Fat Transfer

Fat injection reportedly started over 100 years ago. Dr Franz Neuber used a small piece of upper arm fat to build up the face of a patient whose cheek had large pit caused by a tubercular inflammation of a facial bone. (1) In 1895, another German doctor, Dr. Karl Czerny, did the very first documented breast enhancement when he transplanted the fat from  a large lipoma off the patient’s lower back, to a breast defect.(2)

Overview of current techniques

In the 1990’s, when Liposuction procedures became more widely available, fat also became much more easily withdrawn from the body. Techniques today have been improving, using very small amounts of fat and placing it into areas that have atrophied or have been scarred. These developments have allowed more plastic surgeons to offer their patients fat transfer for cosmetic reasons. Some contend that an advantage of fat transfer is that it is the patient’s own tissue and, hence, not subject to rejection by the body. Another advantage pointed to is that most other dermal fillers are absorbed by the body within three to nine months, making regular injections an ongoing expense.

Essentially, the fat transfer procedure procures fat from one part of the body where an excess exists and then places it in another part of the body where the additional bulk is used for cosmetic purposes. Fat transfer—which is also known as fat grafting, fat autographs, autologous fat transplantation, fat injecting or microlipoinjections to physicians—is being used in cosmetic plastic surgery to:

• Fill wrinkled, creased faces
• Smooth and repair aged hands
• Enlarge breasts
• Create a  shapely, curvaceous buttock
• Use Stem cells to improve scars from Acne or trauma
• Reverse the Atrophy of Aging
• Enhance lips

Procedure

Fat is withdrawn from the patient with a syringe that has a specialized harvesting cannula attached to it. The fat is prepared according to the practitioner’s preferred method and then injected into the patient’s recipient site. The preparation process clears the donor fat blood and the extra fluids placed to make the harvest process as pain free as possible. The procured fat is then centrifuged at a precise rpm to ensure fat viability and compacting (concentrating) the fat into stem cell rich plugs. Fat is then gingerly loaded into small syringes and injected into the desired areas. Dr. Virden is currently also adding Autologous Concentrated Plasma (ACP) to all of his patients fat injections. ACP is derived from the patient’s own serum and contains nutrients and growth factors to assist in giving the fat its best chance for survival.  As Surgeons, we are always evolving techniques that will ensure that fat will last for longer periods of time, and possibly permanently.  Fat injections are placed into several different layers of the skin, subcutaneous fat and muscle to provide a better chance for the fat cells to find a nearby blood supply. Through experience the best location to harvest fat from is the abdomen, hips, bra strap rolls, inner knee and outer thigh.

Current clinical applications

Fat transfer to the hand

A wrinkled, atrophied or bony hand with sun spots and deep grooves can reveal an advanced age even though the patient’s face, breasts or body have been surgically rejuvenated. Consequently fat transfer techniques have emerged as a favorite choice to make hands also look younger. A few practitioners use dermal fillers like Restylane and Juvederm but the longer lasting method seems to be fat transfer via injection which is reported to last for years.

Facial fat transfer

A liposuction technique is used to harvest the fat and prepare it for transfer. The fat is then injected into the desired portion of the face. When using a micro injection technique, extremely small parcels of fat are placed into multiple layers of the face. The procedure is most commonly performed under local anesthesia with a light oral sedation.

Syringes with harvested fat ready to be transferred.

The most common facial locations for fat transfer include:

• Filling in sunken areas beneath the eyes
• Fleshing out the folds of skin that physicians know as nasolabial folds, the deep wrinkles next to the mouth often referred to as “laugh lines.”
• Filling in forehead creases
• Cheek Augmentation
• Lip Augmentation

The long-term efficacy of transferred fat has been documented in numerous studies results are extremely technique dependent. Facial fat transfer is increasingly done in the office under a local block and oral sedation. Often times Laser resurfacing to soften the deeper surface wrinkles is done at the same time to enhance the results.

Results

Many patients are able to return to their normal activities immediately. Most notice some bruising, swelling, and redness in the donor and injection sites. Results from patients, physicians, and other researchers place the durability of fat injections anywhere from half a year up to eight years or longer.

