgent interest in fee adipose transfer  that had started with the development of various ­liposuction techniques. While clinical application was

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ongoing the variable, but generally encouraging, investigations continued in an endeavor to optimize safety and the predictability of clinical outcomes.

57.5  Aspiration Techniques In a study comparing aspiration techniques with gentle surgical excision Marques et al. (18) used an established animal model to compare the viability of free adipose grafts obtained by three different techniques. In the aspiration group specimens were obtained with either blunt edged or sharp edged cannulas. No other details regarding the harvest technique were shared. Outcomes were compared to those obtained by gentle surgical excision. Using retained percentage volume as a measure the results were blunt suction (14%), sharp suction (35%), and surgical excision (45%). Despite the lack of details regarding the aspiration technique the harvesting with sharp-edged cannulas compared favorably to gentle surgical excision demonstrating a similar viability outcome. In 2000, Sommer and Sattler (19) published an excellent review of the literative regarding adipose graft survival utilizing aspiration via syringe, syringe liposuction, and machine liposuction. They found that all three methods had the ability to yield graft tissue of significant viability. They also found that viability seemed to increase with more gentle aspiration i.e. the lowest negative pressures. In 2001, Shiffman and Mirrafati (20) compared various aspiration harvesting techniques utilizing syringes and cannulas. They found significant cell injury at suction pressures of −700 mm Hg and lower. At suction pressures less than 500 mm Hg they found good viability determined histologically. They also found with needle and syringe harvest that cellular damage increases substantially when harvesting with needles smaller than 18 gauge. Other authors/surgeons have contributed to the literature as well (21–26). When the literature regarding aspiration methods is critically reviewed the following clinical recommendations can be substantiated. Adipose tissue, like all free graft tissue, is subject to injury at the time of harvest. Gentle handling during the harvesting procedure yields the highest viability. Regarding harvesting by aspiration, machine and syringe methods compare favorably but suction pressures should be minimized to those levels necessary for success. Cannulas or needles of at least

J. K. Jones

18-gauge diameter should be used for the harvesting procedure.

57.6 Effect of Local Anesthesia and Epinephrine Since the harvesting procedure typically involves regional infiltration of the donor site with local anesthesia solutions frequently containing epinephrine, the effect of these medications on autologous adipose tissue has been investigated. In 1995, Moore et al. (27) reported their findings regarding the effect of lidocaine and epinephrine on adipocytes. Lidocaine was known to significantly inhibit glucose transport in vitro as demonstrated in cell culture. They found that this effect is only noted when the lidocaine is present and clears rapidly with the clearance of the lidocaine by metabolism, or washing. Epinephrine did not seem to have an effect on the harvested adipose tissue. Sommer and Sattler (19) echoed these conclusions in their excellent review and reminded us that the amide local anesthetics facilitate wound healing by reducing leukocyte migration, reducing local metabolic activation of leukocytes, and reducing the release of toxic substances such as free radicals and lysozymes which are known to impair healing. The presence of blood during the harvesting procedure is known to be potent stimulus for an inflammatory response at the donor and recipient sites. The presence of epinephrine as a vasoconstrictor can greatly assist hemostasis during the harvesting process and has not been seen to have any ill effect on the viability of the harvested tissue.

57.7  Tissue Handling Tissue handling protocols after harvesting have been investigated as contributor to graft viability. Various tissue handling techniques have been devised to wash the tissue of undesirable contaminants such as blood, cellular debris, etc, concentrate the adipocytes while removing contaminants, and potentially nourish the adipocytes during the handling process. Smith et al. (26) shared the results of their evaluation comparing multiple different handling protocols including various centrifugation schedules and washing solutions. Cell

57  The Viability of Human Adipocytes After Liposuction Harvest

viability was assessed by metabolic activity in vitro and by graft retention in an established animal model.

57.8  Tissue Storage Despite all of the evidence providing a sound biological basis for free adipose transfer as a choice when softtissue augmentation is desirable., clinical results remain somewhat unpredictable regarding long term graft retention. For this reason overfilling the defect is a common strategy to counter the expected resorption. Since repeat procedures are often necessary the question was raised as to whether adipose specimens obtained by aspiration can be stored for later use obviating the need for sub­ sequent harvesting procedures. In 2001, Shoshani et al. (28) reported on the role of frozen storage in preserving adipose tissue. After aspiration and tissue preparation specimens were stored at −18°C for 2 weeks. At that time they were thawed and injected into an established animal model for adipose transfer evaluation. Results were compared to those obtained with the same specimen injected at the time of harvest. There was no difference in the two groups regarding graft retention indicating retention of viability by cryo-preservation at −18°C.

57.9  Conclusions Viable adipocytes can be harvested via aspiration and yield successful soft-tissue augmentation in appropriate recipient sites. Utilizing viable adipose tissue as a free graft requires great care during the harvesting, transfer, and storage process for predictable results. By utilizing the gentlest possible instruments and procedure for harvest, and minimal tissue handling and preparation, viability can be preserved at a very high level allowing for the transfer of live adipocytes to an appropriate recipient site.

References   1. Neuber F. Chir Kongr Verh Dtsch Ges Chir 1893;22:66.   2. Lexer E. Ueber freie fetttransplantation. Klin Ther Wehnschr 1911;18:53.   3. Bruning P. Cited by Broeckaert TJ. Contribution a l’etude des greffes adipeuses. Bull Acad Roy Med Belgique 1914;28:440.

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  4. Neuhof H. The Transplantation of Tissues. New York, Appleton, 1923, pp. 73.   5. Hausberger FX. Quantitative studies on the development of autotransplants of immature adipose tissue of rats. Anat Rec 1955;122(4):507–515.   6. Gurney CE. Studies on the fate of free transplants of fat. Proc Staff Meet Mayo Clin 1937;12:317.   7. Smith U. Morphological studies of human subcutaneous adipose tissue in vitro. Anat Rec 1971;169(1):97–104.   8. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990;85(3):378–386.   9. Eppley BL, Sidner RA, Plastis JM, Sadove AM. Bioactivation of free-fat transfers: A potential new approach to improving graft survival. Plast Reconstr Surg 1992;90(6):1022–1030. 10. Saunders MC, Keller JT, Dunsker SB, Mayfield FH. Survival of autologous fat grafts in humans and mice. Connect Tissue Res 1981;8(2):8591. 11. Poznanski WJ, Waheed I, Van R. Human fat cell precursors. Morphologic and metabolic differentiationin culture. Lab Invest 1973;29(5):570–576. 12. Van RL, Bayliss CE, Roncari DA. Cytological and enzymological characterization of adult human adipocyte precursors in culture. J Clin Invest 1976;58(3):699–704. 13. Van RL, Roncari DA. Complete differentiation of adipocyte precursors: A culture system for studying the cellular nature of adipose tissue. Cell Tissue Res 1978;195(2):317–329. 14. Van RL, Roncari DA. Complete differentiation in vivo of implanted cultured adipocyte precursors from adult rats. Cell Tissue Res 1982;225(3):557–566. 15. Jones JK, Lyles ME. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997;14(3):275–279. 16. Peer LA. Loss of weight and volume in human fat grafts: With postulation of a “cell survival theory.” Plast Reconstr Surg 1950;5:217–230. 17. Ersek RA. Transplantation of purified autologous fat: A 3 year follow-up is disappointing. Plast Reconstr Surg 1991;87(2):219–227. 18. Marques A, Brenda E, Saldiva PH, Amarante MT, Ferreira MC. Autologous fat grafts: A quantitative and morphometric study in rabbits. Scand J Plast Reconstr Hand Surg 1994;28(4):241–247. 19. Sommer B, Sattler G. Current concepts of fat graft survival: Histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000;26(12):1159–1166. 20. Shiffman MA, Mirrafati S. Fat transfer techniques: The effect of harvest and transfer methods on adipocyte viability and review of the literature. Dermatol Surg 2001;27(9):819–826. 21. Huss FR, Kratz G. Adipose tissue processed for lipoinjection shows increased cellular survival in vitro when tissue engineering principles are applied. Scand J Plast Reconstr Surg Hand Surg 2002;36(3):166–171. 22. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis of lipocyte viability after liposuction. Plast Reconstr Surg 2002;109(2):761–765. 23. Leong DT, Hutmacher DW, Chew FT, Lim TC. Viability and adipogenic potential of human adipose processed cell population obtained from pump-assisted and syringe-assisted liposuction. J Dermatol Sci 2005;37(3):169–176.

444 24. Von Heimburg D, Hemmerich K, Haydarlioglu S, Staiger H, Pallua N. Comparison of viable cell yield from excised versus aspirated adipose tissue. Cells Tissues Organs 2004;178(2):87–92. 25. Moore JH Jr, Kolaczynski JW, Morales LM, Considine RV, Pietrzkowski Z, Noto PF, Caro JF. Viability of fat obtained by syringe suction lipectomy: Effects of local anesthesia with lidocaine. Aesthetic Plast Surg 1995;19(4):335–339.

J. K. Jones 26. Smith P, Adams WP Jr, Lipschitz AH, Chau B, Sorokin E, Rohrich RJ, Brown SA. Autologous human fat grafting: Effect of harvesting and preparation techniques on adipocyte graft survival. Plast Reconstr Surg 2006;117(6):1836–1844. 27. Shoshani O, Ullmann Y, Shupak A, Ramon Y, Gilhar A, Kehat I, Peled IJ. The role of frozen storage in preserving adipose tissue obtained by suction-assisted lipectomy for repeated fat injection procedures. Dermatol Surg 2001;27(7):645–647.

Autologous Fat Grafting: A Study of Residual Intracellular Adipocyte Lidocaine1

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Robert W. Alexander

58.1  Introduction With the evolution of minimal traumatic harvesting equipment and techniques, there is continued growth of interest in the ability to successfully provide volume tissue augmentations of the face and body. Since the advent of superpolished cannulas and closed syringe systems, harvesting has become easier and graft acceptance more predictable (1–6). As the preferred equipment armamentarium has stabilized, attention has turned to recognition of factors that have significant influence on the safety and efficacy of adipose-derived grafts. Among those factors recognized as potentially important, the decision as to whether it is advantageous to provide harvested cells with rinsing prior to addition of additives or actual transfer (4–6). On the basis of evidence that lidocaine solution may influence metabolic activity within the graft or host tissues, evaluation of effects of serial rinsing was carried out. Transplantation of autologous live adipocytes and precursor cells for purposes of contour augmentation, structural enhancement, or filling of defects has become one of the most common modalities and surgical treatment options. With the understanding of tumescent infiltration providing a vehicle in which the donor cellular matrix can become suspended, use of controlled, low pressure harvest with closed syringe

Author has no financial interest in Tulip Medical, Harvest Technologies or Shippert Medical.

1

R. W. Alexander Department of Surgery, University of Washington, Seattle, WA, USA 3500 188th St., S.W. Suite 670, Lynnwood, WA 98037, USA e-mail: [email protected]

techniques has become very important. It is clear, both from clinical and laboratory evidence that viability, in vitro, has been enhanced (1–3). Relatively little information has been available regarding concentration of the intracellular lidocaine solution following use of the standard tumescent concentrations of 0.05–0.1% lidocaine. The potential for metabolic alteration during early graft phases, and in the longer-term reactivation of storage activities seen in tissue culture, makes evaluation of the lidocaine elements a potentially important subject. Throughout existing literature and presentations, controversy still remains as to the cellular survival quantities, and even less understood features of use of additives to enhance the return to metabolic storage activities within the grafted cells. The wide ranges reported in the literature claim survival rates of 40–60%, often not accounting for the fluid medium volumes introduced during the actual grafting. It is clear that cells and matrix are “floated” out of selected donor sites, often compressed slightly with gentle centrifugation, and then transferred within a liquid carrier during placement. It is, therefore, very important to account for the volume of extracellular fluid at the time of all graftings. This fluid volume resorption should be anticipated and certainly not interpreted as loss of cellular volume resultant from the grafts themselves (6). Tissue culture suggests very high cellular survival rates, often reported in the 90+ percentile (1). Selection of the genetically driven fat deposits as potential donor sites has gradually been better recognized and understood (4–19). The surgeon’s access should be given minor importance relative to the harvest of prime storage cellular elements, often referred to as “primary fat deposits.” Such sites are metabolically relatively unavailable to diet and exercise. Further, it is believed that transplanted adipose tissues retain

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donor-site characteristics, known in other graft applications as donor-site memory (4, 6). Evidence derived from large volume grafting, such as retroglandular breast enhancement, has shown the diet-exercise resistance to loss and/or susceptibility of proportionally greater enlargement in cases of weight gain in the years following the procedures. In long-term follow-up evaluations, it has been documented that a patient gains weight in the postoperative period with no gain at the donor-site areas compared to the transferred areas, making additional cup size increases (5–7, 13). Placement of grafts within a series of overlapping tunnels has proven effective, particularly when grafts can be surrounded by other adipose elements and their metabolic environment. Placement of grafts in “pools” is to be avoided, as the circulatory and wound -healing issues are at a disadvantage in the central graft-deposit areas (13). It is important that physicians maintain an open mind when considering utilization of autologous fat transfer, and must consider that incomplete or less than desired results may not be a direct result of an invalid theory, but more related to lack of experience, errors of technique (such as too small harvest-transfer cannulas or too much pressure, etc.), incomplete clinical trials, or inadequate attention to detail (4, 6). Evaluations of efficacy still predominantly based on clinical outcome analyses, which are inherently subjective and challenge us to obtain accurate, objective, and quantitative information (4, 20–21). Studies are now underway to try to provide a biological means to determine quantity of graft versus native tissue elements in graft sites. Published reports regarding the actual cellular survival of transplanted adipose-derived cells and mesenchymal stem cells suggest that selection of genetically select cells high in Alpha 2-type receptors may maximize success (22). Since we do not have a complete understanding of how absorbed chemicals introduced during the harvesting process, including lidocaine solution, affect cellular metabolism or viability of graft cells, the author has studied the effects of serial rinsing on the intracellular lidocaine. Arner et al. (23) reported the inhibitory effects of local anesthetics with free tertiary amino groups, including lidocaine and prilocaine, on human adipocytes in cell culture. Moore et al. (24) expanding further on this concept found that adipocytes exposed to lidocaine, both with and without epinephrine inhibited glucose transport and contributed to lipolysis in vitro. They found a 40% reduction in lipolysis in the short term, coupled with lack of cellular

R. W. Alexander

attachment, spreading, and proliferation. According to Moore, after washing and transferring cells to a lidocaine-free environment, apparent normal metabolic activity and growth patterns were re-established. Moore concluded that basal cells and epinephrine in the samples were probably responsible for restimulating lipolysis after the inhibitory effect of lidocaine was effectively reduced or removed (24). Current techniques for harvesting adipose and matrix tissues commonly involves use of tumescent solutions bearing very dilute local anesthetic and epinephrine. It is currently believed by this author that well-rinsed, highly cellular grafts treated with platelet rich plasma (PRP) have the highest retention rates and long-term augmentation success (4–6, 13). The purpose of evaluating residual intracellular lidocaine levels and demonstrating the effect of serial rinsing techniques is that they may have a positive bearing on graft retention and more rapid return to metabolic activity.

58.2  Materials and Methods Ten consecutive patients scheduled to undergo elective abdominal liposuction were evaluated in this study. Each patient served as his or her own control, using the same site for fat harvest per protocol. Samples of adipocyte and matrix elements were harvested with 1 cc of tumescent infiltrate per cc of adipose removal. The tumescent solution concentration was specifically 0.1% lidocaine with 1:1,000,000 epinephrine in normal saline. Following injection of tumescent solution, a delay of 15 min was allowed to insure equal absorption and vasoconstrictive effects. The fat tissues were then harvested from the infraumbilical abdominal area utilizing the patented closed Tulip Syringe Cell Friendly systemTM. A 25-cm, 3.7-mm bi-beveled cobra tip cannula using the 60-mL Toomey syringe was selected. Harvest was performed with low pressure application of 20 mL incremental withdrawal of plunger. The first group of samples consisted of 10 mL aliquots of harvested adipose cells and matrix and was not rinsed. The second group of samples extracted was rinsed in an equal volume of normal saline. Five minutes were allowed between washing and separation of infranatant fluids. The third group was submitted to two such rinsing cycles using the same parameters. The final group underwent three rinse cycles per protocol. In each patient, the initial samples were not rinsed,

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

and served as control for the individual patient sampling groups. After extraction and rinsing, each sample was immediately frozen at −4°C. In a follow-up study, hand centrifugation was performed with noncontrol group to evaluate any significant differences in cases where slow speed centrifugation would be used. The results were unchanged by the use of slow speed centrifugation used to attempt to compress the cellular elements into smaller volume prior to transfer.

58.3  Processing of Samples The samples of frozen adipose tissues were processed (20–25). Each sample was thawed at room temperature and blot-dried on filter paper before being weighed. Weight was typically between 50 and 100 mg. One milliliter of 1 M NaOH was added to each sample. The samples were then lysed and homogenized. A 3 mL volume of heptate ethyl acetate at 1:1 concentration was added to each sample, along with internal standard, bupivacaine 0.5 mg, to act as control for gas chromatography. Each sample was then mixed via vortexing and centrifugation for 1 min at 1,500 × g. The samples were then transferred to an auto sampler vial to undergo analysis by mass spectrometry gas chromatography (25–30).

447

Statistical analysis was performed to determine whether there was a significant difference in intracellular lidocaine concentrations between samples with different numbers of rinses performed. Table 58.2 show the mean concentration (mg/g) of intracellular lidocaine within each group. The standard deviation and standard error of the mean arc were listed. The normality test pass with p > 0.200 and the equal variance test passed with p = 0.067. The differences in the mean values amongthe treatment groups were greater than expected by chance, meaning that there is a statistically significant difference (p < 0.001). To isolate which group or groups differed from the others, a multiple comparison procedure was performed using the Bonferroni t-test. The results are provided in Table 58.3. Table 58.2  Analysis of lidocaine concentration within each group Sample group

Mean concentrationa (mg/g)

Standard deviation

Standard error mean

No rinse (Group 1) One rinse (Group 2) Two rinse (Group 3) Three rinse (Group 4)

276

121

38

132

  74

24

  72

  48

15

  34

  23

 7

a Mean concentration (mg/g) of intracellular lidocaine within each group

Table 58.3  Bonferroni t-test results

58.4  Results of Samples The results for the patient samples and various rinses are listed in Table 58.1. The reported measurements are in micrograms of lidocaine per gram of adipose tissue. Table 58.1  Micrograms of lidocaine per gram (mg/g) of adipose tissue for the four samples from each subject

Comparison

Difference of mean

t score

p < 0.05

Group 1 vs. Group 4 Group 1 vs. Group 3 Group 2 vs. Group 2 Group 2 vs. Group 4 Group 2 vs. Group 3 Group 2 vs. Group 4

2.42e + 0.002 2.04e + 0.002 1.44e + 0.002 97.9 59.8 38.1

10.2   8.6   6.1   4.1   2.5   1.6

Yes Yes Yes Yes No No

Patient

No rinse (control)

One rinse (mg/g)

Two rinses (mg/g)

Three rinses (mg/g)

D.B. K.H. J.P. L.H. A.T. C.B. A.M. R.M. A.H. J.A.

177 250 199 395 423 457 373 162 144 184

150 109 102 271 199 145 192   57   56   38

  51   63   24 126 132   71 152   54   29   19

33 31 10 18 90 46 47 29 24 12

448

58.5  Discussion Liposuction for the removal of unwanted fat deposits or for autologous graft purposes has become one of the most frequently performed procedures worldwide. Fat grafting for site specific augmentation and structural enhancement has great acceptance of useful procedures that are safe and effective. Appreciation of the use of such grafts in three dimensional facial aging applications, as well as in breast tissues has greatly increased in the surgical communities over the past 5 years. Foreign materials and devices for augmentation often present with certain disadvantages when compared with use of plentiful autologous materials. Surgeons performing procedures using fat transfer techniques must develop and standardize protocols in order to reach valid conclusions regarding safety and to maximize efficacy of such techniques. In addition, more scientific studies are needed to determine many fundamental considerations when rationally evaluating autologous fat transfer procedures. Shiffman (31, 32) presented a compilation of materials that clearly identify wide range of opinions and controversy surrounding the variety of protocols involved in fat grafting techniques. To be able to interpret results, standardization is a critical issue. Notwithstanding the variety of techniques and additives used during harvest, preparation, and transfer of adipose tissue, clinical studies are gradually addressing such issues as the basic media in which to harvest or transfer, the ideal cannula configuration (tips, internal diameters, pressures applied), and clinical volumes achieved. Over the past 10 years, the efficacy and advantages contributed by additives such as PRP, membrane stabilization (albumin, etc.), and insulin-based materials has been enhanced significantly (33–36). Enhancement of cellular survival, coupled with the potential induction of included stem cell elements in the adipose matrix seems to play a key role in successful autologous fat grafting. It is intuitive to realize that factors that increase cellular survival and differentiation coupled with early return to metabolic activity should become a part of the standards in these techniques (5, 13). There is an increasing number of studies confirming that the use of protein-rich plasma and plateletderived growth factors increase cellular viability, rate of graft acceptance, and early return to metabolic state. All these contribute to a long-term augmentation value achieved by grafting autologous fat (5, 13). As it is well known that lidocaine solutions are very lipophilic, understanding the implications to success

R. W. Alexander

with fat grafting is important. The presence of high concentrations of intracellular local anesthetic solutions in grafted lipocytes is among the potential influential factors in the overall graft success. Likewise, the potential for adverse effects must be addressed in this regard. For example, it has been shown that lidocaine inhibits lipolysis (23, 24). It has also been suggested that rinsing the lidocaine-containing fat cells restimulates lipolysis as if lidocaine was never present (24). In this report, there was a statistically significant decrease in the amount of lidocaine within the adipocyte with two rinsings as compared with the control (no rinse). However, it appears that subsequent rinsings did not significantly alter residual intracellular concentration. Gas chromatography analyses of both control and rinsed samples suggest that lidocaine still exists within the adipocyte, even after three separate rinsings. These findings have generated many new questions, the answers to which may have a profound effect in the fields of lipocontouring and esthetic surgery applications. If lidocaine adversely effects fat cell metabolism on a short or longer-term basis, and if we are not able to completely remove the intracellular lidocaine with rinsing, then are we inhibiting lipolysis, proliferation and growth of grafted adipocytes and stem cell elements? Should only dilute epinephrine and balanced salt solutions be used when graft cells are harvested for transplantation? How does the addition of other metabolically active or stimulatory proteins and growth factors alter cellular survival or metabolic recovery? How can we document the quantitative acceptance of grafted cells in the recipient environment? In any case, it is the author’s opinion that reasonable reduction of intracellular lidocaine levels is considered advantageous. To that end, many small volume grafting to the facial areas are harvested without local anesthetic solution, but include 1:1,000,000 epinephrine. In larger volume transfers such as breast and buttock areas, rinsing and addition of PRP (Harvest Technologies, Plymouth, MA) is currently favored.