Lip augmentation

For Lip augmentation, fat is packed into stem cell rich syringes. The fat is artfully used to sculpt the various elegant features of the lip to preserve a natural look. This technique produces a more natural lip than augmentation with popular injectable facial fillers or filler materials like medical Gore-Tex or, e-PTFE (polytetrafluorethylene). Small stab incisions are made at the corners of the patient’s mouth, fat is carefully put into the upper lip, the lower lip, or both lips. This procedure is done in the office with a local block, and oral sedation. Lip augmentation is also done under anesthesia when a patient is having other procedures done at the same time.

Natural Breast Enhancement with Fat

Fat grafting to enlarge female breasts is a procedure that is on the rise. Recent studies have shown that fat transplanted to the breast can remain viable and not obscure mammographic detection for breast screening. Fat transfer can also be done for other deformities of the breast like a mastectomy, a lumpectomy, a breast implant problem. In thin women whose implants ripple because of a very low body fat content, fat can add a beautiful and smooth disguise over the rippling.

Coleman compiled statistics on a series of fat injection breast augmentation patients and reported that improvements in the size and shape of the breasts are possible with a fat grafting technique (3).  In this procedure, the doctor harvests donor fat, centrifuges it for refinement, then, in a 3-4-hour procedure, inject the fat into the layers of the breast through multiple small stab incisions in each breast. (One millimeter is the width of a single line drawn by a pencil.) Special small injection needles are used to place the fat so that no damage is done to nerves or blood vessels. The fat is layered from the chest muscle up through the top of the breast. The surgeon relies on the fat injections to shape the breasts for an aesthetic, natural-looking result.

The ASPS issued a new policy paper on Fat Transfer/Fat Graft and Fat Injection (March 11, 2009). In it, the Executive Committee approved the policy paper, “Fat Transfer/Fat Graft and Fat Injection ASPS Guiding Principles”. The paper offers background information on the applications, risks and complications, and techniques of fat transfer procedures. The paper also summarizes scientific evidence. Additionally, four guiding principles are stated, based on the conclusion that fat grafting is a safe procedure in select cases; and that results are dependent on a surgeon’s technique and expertise. Indications for fat grafting included: Micromastia; Post breast augmentation deformity, with or without removal of implant; Tuberous breasts; Poland’s Syndrome, Post lumpectomy deformity; Post mastectomy deformity; Deficits caused by conservative treatment or reconstruction with implants and/or flaps (latissimus dorsi or TRAM); Damaged tissue resulting from radiotherapy and nipple reconstruction. (See full text on www.plastic surgery.org and select Health Policy and Advocacy.)

Buttocks augmentation via fat injections

Many women and a growing number of men want a curvier, rounder and shapelier buttock. While thin patients must opt for insertion of special buttock implants to fill out their rear end, patients who can spare the fat can undergo fat injection in a surgical procedure known as gluteoplasty or Brazilian butt lift. Working through small incisions in each gluteal cheek, the surgeon places fat cells at dozens of levels through the patient’s rear. After the procedure, the patient must wear a garment for about six weeks and sleep on the stomach for about a week. In most cases, non-athletic activities and driving can be resumed in about five days.

Because the surgeon usually must inject too much fat to allow for re-absorption, the overcorrection can make the patient’s face look too plump or swollen for about a week. However, many patients are able to return to their normal activities immediately. Most notice some bruising, swelling, and redness in the donor and injection sites. Results from patients, physicians, and other researchers place the durability of fat injections anywhere from half a year up to eight years or longer.

Potential risks and side effects

Fat transfer continues to gain acceptance as a safe and reliable procedure. Fat transfer patients are generally pleased with their results and are not inconvenienced significantly by the process(4).

Potential risks of any fat transfer include bleeding or hematoma, (a pool of blood forming under the skin), infection, nerve damage or wound dehiscence, when a surgical wound opens. Sometimes, fluid collection, or seroma, around a surgical wound happens. While all are normally easily controlled and healed, more serious complications can arise.  Overall, the survival of injected fat seems to depend on how the physician harvests the donor fat, the technique used to treat the fat and how the prepared fat cells are put back into the patient and the site to which the fat was moved. When a large area like the buttocks is treated, the patient may have to stop normal activities for a while and can expect some swelling, bruising or redness.

References