58.6  Conclusions Autologous fat transplantation does offer a viable methodology for purposes of contour and volume augmentation, enlargement, or filling of defects within esthetic and reconstructive surgery. The use of fat grafting in large and small volume applications are

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

gaining popularity because of the ready availability of donor grafts during lipocontouring procedures, more and better long-term survival reports, improved standard protocols for harvest, preparation and transfer, and improved appreciation of scientific factors in fatcell differentiation and metabolism. Consistent and long-term results appear to be relatively technique specific, and should be judged relative to the degree of long-term clinical contour improvement and degree of patient satisfaction. At this point in time, estimates of graft success are predominantly subjective; such evaluations offer the challenge to obtain accurate, objective, quantitative information. Evaluation via tissue culture evidence, biopsy of grafted adipocytes, and reports of sustained augmentation effects in long-term grafts seem to be our best parameters. This study indicates that serial rinsing of minimally traumatize adipose elements effectively reduces the residual intracellular lidocaine concentrations. With a minimum of two such rinses, statistically significantly lower concentrations are left in the grafted cells. Besides effectively reducing lidocaine concentrations, reduction of cellular remnants and free lipids can be separated and removed from intended grafts. These factors are considered as important in large volume transfers as they are in the more common small volume applications.

References   1. Jones JK, Lyles ME. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997;14:275–280.   2. Kononas TC, Bucky LP, Hurley C, May JW. The fate of suctioned and surgically removed fat after re-implantation for soft-tissue augmentation: A volumetric and histologic study in the rabbit. Plast Reconstr Surg 1993;91(5):763–768.   3. Johnson GW. Body contouring by macroinjection of autologous fat. Am J Cosmet Surg 1987;4:103–109.   4. Alexander RW. Liposculpture in the superficial plane; closed syringe system for improvements in fat removal and free fat transfer. Am J Cosmet Surg 1992;11:127–134.   5. Abuzeni PZ, Alexander RW. Enhancement of autologous fat transplantation with platelet rich plasma. Am J Cosmet Surg 2001;18:59–70.   6. Alexander RW, Sadati K, Corrado A. Platelet rich plasma (PRP) utilized to promote greater graft volume retention in autologous fat grafting. Am J Cosmet Surg 2006;23(4): 203–221.   7. Fulton JE. Breast contouring by autologous fat transfer. Am J Cosmet Surg 1992;19:273–279.

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  8. Newman JE, Ftaiha Z. The bibliographical history of fat transplantation surgery. Am J Cosmet Surg 1987;4:85–90.   9. Fournier PF. Liposculpture: The Syringe Technique. Paris, France, Arnette, 1991. 10. Asken S. Autologous fat transplantation: Micro and macro techniques. Am J Cosmet Surg. 1987;4:111–117. 11. Krulig E. Lipoinjection. Am J Cosmet Surg 1987;4:123–127. 12. McCurdy JA. Five years of experience using fat for leg contouring (commentary). Am J Cosmet Surg 1995;12: 228–233. 13. Alexander RW. Fat transfer with platelet-rich plasma for breast augmentation. In: Shiffman MA (ed), Breast Augmentation: Principles and Practice, Berlin, Springer 2008 In publication. 14. Asaadi M, Haramis HT. Successful autologous fat injection at 5 year follow-up. Plast Reconstr Surg 1993;91(4):755–756. 15. Carraway JH, Mellow CG. Syringe aspiration and fat concentration: A simple technique for autologous fat injection. Ann Plast Surg 1990;24(3):293–296. 16. Bircoll M. Autologous fat tissue augmentation. Am J Cosmet Surg 1987;4:141–149. 17. Billings E, May J. Histological review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;83(2):368–381. 18. Obaji S. Selecting for fat transfer success. Cosmet Surg Times 2006;9(4):26. 19. Bircoll M. A nine-year experience with autologous fat transplantation. Am J Cosmet Surg 1992;(1):55–61. 20. Peer LA. Transplantation of Tissue, Transplantation of Fat. Baltimore, MD, William & Wilkins, 1959. 21. Illouz YG. The fat cell “graft”: A new technique to fill depressions. Plast Reconstr Surg 1986;78(1):122–123. 22. Hiragun A, Sato M, Mitsui H. Establishment of a clonal cell line that differentiated into adipose cells. In Vitro 1980; 16(8):685–693. 23. Arner P, Arner O, Ostman J. The effect of local anesthetic agents on lipolysis by human adipose tissue. Life Sci 1973; 13(2):161–169. 24. Moore JH, Kolaczynski JW, Morales LM. Viability of fat obtained by syringe suction lipectomy: Effects of local anesthesia with lidocaine. Aesthetic Plast Surg 1995;19(4):335–339. 25. Kawai R, Fujuta S, Suzuki T. Simultaneous quantitation of lidocaine and its four metabolites by high-performance liquid chromatography: Application to studies on in vitro and in vivo metabolism in lidocaine in rats. J Pharm Sci 1985; 74(11):1219–1224. 26. Benowitz N, Rowland M. Determination of lidocaine in blood and tissues. Anesthesiology 1973;39(6):639–641. 27. Karch FE, Chmielewski KF. GLC assay for lidocaine in human plasma. J Pharm Sci 1981;70(2):229–230. 28. Naito E, Matsuki M, Shimoji K. A simple method for gas chromatographic determination of lidocaine in tissue. Anesthesiology 1977;47(5):466–467. 29. Chen Y, Potter J, Ravenscroft PJ. A quick, sensitive high-performance liquid chromatography assay for monoethylglycinexlidide and lignocaine in serum/plasma using solid-phase extraction. Ther Drug Monit 1992;14(4):317–321. 30. Kushida K, Oka K, Suganuma T, Ishizaki T. Simultaneous determination of lidocaine and its principal metabolites by liquid chromatography on silica gel, with aqueous eluent. Clin Chem 1984;30(5):637–640.

450 31. Shiffman MA. Autologous fat transplantation. Am J Cosmet Surg 1997;14:433–443. 32. Shippert R. Autologous fat transfer: Eliminating the centrifuge, decreasing lipocyte trauma, and establishing standardization for scientific study. Am J Cosmet Surg 2006;23(1): 21–27. 33. Ullmann Y, Hyams M, Ramon Y, Beach D, Peled IJ, Lindenbaum ES. Enhancing the survival of aspirated human fat injected into nude mice. Plast Reconstr Surg 1998; 101(7):1940–1944.

R. W. Alexander 34. Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg 1993;17(2):113–115. 35. Sugihara H, Yonemitzu N, Yun K. Primary cultures of unilocular fat cells: Characteristics of growth in vitro and changes in differentiation properties. Differentiation 1986;31(1):42–49. 36. Hauner H, Schmid P, Pfeiffer EF. Glucocorticoids and insulin promote the differentiation of human adipocyte precursor cells into fat cells. J Clin Endocrinol Metab 1987;64(4): 832–835.

Autologous Fat Transfer National Consensus Survey: Trends in Techniques and Results for Harvest, Preparation, and Application

59

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 59.1  Introduction There has been interest in autologous fat transfer since the inception of whole-fat grafts in the 1890s (1) and injectable fat grafts in the 1920s (2). The earliest recorded human free fat transfer was performed by Neuber in 1893. He demonstrated viability of autologous fat transferred into scar tissue based upon clinical evaluation. Neuber emphasized the importance of small grafts for more predictable results, a concept believed integral in current methods. Early optimism was tempered by Peer (3), a pioneer in the science of autologous tissue transfer, who histologically determined that fat grafts lost about 45% of their weight and mass 1 year or more following transplantation. Interest in autologous fat transfer waned until the re-emergence of the procedure in the late 1980s, which correlated with the widespread application of suction lipectomy for body contouring. In the last 20 years, the literature has seen numerous clinical reports highlighting the benefits of autologous fat transfer for facial recontouring (4–7). A  greater understanding of how to maintain viable fat  has led to modifications in technique, which is believed to improve clinical results. These modifications are intended to preserve the delicate structure of  adipocytes and provide a robust blood supply upon  which fat cells are extremely dependent (8). Unfortunately, the clinical optimism expressed by the proponents of the procedure has not been corroborated by objective scientific assessments. There are

J. P. Bradley () Division of Plastic and Reconstructive Surgery, 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA e-mail: [email protected]

many conflicting studies and physician experiences that exist regarding the durability and integrity of autologous fat grafts (9). It has been suggested that the variability in donor site and tissue preparation make a difference in graft take and survival (10). Ultimately, it may be that physician and patient satisfaction are the true indicators of the utility of the ­procedure. In order to assess this, we distributed a 30-question survey to a subset of plastic surgeons to examine the beliefs, practices, and satisfaction of both physician and patient.

59.2  Methods A questionnaire was mailed to 650 plastic surgeons randomly selected from the American Society for Aesthetic Plastic Surgery master file in February 2005. The completion of the questionnaire was strictly voluntary and without compensation. The questionnaire was designed to delineate the experience, practices, and beliefs among plastic surgeons with regard to the use of autologous fat for contour restoration. The questionnaire contained 30 multiple-choice questions with ordinal variables as well as an open-ended question used to obtain data for further focus group research (Table 59.1). Surgeon experience was assessed on the basis of the number of fat transfers performed per year either independently or in conjunction with other facial rejuvenation procedures. Surgeon practices and methods for autologous fat transfer were evaluated on the basis of surgeons’ preferences for (a) harvest and transfer sites, (b) local anesthetic used at both sites, (c) technique used for fat harvest (e.g., cannula, microcannula, excision) and transfer (e.g. cannula, needle, and ratchet gun),

M. A. Shiffman (Ed.), Autologous Fat Transfer DOI: 10.1007/978-3-642-00473-5_59, © Springer-Verlag Berlin Heidelberg 2010

451

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M. R. Kaufman et al.

Table 59.1  The 30-question autologous fat transfer survey sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. 508 surgeons responded Autologous fat transfer survey 1)  How many fat transfer procedures do you perform per year? (a)  <10 (b)  10–30 (c)  30–50 (d)  >50 2)  What percentage of fat transfers are performed in conjunction with other facial rejuvenation procedures? (a)  <25% (b)  25–50% (c)  50–75% (d)  75–100% 3)  What is/are the preferred harvest location/donor site(s). for injectable fat? (mark all that apply). (a)  Gluteal (b)  Thigh (c)  Flank (d)  Abdomen (e)  Knee (f)  Other (g)  I do not perform fat injection 4)  What is/are the preferred harvest location/donor site(s). for excised fat? (Mark all that apply). (a)  Gluteal (b)  Thigh (c)  Flank (d)  Abdomen (e)  Knee (f)  Other (g)  I do not perform fat excision 5)  What local anesthesia is used for the donor site? (a)  0.5% xylocaine with epinephrine (b)  1% xylocaine with epinephrine (c) Wetting solution (50 mL 1% xylocaine + 1 mL epinephrine 1:1,000 + 1 L NS). (d)  Epinephrine alone (e)  Other 6)  What harvest technique is used? (a)  Liposuction cannula (b)  Microcannula (c)  Syringe + large bore needle (d)  Direct excision (e)  Other 7)  If a liposuction cannula is used, what size? (a)  1 mm (b)  2 mm (c)  3 mm (d)  4 mm (e)  Other (f )  n/a 8)  If a syringe and needle are used, what size? (a)  14 gauge (b)  16 gauge (c)  18 gauge

(d)  Other (e)  n/a   9)  After harvest how do you treat the fat? (a)  Nothing (b)  Washing (c)  Centrifugation (d)  Adding insulin (e)  Other 10)  Do you ever freeze excess fat for later application? (a)  Yes (b)  No 11)  If you perform direct excision, what does the graft consist of? (a)  Fat alone (b)  Dermis and fat (c)  Fascia and fat (d)  Dermis, fascia, and fat (e)  Other (f )  I do not perform direct excision 12)  What local anesthesia is used at the injection site? (a)  0.5% xylocaine with epinephrine (b)  1% xylocaine with epinephrine (c) Wetting solution (50 mL 1% xylocaine + 1 mL epinephrine 1:1,000 + 1 L NS). (d)  Epinephrine alone (e)  Other 13) What anatomical locations do you place fat grafts? (mark all that apply). (a)  Forehead (b)  Upper eyelids (c)  Lower eyelids (d)  Nasojugal region (e)  Malar region (f )  Nasolabial fold (g)  Lips (h)  Chin 14)  What do you use to inject the fat? (a)  Cannula (b)  Needle (c)  Ratchet gun (d)  Other 15)  Do you overcorrect the defect? (a)  Yes (b)  No 16)  If so, by what percentage? (a)  10% (b)  20% (c)  30% (d)  40% (e)  50% or greater 17) Into what layer do you place the graft? (a)  Dermal (b)  Subcutaneous (c)  Intramuscular (d)  Other (continued)

59  Autologous Fat Transfer National Consensus Survey

453

Table 59.1  (continued) 18) How do you assess the long-term results of fat injection? (mark all that apply) (a)  Photography - 35 mm camera (b)  Digital photography (c)  Examination: palpation (d) Volumetric imaging: Radiographic imaging, Laser scanner or 3D photography 19)  Do you believe all fat that is injected survives? (a)  Yes (b)  No 20)  If not, what % do you think survives? (a)  >75 (b)  50–75 (c)  25–50 (d)  <25 21) Do you think that augmentation from fat persists 6 months after injection? (a)  Yes (b)  No 22) If not, what % of original augmentation persists 6 months after injection? (a)  >75 (b)  50–75 (c)  25–50 (d)  <25 23) Do you think the maintenance of volume at 6 months is a result of fat survival, replacement with scar, or a combination? (a)  Fat survival (b)  Replacement with scar (c)  A combination 24) Do you think there is a difference in survival based upon injection site? (a)  Yes (b)  No 25) If so, what site(s). do you think are best with regard to fat survival? (mark all that apply). (a)  Forehead (b)  Upper eyelids

(c)  Lower eyelids (d)  Nasojugal region (e)  Malar region (f )  Nasolabial fold (g)  Lips (h)  Chin 26)  What is the longest graft survival you have achieved? (a)  6 months or less (b)  6 months to 1 year (c)  1–2 years (d)  >2 years 27) What % of patients require repeat injections? (a)  <10 (b)  10–30 (c)  30–50 (d)  <50 28) In your estimation, what is the short-term (<6 months). patient satisfaction with the procedure? (a)  Excellent (b)  Good (c)  Fair (d)  Poor 29) In your estimation, what is the long-term (>6 months). patient satisfaction with the procedure? (a)  Excellent (b)  Good (c)  Fair (d)  Poor 30) In your estimation, what is the overall patient satisfaction with the procedure? (a)  Excellent (b)  Good (c)  Fair (d)  Poor

Please feel free to comment on your personal experience and/or technique with autologous fat transfer (i.e., What do you do to achieve better, longer lasting results?)

(d) postharvest pretransfer fat preparation, (e) need for overcorrection, and (f) method for long-term evaluation of results. Finally, the questionnaire elucidated surgeons’ attitudes and beliefs regarding autologous fat transfer by asking their experience regarding (a) the percentage of fat that persists at 6 months; (b) whether what persists is fat, scar, or a combination; (c) the percentage of patients who require repeat transfers; and (d) short- (<6 months) and long-term (>6 months) patient satisfaction.

Surveys were returned to the investigators via mail or facsimile. In order to increase the response rate, “no  response” was followed up with one phone call asking the physician to take time for the survey, or by resending the questionnaire. The completed questionnaires were entered into a database (MS Access) by one investigator, and the quality of data entry was checked by a separate investigator. Calculation of crude percentages and correlations were conducted by our group of statisticians.

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Of the 650 questionnaires mailed, 508 (78%) were returned completed in their entirety and used for analysis. Three hundred and six physicians responded after a first request, and 202 responded after a second request. The 508 who responded represented surgeons from all 50 states. Ten questionnaires were returned blank, either because of bad addresses or with notes indicating valid reasons for non-response (e.g., intended recipient deceased or not in practice). Sixteen questionnaires were returned incomplete, and no response was received from 116 physicians surveyed.

Percentages

59.3  Results

100 90 80 70 60 50 40 30 20 10 0

89

34 25

Abdomen

Thigh

Flank

12

11

Gluteal

Other

Location

Fig. 59.1  Percent of surgeons choosing these harvest locations/ donor sites. The surgeons could choose more than one site 60

54

59.4  Experience Of the 508 surgeons surveyed regarding general fat transfer (injectable fat, dermal fat graft or other transfers), 41% perform less than 10 fat transfers annually, 35% perform between 10 and 30, and 24% perform more than 30. Forty-four percent of physicians perform fat transfers concurrent with other facial reju­ venation procedures in a majority of cases, whereas the remaining 56% tend to perform them as isolated procedures.

59.5  Technique The most common solutions used for local anesthesia at the harvest site are wetting solution (50 mL 1% xylocaine + 1 mL epinephrine 1:1,000 + 1 L normal saline) (40%), 0.5% xylocaine epinephrine mixture (30%), or 1% xylocaine epinephrine mixture (22%), whereas 8% of respondents use either epinephrine alone or some other solution. Eighty percent of physicians report using either 0.5 or 1% xylocaine epinephrine mixture at the recipient site, whereas the remaining 20% use either wetting solution or some other solution. The most preferred site for fat harvest is the abdomen (89%), followed successively by the thigh (34%), flank (25%), gluteal region (12%), and knee (9%) (Fig. 59.1). Another 2% of physicians report harvesting fat from alternative sites including the sacrum or temporal region. The Coleman microcannula technique is the most common method of fat harvest (54%), followed by standard liposuction cannula (25%),

Percentage

50 40 30

25

20

16

10

5

0 Microcannula

Liposuction cannula

Needle

Excision

Method

Fig. 59.2  Percent of surgeons using these harvest techniques primarily

syringe and large bore needle (16%), and direct excision (5%) (Fig. 59.2). The percentages reflect that individual physicians will utilize multiple sites of ­harvest and more than one harvest technique in their practice. Following fat harvest, 47% of respondents perform centrifugation of fat, 29% perform fat washings, and 12% site-unspecified “other” treatment techniques, whereas 12% do not use any preparation methods, and none of the respondents add insulin to the harvested fat. Each respondent was asked to select locations that could benefit from fat injections. The nasolabial folds (83%) and lips (74%) are the most popular sites for injection, followed by the nasojugal region (59%), malar eminence (43%), chin (35%), forehead (30%), lower eyelids (20%), and upper eyelids (12%) (Fig. 59.3). A majority of physicians use a cannula (60%) or ­needle (38%) for fat application, whereas 2% use a ratchet gun. Six percent of physicians froze excess fat for later application. Fifty-five percent of physicians use direct surgical excision as one of their harvest techniques. Of the

83

74 59 43

35

32

el id ey

el id pp

er

ey er

11

U

Location

N

w Lo

Fo

re h

ea

d

hi n C

al

al ar M

oj ug

as

N

ol ab

as

ia l

Li ps

20

Fig. 59.3  Percent of surgeons placing fat grafts at these anatomical locations. Surgeons were asked to mark all locations where they apply fat grafts 70

63

Percentage

60 50 40 30

21

20

12

10 0

4 Dermis- fat

Fat alone

Fat- fascia

Type of Graft

Dermis- fatfascia

Fig. 59.4  Percent or surgeons choosing these graft consistencies when performing direct excision

surgeons that excise fat grafts, most often the grafts consist of dermis-fat (63%) or fat alone (21%), and less frequently fat-fascia (12%) or dermis-fat-fascia (4%) (Fig. 59.4). The preferred harvest sites for those who perform direct surgical excision of grafts include abdomen (50%), gluteal region (9%), thigh (4%), flank (3%), and knee (2%). Nine percent of respondents use an alternate site such as the sacrum or temporal region, and the rest do not perform direct fat excisions (23%). Eighty-seven percent of physicians believe that it is important to overcorrect autologous fat grafts. Nineteen percent of those polled believe a 10% overcorrection is required, whereas 60% recommend overcorrecting by 20–30%, and 21% overcorrect by 40–50%.

59.6  Outcomes The manner in which most practitioners assess the results of autologous fat transfer are by examination with palpation (55%) and/or photos (48%) (digital

455

photography 39%; photography with 35 mm camera 9%), and less often by other methods (13%) such as imaging studies for facial volume measurements with radiography, laser scanners, or 3D photography. The percentage of physicians who believe that there is at least some resorption of fat at 6 months is 92%. Of  these, 52% believe the resorption rate is 50% or greater, while the remaining 48% believe it to be less than 50%. A majority (63%) of respondents are of the opinion that the remaining volume consists of a combination of fat and scar tissue, whereas 34% believe the volume is all viable fat and 3% that it is all scar tissue. Sixty-nine percent of physicians believe they have observed fat grafts persisting for more than 2 years, whereas the remaining 20% have only witnessed survival for either 1–2 years (19%), 6 months to 1 year (9%), or less than 6 months (2%) (Fig. 59.5). When physicians who perform a few fat transfers (<10 annually) were compared to physicians who ­performed many fat transfers (>30 annually), there were differences in perceived “take.” With regard to percentage of fat that survives injection, 76% of the few fat transfer group recorded that less than 25% survived. In contrast, 72% of the many fat-transfer groups recorded that more than 50% of fat survived. In addition, 89% of the many fat-transfer groups compared to only 16% of the few fat-transfer groups had observed fat grafts persist for more than 2 years. Thirty-one percent of physicians reported that more than half of their patients require reinjection, whereas the remaining 69% felt this value was less than half. Short-term (<6 month) patient satisfaction was believed to be excellent for 36%, good for 52%, fair for 8%, and poor for 4% by the physicians surveyed. Long-term (>6 month) patient satisfaction was believed to be

Percentage

90 80 70 60 50 40 30 20 10 0

fo ld s

Percentage

59  Autologous Fat Transfer National Consensus Survey

80 70 60 50 40 30 20 10 0

69

19 6 < 6 months

9 6 months 1 year

1 - 2 years

> 2 years

Duration

Fig. 59.5  Percent of surgeons achieving these longest graft ­survival durations

456

M. R. Kaufman et al.

100 90

Short-term Long-term

Percentage

80 70 60 50 40 30 20 10 0 Excellent

Good

Fair

Poor

Patient Satisfaction

Fig. 59.6  Percent of surgeons rating patient satisfaction as Excellent, Good, Fair, or Poor in the short and long term

excellent for 13%, good for 40%, fair for 41%, and poor for 6% (Fig. 59.6).

59.7  Discussion Facial recontouring is one of the more sought after plastic surgery procedures for correction of congenital defects, traumatic injuries, or the aging face. Numerous surgical approaches and methods have been investigated using either alloplastic materials or autologous tissue (11–38). Facial alloplasts include injectable forms (e.g., collagen, silicone, polyacrylamide gel) and solid implants (e.g., expanded polytetrafluoroethylene (ePTFE; brand name, Gore-Tex), allogeneic dermis (AlloDerm). Autologous grafts include fat alone, dermis-fat, dermis-fat-fascia, fascia alone, and free tendon grafts (36–38). Some of the problems associated with alloplastic materials are foreign body reactions and fatigue or warping of the material. Although injectable silicone was widely advocated in the past, its use was associated with significant morbidity including abscess formation, inflammatory tissue reaction, and granulomas (11–15). The American College of Plastic Surgeons has subsequently deemed it unacceptable to perform silicone injections for facial recontouring. Instead, collagen and hyaluronic acid injections have gained popularity because of both a high rate of patient satisfaction and because these injectables are generally regarded as safe (17–21). Nonetheless, since these substances are biologic materials, they are subject to degradation by

the body and the effects often are limited to 6 months before reinjection is required (22, 23). The ideal augmentation material necessitates certain qualities, including consistent and reproducible results, biocompatibility, lack of toxicity, ease of use, and economically prudent. In addition, the material should have a natural feel, be customizable to each individual patient, and be easily removable in the event of complication or patient dissatisfaction. While various options exist for facial recontouring, to date there is still no ideal filler, mainly because of complications that have been associated with each method. Autologous fat represents a contour material that meets many qualities of an ideal augmentation material. The greatest technical challenge of autologous fat transfer is maintaining longevity, and the current literature is controversial regarding the durability of fat grafts. The purpose of this study was to survey a subset of plastic surgeons in order to analyze the beliefs, practices, and perceived outcomes of short- and long-term viability. Although there is a perception that autologous fat transfer is a commonly performed procedure by plastic surgeons in the United States, the results of the survey may refute this notion. Many (41%) of respondents perform less than 10 procedures annually. Furthermore, it appears that there are relatively few practitioners performing large volumes of this procedure, as only 24% reported more than 30 procedures annually. It may be that the apparent interest in fat transfer is propagated by those few most active in performing the procedure. Alternatively, the results of this survey may not reflect the craniofacial and reconstructive surgeons performing the procedure for congenital or traumatic defects. Techniques for harvest are, for the most part, uniform across the country. There is little variability with regard to local anesthesia solution or harvest site. Most  practitioners use a mixture of xylocaine and ­epinephrine, with or without saline, and the abdomen is overwhelmingly the choice for harvesting fat. It is interesting to note that the techniques described by Coleman (6, 8) have had a large influence on the way physicians perform the procedure. More than half of the respondents (54%) perform the harvest with microcannulas and nearly half (47%) centrifuge the graft, as Coleman described. The preferred sites of application tend to be within the lower third of the face (nasolabial folds and lips), whereas the least preferred sites are within the upper

59  Autologous Fat Transfer National Consensus Survey

third of the face (upper/lower eyelids and forehead). These trends likely reflect the increased likelihood of a poor aesthetic result when injecting around the eyes. The thin periorbital skin will reveal even the slightest irregularity, and it is not uncommon to have visible and palpable nodularity of fat grafts, especially when performed by less experienced physicians. Furthermore, the most morbid complications of fat grafting (blindness, cerebrovascular accident (CVA) have been reported from fat injections into the forehead and eyelids (39). The results of the survey indicate that there is some interest in fat grafts harvested with other tissue types, especially dermis. One interpretation of this trend is that physicians are continuing to explore ways in which to overcome the limitations and unpredictable results of “fat only” grafts. Dermis and/or fascia may provide an additional conduit for neovascularization of the graft, thus preventing or reducing the high resorption rates associated with autologous fat transfer. An overwhelming majority of respondents (87%) believe it is necessary to overcorrect the contour irregularity, presumably due to the tendency for fat loss or resorption. This belief, held by a majority of surgeons, is not shared by proponents of fat grafting. Coleman has suggested that micrografts of “seeded fat” get vascularized within muscle or subcutaneous tissue, and Guerrosantos stated that fat stem cells from fat grafting recruit other cells into the recipient site. However, a recent review of the literature that reported on longterm (6 months) fat loss rates in animal studies supports the belief of many clinicians surveyed that there is fat loss (40). Animal studies have documented fat resorption rates of 60–70%, many incorporating objective measures of assessment. The reported rates of resorption in clinical studies vary widely (25–90%) and the outcome measures are often based upon subjective assessments. The results of our survey would indicate that most practitioners (92%) believe there is at least some resorption after 6  months. A majority of practitioners (52%) believe the loss is greater than 50% and of the volume that persists, and 66% believe it is partially a result of scar tissue. In contradistinction, 69% of respondents have observed fat graft survival beyond 2 years. Clearly, we have yet to determine all the factors responsible for graft survival beyond 2 years, as it seems that many fat grafts undergo significant resorption within 6 months. It appears that most physicians are correctly estimating the amount of required overcorrection, as only 31%

457

reported that more than half of their patients require reinjection. This seems to correlate with patient satis­ faction as reported by practitioners. A majority of phy­ sicians reported short-term patient satisfaction to be excellent to good, and long-term satisfaction to be good to fair. It may be argued that the true test of a procedure is patient satisfaction, and if so, are we willing to accept “good” or “fair” patient satisfaction over the long-term?

59.8  Conclusions Autologous fat may be the best material we have for facial contouring; however, it seems that it is less than perfect. The rationale for performing the procedure in the face of varied and somewhat unpredictable results may be the low associated morbidity, good to excellent short-term patient satisfaction, readily available graft material for repeat injections, and lack of something better. Continued modifications in technique driven by objective outcome studies will likely lead to improved clinical results in the future. In the meantime, it appears that there is some uniformity of techniques across the country, which results in a rate of patient satisfaction that is acceptable to many physicians.

References   1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir 1893;22:66.   2. Miller CG. Cannula implants and review of implantation techniques in esthetic surgery. Chicago, Oak Press, 1926   3. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg 1950;5:217.   4. Ellenbogen R. Free autologous pearl fat grafts in the face: a preliminary report of a rediscovered technique. Ann Plast Surg 1986;16(3):179–194.   5. Carraway JH, Mellow CG. Syringe aspiration and fat concentration: a simple technique of autologous fat injection. Ann Plast Surg 1990;24(3):293–296.   6. Coleman SR. Structural Fat Grafts: the ideal filler? Clin Plast Surg 2001;28(1):111–119.   7. Guerrerosantos J. Long-term outcome of autologous fat transplantation in aesthetic facial recontouring. Clin Plast Surg 2000;27(4):515–543.   8. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347–367.   9. Calabria R. Fat grafting: fact or fiction? Aesthetic Surg 2005;25:55.

458 10. Hwang K, Kim DJ, Lee IJ. An anatomic comparison of the skin of five donor sites for dermal fat graft. Ann Plast Surg 2001;46(3):327–331. 11. Maly A, Regev E, Meir K, Maly B. Tissue reaction to liquid silicone simulating low-grade liposarcoma following lip augmentation. J Oral Pathol Med 2004;33(5):314. 12. Schmidt-Westhausen AM, Frege J, Reichart PA. Abscess formation after lip augmentation with silicone: case report. Int J Oral Maxillofac Surg 2004;33(2):198–200. 13. Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injection of cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med 2004;33(2):115–120. 14. Bigata X, Ribera M, Bielsa I, Ferrandiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg 2001;27(2):198–200. 15. Hoffmann C, Schuller-Petrovic S, Soyer HP, Kerl H. Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol 1999;40(1):100–102. 16. Felman G. Direct upper-lip lifting: a safe procedure. Aesthetic Plast Surg 1993;17(4):291–295. 17. Jordan DR. Soft-tissue fillers for wrinkles, folds and volume augmentation. Can J Ophthalmol 2003;38(4):285–288. 18. Byrne PJ, Hilger PA. Lip augmentation. Facial Plast Surg 2004;20(1):31–38. 19. Fagien S, Elson ML. Facial soft-tissue augmentation with allogeneic human tissue collagen matrix (Dermalogen and Dermaplant). Clin Plast Surg 2001;28(1):63–81. 20. Lemperle G, Gauthier-Hazan N, Lemperle M. PMMAMicrospheres (Artecoll) for long-lasting correction of wrinkles: refinements and statistical results. Aesthetic Plast Surg 1998;22(5):356–365. 21. Matti BA, Nicolle FV. Clinical use of Zyplast in correction of age- and disease-related contour deficiencies of the face. Aesthetic Plast Surg 1990;14(3):227–234. 22. Maloney BP. Cosmetic surgery of the lips. Facial Plast Surg 1996;12(3):265–278. 23. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histological study. Dermatol Surg 1998;24(12):1317–1325. 24. Singh S, Baker JL Jr. Use of expanded polytetrafluoroethylene in aesthetic surgery of the face. Clin Plast Surg 2000; 27(4):579–593. 25. Wang J, Fan J, Nordstrom RE. Evaluation of lip augmentation with Gore-Tex facial implant. Aesthetic Plast Surg 1997; 21(6):433–436.

M. R. Kaufman et al. 26. Conrad K, MacDonald MR. Wide polytef (Gore-Tex) implants in lip augmentation and nasolabial groove correction. Arch Otolaryngol Head Neck Surg 1996;122(6):664–670. 27. Sherris DA, Larrabee WF Jr. Expanded polytetrafluoroethylene augmentation of the lower face. Laryngoscope 1996; 106(5 Pt 1):658–663. 28. Wall SJ, Adamson PA, Bailey D, van Nostrand AW. Patient satisfaction with expanded polytetrafluoroethylene (Softform) implants to the perioral region. Arch Facial Plast Surg 2003;5(4):320–324. 29. Hanke CW. A new ePTFE soft tissue implant for naturallooking augmentation of lips and wrinkles. Dermatol Surg 2002;28(10):901–908. 30. Hubmer MG, Hoffmann C, Popper H, Scharnagl E. Expanded polytetrafluoroethylene threads for lip augmentation induce foreign body granulomatous reaction. Plast Reconstr Surg 1999;103(4):1277–1279. 31. Hoffmann C, Schuller-Petrovic S, Soyer HP, Kerl H. Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol 1999;40(1):100–102. 32. Wolf DL. Complications following lip augmentation with Gore-Tex. Plast Reconstr Surg 1995;95(7):1334–1335. 33. Linder RM. Permanent lip augmentation employing polytetrafluoroethylene grafts. Plast Reconstr Surg 1992;90(6): 1083–1090. 34. Fernandez-Acenero MJ, Zamora E, Borbujo J. Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation. Dermatol Surg 2003;29(12):1225–1226. 35. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2003;29(6):588–595. 36. Davidson BA. Lip augmentation using the palmaris longus tendon. Plast Reconstr Surg 1995;95(6):1108–1110. 37. Gatti JE. Permanent lip augmentation with serial fat grafting. Ann Plast Surg 1999;42(4):376–380. 38. Erol OO. Facial autologous soft-tissue contouring by adjunction of tissue cocktail injection (micrograft and minigraft mixture of dermis, fascia, and fat). Plast Reconstr Surg 2000; 106(6):1375–1387. 39. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthetic Surg 2002;22:555. 40. Kaufman MR, Miller TA, Huang C, Roostaien J, Wasson KL, Ashley RK, Bradley JP. Autologous fat transfer for facial recontouring: is there science behind the art? Plast Reconstr Surg 2005;119(7):2287–2296.

Medical Legal Aspects of Autologous Fat Transplantation1

60

Melvin A. Shiffman

60.1  Introduction The few complications encountered in autologous fat transplantation make this procedure of a relatively low risk for litigation. Autologous tissue has less potential problems than most of the presently available injectable materials.

breach may be established by an expert witness testifying to the opinion that the defendant failed to follow the Standard of Care. The types of breaches may also include lack of informed consent. A lay jury may establish the standard if the facts are within the knowledge and experience of lay persons. This can best be seen in the case in which a foreign body (sponge, instrument) is left in the surgical wound.

60.2 Requirements for Medical Negligence

60.2.3  Injury

The plaintiff’s attorney must establish all four aspects of negligence in order to pursue a case of medical neg­ ligence.

An injury, physical or mental, to the plaintiff must be shown by the facts of the case, usually through medical records.

60.2.1  Duty When the physician establishes a relationship with a patient, the physician has a duty of due care in the care and treatment of that patient.

60.2.2  Breach of Duty The physician may breach that duty by not using adequate skill and knowledge in treating a patient. This

1

Reprinted with permission of Lippincott Williams and Wilkins.

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

60.2.4  Causation Causation requires that the injury be caused by the breach of duty. In other words, there is no causation if the breach of the standard of care may have been a failure to place a breast implant under the muscle on the right side but the injury was capsule contracture was on the left side.

60.2.5  Standard of Care The standard of care is what a reasonably prudent (careful) physician would do under the same or similar circumstances. The court considers expert testimony to establish the standard of care in most instances except if the circumstances are in the purview of a lay person. Also, the court may consider what a responsible minority

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of physicians would do under the same or similar circumstances. Medical literature may help to ­establish standard of care.

60.3  Informed Consent 60.3.1  Definition The patient has the absolute right to receive enough information about his diagnosis, proposed treatment, prognosis, and possible risks of proposed therapy and alternatives to enable her/him to make a knowledgeable decision. The patient is the one who makes all the decisions in opposition to the old paternalistic theory that gave the physician complete control over all decisions. A physician would now have to prove that the decision he made was due to the patient’s inability to make the decision or due to an extreme emergency. Other requirements of the “Informed Consent” doctrine in law require that a complication that was not explained to the patient did in fact occur and that the patient would not have agreed to have the surgery had she/he been informed of that particular risk or com­ plication.

60.3.2  Legal Definition In terms of surgical procedures, the surgeon must have explained to the patient the nature and purpose of any proposed operation or treatment, any viable alternatives, and the material risks and benefits of both. All questions must be answered. In order for the plaintiff to succeed in a complaint for lack of informed consent, he must show: 1. That the risk or complication, which was not explained to him, indeed did occur. 2. That if he had been informed of that particular risk, he would not have consented to the surgical pro­ cedure. There are different means of proof at trial depending upon the jurisdiction (state). The opinion as to what risks is “material” to the patient in order to make his decision, under the same or similar circumstances, can be that of:

M. A. Shiffman

1. A reasonably prudent physician: This allows a physician to testify as to what is material. 2. A reasonably prudent patient: This allows the jury to decide what a reasonably prudent patient would consider material risks. 3. The plaintiff patient: This places the onus on the plaintiff to decide what would be the material risks. The cosmetic surgery patient may be unique because cosmetic surgeries are elective procedures and not medically required except, perhaps, for the patient’s mental well-being.

60.4  Medical Record Handwriting that cannot be deciphered should be avoided. Not only is this irritating to the attorneys and expert witnesses but the state Medical Board may find this to be inadequate records and thus unprofes­ sional conduct and loss of medical license may ensue. Handwritten notes are a continuous problem especially when years later the doctor who wrote the note cannot read it. Typewritten notes are easy to read and usually contain much more information than written notes. This author dictates all of the medical record notes. The cost to get a microcassette for dictation and hire someone to take off the dictation will save the surgeon time with minimal cost including maintaining the medical license.

60.5  Legal Aspects The first thing an attorney thinks is that a bad result is the fault of the surgeon because of a negligent act. This may include claims of poor training, lack of skill, or inattention during surgery. The attorney will seek out an “expert witness” to show a breach in the standard of care. The standard of care is essentially a legal term meaning what a reasonably prudent (careful) physician would do under the same or similar circumstances. The defendant surgeon’s attorney will try to find an expert witness to show that there was no breach in the standard of care. The surgeon should be realistic because everyone makes mistakes and the expert witness should not be biased and should give an honest

60  Medical Legal Aspects of Autologous Fat Transplantation

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opinion as to whether or not the standard of care has been breached.

back, no blood was produced, and injection was done while withdrawing the cannula.

60.6  Dangers in Glabellar Injection

60.8  Fat Transfer to the Breast

When injecting the glabellar area, a blunt-tipped needle or cannula of sufficient size should be utilized (1). The patient should be informed of the reported cases of unilateral blindness and cases of central nervous system damage following injection of fat into the glabella area (2–9).

Fat transplantation to the breast should be undertaken with extreme caution. Injections should be outside the breast parenchyma but inadvertent injection into the breast gland may still happen. Complications such as oil cyst(s) and microcalcifications may occur and this possibility requires a thorough explanation to the patient preoperatively. There are surgeons who may testify to the “fact” that it is an unwarranted and dangerous procedure because of the possibility of calcifications “in the breast” that cannot be distinguished from possible malignancy. They may also testify that the results of augmentation are minimal. There have been at least four claims filed against physicians performing fat augmentation of the breast (10). One was lost by the plaintiff at trial, two others settled, and one tried and won by the plaintiff. Doctor’s Company will not cover this procedure under its medical malpractice insurance. There has never been a case reported of delay in diagnosis of breast cancer due to calcifications despite the concern about this possibly occurring. Fat transfer is now being used in filling defects and in reconstruction of the breast following surgery for breast cancer. There is need for accurate and honest research in evaluating the complications of augmentation of the breast with autologous fat. Specifically, the study should include the actual risk of microcalcifications, the procedures to distinguish this from possible breast malignancy, and the long-term effect of these calcifications, both progression of calcifications and psychological effect to the patient.

60.7 Blindness and Central Nervous System Injury The author has encountered a case of a woman patient born in 1982 with severe cleft palate and cleft lip. Multiple procedures for repair were performed from age 3½ months to age 9. At age 15, she had advancement of the lower lateral cartilages for a deformed nasal tip, and at age 22 she had open nasal tip rhinoplasty. At age 24, she had injection of 0.5 mL of fat to her right nasal tip using an 18-gauge needle. Three to four minutes after the injection, the patient lost vision in her right eye, her right pupil became dilated, and there was numbness and weakness of the left arm and hand. She was noted to have left homonymous hemianopsia and developed ptosis and superior rectus muscle palsy indicating left third nerve palsy. Fat venous emboli were seen in the central retinal vessels. The origin of the emboli was most likely from pressure injection of the fat that entered torn veins in the field of needle insertion and not direct injection into a vein, since aspiration prior to the injection of fat did not produce blood and injection was in a retrograde manner while withdrawing the needle. There is an intimate connection of the venous supply of the nose to the retina via the ophthalmic veins and to the sagital sinus system that resulted in the visual and neurologic damage. This case has not reached the point of litigation, but the patient’s attorney is asking for a settlement alleging that the defendant did not draw back on the needle before injecting that fat and therefore injected directly into a vessel. The defendant claims that after insertion of the needle he did draw

60.9  Fat Hypertrophy There has been litigation (11) concerning a patient having had fat transfer for fat atrophy of the face secondary to HIV infection. There was severe fat hypertrophy in the face months later that required multiple liposuctions of the excess fat. The plaintiff claimed that there was lack of informed consent concerning the

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possibility of fat hypertrophy and that the request by the plaintiff was for minimal amount of fat to be injected into the cheeks and that the defendant injected the whole face with fat. The case is still in progress.

References   1. Skouge JW. Autologous fat transplantation in facial surgery. In: Coleman, WP III, Hanke, CW, Alt, TH, Asken, S. (Eds), Cosmetic Surgery of the Skin: Principles and Techniques, Philadelphia, B.C. Decker, 1991, pp. 239–249.   2. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 1988;82(2):361.   3. Driezen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107(1):85–87.   4. Coiffman F. Lipoinjection complications. In: Hinderer, V. (Ed), Plastic Surgery, Vol. 2, Amsterdam, Excerpta Medica 1992, pp. 759–760.

M. A. Shiffman   5. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24(4):615–616.   6. Niechajev I, Sevcuk O. Long term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg 1994;94(3):496–506.   7. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion AND ocular fat embolism after autoplogous fat injection in the face. J Neurol 1998;245(1):53–54.   8. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and small case series: Ocular and cerebral ischemia following facial injection of autologous fat. Arch Ophthalmol 2001; 119(5):777–778.   9. Coleman SR. Problems, complications, and postprocedure care. In: Coleman SR. (Ed), Structural Fat Grafting, St. Louis, MO, Quality Medical Publishing 2004, pp. 75–102. 10. Gorney M. Fat injection to breast compromises safety. Commenting on calcifications. Cosmet Surg Times 1998; 2(6):3. 11. Dennis v Montegut, Parish of Orleans, No. 2006–660, Div “B-15”.

Editor’s Commentary

61

Melvin A. Shiffman

61.1  Introduction This book shows the varieties of techniques used by various cosmetic surgeons in performing autologous fat transfer. In order to dissipate some of the confusion encountered by surgeons wishing to start doing fat transfer or by surgeons who have had unsuccessful attempts at fat transfer, the editor has analyzed these techniques to see which are the most useful in obtaining a high percentage of fat retention. 1. Donor site There is a consensus in the literature that fat cells with alpha receptors (least likely to respond to weight change) are in fact deposits that are preferred as donor sites. Those areas that are easily accessible, tend to have excess fat, and those that are not fibrous include the lower abdomen, outer thighs, and hips. 2. Tumescent solution The donor site is best infiltrated with tumescent solution containing epinephrine in a physiologic fluid, saline, or Ringer’s lactate. Lidocaine in the solution will depend upon the type of anesthesia (general, conscious sedation, deep sedation) being used. In patients having liposuction of the body under local tumescent anesthesia, 500 mg lidocaine, 12.5 mg sodium bicarbonate, and 0.5–1.0 mg epinephrine in each 1,000 mL is unnecessary. An interesting new concept is the use of 12.5 g albumin in each 1,000 mL of physiologic solution in

M. A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

order to maintain a normal oncotic pressure external to the fat cells when injecting larger amounts of fluid into the tissues. This oncotic pressure is maintained when the fat is withdrawn from the body by suctioning or aspiration. 3. Cannula with pump vs. needle with syringe Fat aspirated by cannula with suction machine or needle with a syringe is viable as long as the pressure on the vacuum pump is less than −500 mm/Hg or with the larger syringe (20–60 mL) filling 10% of the syringe with saline. The negative pressure in the syringe rapidly reduces as the fluid and fat is pulled into the syringe. Vacuum in the pump at −700 mm/Hg results in some damage to the fat cells that are in the periphery of the fat “pearl,” which is not seen at −500 mm/Hg suctioning (Fig. 61.1). 4. Fat trap A fat trap can be used when collecting fat by means of cannula and suction machine. 5. Washing Gentle handling is essential. The fat should be washed to remove blood products and residual lidocaine, epinephrine, and sodium bicarbonate. The wash solution should be physiologic saline, normal saline, or Ringer’s lactate. Gentle tilting to mix the solution and fat followed by decanting is important. Avoid vigorous mixing, shaking, or straining, and do not let the fat be exposed to dehydration. Use only fat that is yellow and blood-free. A promising beneficial addition to the fat following washing is 12.5 g albumin to each 1,000 mL. This will maintain a normal oncotic pressure outside the fat cells so that cells will not expand from external fluids being drawn into the cells and disrupting them.

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result in damage to the fat cells being transferred (oncotic pressure is decreased allowing fluid to enter and expand the fat cells). If possible, a regional block or general anesthesia should be used.

a

(c)  Location of injection site The needle insertion should be far enough from the area being filled to prevent extrusion of fat through the entry site. (d)  Injection cannula

b

The smallest cannula used for injecting fat should be 18 gauge when fat retrieval has been through a cannula that is at least 18-gauge in size. A sharp needle does not usually require a skin incision but may cause undesirable bleeding. A small blunt cannula requires an incision that should be placed in an inconspicuous place if possible. (e)  Multilayering Fat injected should be placed in small amounts in any single spot (under 1/10th mL). It is best to inject fat in a linear fashion while withdrawing the cannula. The fat has to be inserted in various layers and from multiple injection sites (when possible).

c

(f)  Ratchet gun vs. syringe

Fig. 61.1  (a) Destruction of fat cells in the periphery of the fat “pearl” with liposuction at −700 mm/Hg using a 3-mm cannula. Hematoxylin eosin staining, 200×. (b) Center of “pearl” removed at −700 mm/Hg using a 3-mm cannula showing intact fat cells. Hematoxylin-eosin, 200×. (c) Periphery of fat “pearl” removed at −500 mm/Hg using a 3-mm cannula showing intact fat cells. Hematoxylin-eosin, 200×

6. Injection into recipient area (a)  Subcision Areas with skin attachment to underlying tissues (scar, muscle, fascia, or bone) must be subcised before fat is injected. (b)  Anesthesia The injection of local anesthesia into the recipient site tissues (other than the skin) is not physiologic and may

When injecting fat with a syringe using finger or hand pressure, there is usually some point where the fat gets stuck in the needle and increasing pressure is applied. This may result in too much fat being placed in a single  spot. The chances of fat survival, therefore, are decreased. A ratchet gun is a simple solution to the problem. • Dressings Avoid compression dressings to prevent shifting (migration) of the fat transplant and loss of fat cells from compression of the blood supply needed for neovascularization. • Frozen fat There is some evidence that frozen fat survives. It is, therefore, reasonable to freeze fat to limit the need for fat retrieval a second or more times. The freezing should maintain quality control with careful and distinct labeling of the fat container, strict sterile precautions, functioning temperature gauge with an alarm system if the temperature elevates, and a means of rapid action by the healthcare personnel to respond to

61  Editor’s Commentary

the alarm and re-establish the proper temperature within 8 h. Fat not adequately protected by these means probably should not be utilized if there is any question that the temperature was kept at the proper level, usually at least 2° below zero. • It takes approximately 4 days for the angiogenesis around the fat globules to begin. The center of the “pearl” will usually necrotize and be absorbed. • Transferred fat is usually stable in amount after 4 months.

465

11. Breast augmentation with fat is a desirable procedure for those patients who do not wish breast implants (because of the complications) and want only mild enlargement. (a) The fat should be transferred to the tissue surrounding the breast including the underlying pectoralis major muscle and beneath and above the muscle but not into the breast gland.

Index

A Abscess, 221 Adhesion, 159 Adipose-derived stem/stromal cells (ASCs), 261–264, 268, 269 Agris, J., 15 Aiache, A.E., 287 Ailhaud, G., 30 Albumin, 116, 117, 123–125, 127, 128, 131, 204, 255, 448 Alexander, R.W., 225 Alloderm, 161, 197, 456 Al-Qattan, M.M., 316 Amar, R.E., 49, 80, 175 American Academy of Neurology, 352 American Society for Aesthetic Plastic Surgery (ASARS), 223, 225, 451, 456 American Society of Liposuction Surgery, 253 American Society of Plastic and Reconstructive Surgery (ASPRS), 4, 225 American Society of Plastic Surgeons, 297 Anoxia, 139 Asaadi, M., 115 Asadi, M., 12, 15 Asken, S., 6, 11, 15, 79, 114, 223 Asymmetry, 183, 198, 201, 210, 224, 225, 418, 420–421 Atanassova, P., 29 Atrophy, 80, 81, 84, 203, 273, 394, 420 B Baibak, G.J., 224 Bames, H.O., 6, 223 Baran, C.N., 393 Bastelica, 33 Benito, M., 30 Bennett, G.K., 224 Benzaquen, I., 341 Berdeguer, P., 115 Berman, M., 49, 79 Billie, J.D., 13 Billings, E. Jr., 6, 155 BioAlkamid, 49 Bircoll, M.J., 3, 4, 223, 224, 239 Bissacia, E., 422 Blair, V.P., 361 Bleeding, 65, 67, 193, 298, 386, 422, 427 Blepharoplasty, 60, 62, 63, 155, 166, 176, 209, 210, 216 Blindness, 75, 143, 418–419, 457, 461 Body mass index (BMI), 265, 266, 268, 269

Bone marrow-derived stem cells (BMAC), 91 Boschert, M.T., 392 Botulinum toxin, 150, 153, 154, 352, 424 Brachioplasty, 22 Brandenburg, J.H., 358 Brandow, K., 15, 114, 392 Breast augmentation, 4 Brown, F.E., 224 Bruising, 13, 14 Bruning, P., 3, 410 Buccal fat pad, 84, 157 Buren, J., 32 C Calcifications, 13, 108, 118, 150, 157, 221, 224, 225, 240, 245, 257, 261, 270, 345, 361–363, 379, 418–421, 461 Campbell, G.L., 6, 11 Camper’s fascia, 22, 23 Campiglio, G.L., 33 Carpaneda, C.A., 8, 394 Carraro, R., 30 Castello, J.R., 419 Cavernous sinus, 422 thrombosis, 422 Cellulite, 22 Centrifugation, 83, 114–117, 124, 156, 172, 183, 185, 193, 200, 211, 212, 248, 264, 269, 281, 328, 341, 359, 393, 397, 398, 403 Chajchir, A., 15, 114, 124, 341, 393 Ciliary margin, 60 Coleman, S.R., 4, 8, 47, 49, 65, 79, 155, 175, 226, 342, 345, 391, 392, 419, 434, 454, 456, 457 Coleman technique, 404 Coleman, W.P. III, 124 Cotton, F.J., 3, 316 Courtiss, 7, 8 Crohn’s disease, 319 Crow’s feet, 165, 169, 318 Cushman, S.M., 123 Cysts, 5–7, 201, 221, 254, 270, 363 Czerny, A., 223 Czerny, V., 3, 135 D Da Silveira, W., 225 De Chalain, T., 193 DeFronzo, R.A., 32 467

468 De Jonckere, P.H., 315, 358 Dermal fat grafts, 6 Dimitroulis, G., 319, 363, 379 Donofrio, L.M., 79 Dumas, 319 Durr, E.D., 361, 378 Dyspnea, 325 E Ecchymoses, 279, 300 Edema, 74, 100, 118, 126, 128, 157, 193, 225, 252, 255, 277, 279, 422 Ehrhart-Bornstein, M., 32 Elam, M.V., 16 Elasticity, 80 Elastosis, 79 Ellenbogen, R., 412 Emboli, 419 Embolism, 418 Eppley, B.L., 7, 105, 257, 395 Ersek, R.A., 7, 47 Ettelson, C.D., 224 F Facial atrophy, 148 Fagrell, D., 8, 344 Fat, 11–16 cryopreservation, 306, 310 cysts, 6, 14, 89, 108, 118, 150, 183, 225, 254, 279, 300, 332, 418–420 embolism, 141, 143, 150, 220, 221 freezer, 206, 287 frozen, 74, 86, 93, 120, 182, 219, 278, 279, 305, 307–309, 342, 397, 443, 447, 464 hypertrophy, 75, 101, 201, 215, 422, 427, 429, 435, 462 migration, 424 necrotic, 7 subperiosteal, 407, 409 Feathering, 101 Federal Drug Administration (FDA), 255 Fibrosis, 118, 183, 332, 338, 361–363, 366, 376, 379, 403, 410, 435 Fibrous, 463 Fischer, G., 3, 113, 225, 229, 297, 301 Fitzpatrick, scar, 71 Food and Drug Administration (FDA), 113, 197 Fournier, P.F., 50, 53, 79, 80, 175, 225, 391, 392, 410 Fragen, R., 13 Frontal sinus, fractures, 315 Fulton, J.E., 15, 16, 66, 114, 115, 124, 128, 200, 225, 239, 240, 422 G Galitzky, J., 31 Gampper, T.J., 384 Gasparotti’s point, 283 Gaza, W.V., 358 Gemellus muscle, agenesis, 295 Ghobadi, F., 316 Glabellar, 12–14, 47, 48, 65, 117, 141, 149, 150, 186, 351, 352, 355, 461

Index Glogau, R.G., 79 Gore-Tex, 113, 147, 197, 456 Gottschling-Zeller, H., 32 Gradinger, G.P., 224 Grazer, F.M., 224 Green, J.R., 6 Gregoire, F.M., 128 Growth factors, 106 Guerney, C.E., 5 Guerrosantos, J., 341, 412, 457 Gullar, J.P., 429 Gurney, C.E., 439 Guyuron, B., 317 H Hansberger, F.X., 6 Haramis, H.T., 12, 15, 115 Har-Shai, Y., 128, 419 Harsh, G., 315 Hartrampf, C.R. Jr., 224 Hausberger, F.X., 439 Hazen, S.A., 123 Health Insurance Portability and Accountability Act (HIPAA), 59 Hematomas, 118, 141, 150, 200, 201, 207, 213, 300, 366, 371, 372, 418, 421 Hemifacial atrophy, 12, 143, 217, 316, 331, 333–336, 370 Hemifacial lipoatrophy, 267 Hemostasis, 5, 6 Hilse, A., 6 Hin, 225 Hiragun, A., 11, 15, 114 HIV, 137, 427, 429, 461 Hoffstedt, J., 32 Horl, H.W., 341 Hudgins, L.C., 142 Hudson, D.A., 7 Hyaluronic acid, 147, 150 Hyperkeratoses, 273 Hyperpigmentation, 43, 63, 273, 424 Hyperplastic, 292 Hypertension, 32–34 Hypertrophic, 292 Hypomastia, 6, 223, 225 Hypopigmentation, 43, 273 Hypoplasia, 237 Hypoplastic, 229 I Illouz, Y.G., 4, 6, 7, 11, 135, 174, 297, 338, 341 Infection, 13, 118, 143, 150, 157, 183, 193, 199, 201, 207, 219–221, 278, 331, 343, 371, 372, 377, 386, 417, 418 herpes, 75 Infra-mammary fold, 268 Insulin, 30–32, 103, 114, 255, 256, 411, 448 Ischemia, 255, 379, 394, 412 J Jacobs, R.R., 316 Jensen, T.T., 316 Jessner’s peel, 203 Jessner’s solution, 204

Index Johnson, G.W., 4, 13, 223 Jones, J.K., 8, 440, 441 Juri, J., 198 Juvederm, 69 K Kajimoto, K., 30 Kaminer, M.S., 142 Kaminski, M.V. Jr., 117, 128 Kanavel, A.R., 5 Karras, S.C., 319, 362 Kaufman, M.R., 193, 403 Kawada, T., 30 Keratoses, 280 Khouri, R.K., 103, 255 Klein, J.A., 124, 229, 391 Klein’s solution, 13, 19, 20, 116, 117, 123, 125, 126, 128, 148, 181, 218, 219, 237, 287, 421 Knighton, D.R., 103, 255 Kohn, D., 379 Kononas, T.C., 7 Kranendonk, S., 434 Krulig, E., 4, 223 L Lafontan, M., 30, 32 Lalikos, J.F., 392 Landsberg, R., 318 Langenskiöld, A., 315 Langer’s tension lines, 287 Large, V., 31 Lasers, 72, 203, 204, 207, 455 Leptin, 31–33 Leuchter, I., 358 Levin, J., 15, 115 Lewis, C.M., 288 Lexer, E., 3, 5, 155, 223, 297, 332, 410, 439 Linder, R.M., 224 Lipodystrophy (LD), 97, 427 Lipolysis, 6, 11, 15, 30–32, 114, 448 Lipolytic, 30, 31 Lipo-shifting, 289 Li, Z.H., 29 Locke, M.B., 193 Low-pressure liposuction, 87 Low pressure suction, 243 Lumbar disk, herniation, 316 Lumps, 213, 225 Lupus erythematosis, 316 Lyles, M.E., 8, 245, 247, 440, 441 Lynch, D.J., 225 M Malar fat pad, 84–85 fracture, 316 Mandrekas, A.D., 419 Mann, F.C., 5, 8 Marchand, F., 135 Marionette lines, 190, 194 Markman, B., 7

469 Marques, A., 442 May, H., 223 May, J.W. Jr., 6, 16, 155 McCurdy, J.R. Jr., 11 Merikanto, J.E., 379 Metabolic syndrome, 39 Microdermabrasion, 72 Migraine headaches, 317, 347, 355 Mikaelian, D.O., 358 Millard, G.F., 419 Miller, C.G., 174 Miller, C.L., 224 Mirrafati, S., 442 Missana, M.C., 315 Mitnick, J.S., 224 Monitored anesthesia care (MAC), 172 Montanana Vizcaino, J., 419 Moore, J.H. Jr., 442, 446 Morphea zoniform, 318 Mucocele, 201 Multiple symmetric lipomatosis, 33–34 Murphy, J.B., 361 Myringoplasty, 318 N Necrosis, 48, 201, 207, 221, 245, 254, 261, 332, 345, 392, 409, 410, 418, 420, 435, 465 Nerve damage, 193 Nerve injury, 207 Nerve palsy, 461 Neuber, F., 3, 113, 124, 135, 155, 174, 297, 332, 341, 403, 410, 439, 451 Neuber, G.A., 391 Neuhof, H., 5, 135, 439 Neuralgia, 183 Neuropraxia, 421 Newman, J., 4, 15, 114, 115, 392 Nguyen, A., 7, 16 Niechajev, I., 8, 15, 16, 115 Nishiyama, K., 319 Nisoli, E., 33 Nodules, 254, 345, 423, 435 Noushmehr, H., 32 Novack, B.H., 223 O Obagi, S., 79, 80, 434 Obesity, 38, 130 disharmonious, 241 Omura, N.E., 142 Ousterhout, D.K., 223 Ozena, 318 P Pain, 118, 143, 279, 300, 325, 363, 375 Parastouk, N., 200 Parry, 331 Pausova, Z., 31 Pectus excavatum, 318, 323, 324, 327, 328 Peer, L.A., 3, 6, 135, 148, 155, 223, 297, 341, 384 Pereira, L.H., 318

470 Peterfy, M., 30 Pflug, M.E., 341 Phenol peel, 274 Pinski, K.S., 128 Pitman, G.H., 23 Planotome, 3 Platelet-derived growth factors (PDGF), 88, 89, 91, 244–247 Platelet poor plasma (PPP), 92, 247, 248 Platelet rich plasma (PRP), 88–93, 95, 100–103, 105, 108, 110, 244–251, 446, 448 Platysmaplasty, 206 Portillo, M.P., 31 Postradiation, 318 Powell, D.M., 103, 255 Poznanski, W.J., 440 Ptosis, 80, 85, 156, 171, 203, 419, 461 brow, 85, 203 Pulgam, S.R., 419 Pulmonary emboli, 418 R Raclot, T., 30 Radiesse, 50, 69 Ramon, Y., 140, 193, 393 Rattan, V., 363 Reston foam, 57 Restylane, 69, 161 Rhytids, 116, 117, 137, 189, 197, 217, 351 Ribeiro, M.T., 8, 394 Rieck, B., 142 Rodbell, M., 123 Roenigk, H.H. Jr., 128 Rogers, 331 Rohrich, R.J., 138, 193 Romberg, 331 Romberg’s disease, 143, 331 Roncari, D.A., 6 Rose, J.G. Jr., 193, 393 Ryden, M., 31 S Saboeiro, A.P., 4, 226 Sadick, N.S., 142 Sakaloff, R.T., 319 Samdal, F., 7 Sattler, G., 8, 393, 403, 442 Saunders, M.C., 6, 379 Scarborough, D.A., 422 Scarpa’s fascia, 22, 23 Scars, 7, 12, 43, 63, 65–67, 72, 74, 117, 118, 159, 201, 261, 274, 327, 343, 371, 380, 394, 453, 455 acne, 69–71 hypertrophic, 71 lasers, 71 Schaeffer, I., 225 Schenk, J., 323 Schlaak, S., 142 Schorcher, F., 6, 223 Schuller-Petrovic, S., 338 Scleral show, 80 Sculptra, 50, 74

Index Seroma, 366, 371, 372, 418, 421 Sevchuk, O., 8 Sev’uk, O., 15, 16, 115 Shapiro, B., 6 Shiffman, M.A., 148, 442, 448 Shoshani, O., 307 Sidman, R.L., 15, 114 Signorini, M., 33 Skouge, J.W., 11, 12, 148 Sleep apnea, 376 Smith, P., 281 Smith, U., 440 Society of Plastic and Reconstructive Surgeons (ASPRS), 224 SoftForm, 197 Sommer, B., 8, 393, 403, 442 Spear, S.L., 226 Starling’s equation, 116 Starling’s Law, 125 Steatonecrosis, 102 Steed, D.L., 255 Stem cells, 446, 448 Sterodimas, A., 318 Stevenson, T.W., 155 Straatsma, C.R., 3 Subcision, 65, 67, 72, 74, 117, 190, 193 Subcutaneous musculoaponeurotic system (SMAS), 22, 422 Sulamanidze, M.A., 65 Sulcus vocalisa, 318 Superficial fascial system (SFS), 23 Superficial musculoaponeurotic system (SMAS), 136, 140, 165, 166, 169, 203, 206, 332, 412 Supraperiosteal, 213 Sweeney, G., 32 Swelling, 143, 157 T Tear trough, 129, 138, 176, 179, 303, 399, 433 Teimourian, 13 Temporomandibular joint, 319 Thermage, 74 Thomas, B.J., 361 Tobin, H., 14 Toledo, L., 65, 114 Transsphenoidal surgery, 319 Trauma, 8, 12, 13, 116, 213, 220, 243, 248, 249, 255, 331, 445 Trepsat, F., 138 Triamcinolone, 148 Trichloracetic aicd peel (TCA), 203 Tuffier, T., 3 Tunneling, 67, 246, 249, 250, 252, 254, 256 Tunnels, 96, 101, 193, 211, 246, 250, 252, 254 U Uebel, C.O., 15 Ullmann, Y., 8 V van der Meulen, 155, 297 Van Harmelen, V., 31 Van, R.L., 6, 440 van Wijngaarden, H.A., 315, 358

Index Velopharyngeal, insufficiency, 357, 358, 360 Verderame, P., 3, 5, 135 Vikman, K., 30 Vitamin E, 11, 103, 255, 421 Vocal cord paralysis, 319 scar, 319 W Weber, K.T., 20, 128 Weber, R., 315 Wertheimer, E., 6 Wetmore, S.J., 148 White adipose tissue (WAT), 37–40 Willi, C.H., 53, 54, 297 Wolford, L.M., 319, 362

471 Y Yamaguchi, M., 379 Yokota, T., 30 Yuksel, E., 105, 256 Z Zuk, P.A., 25, 131 Zyplast, 47