Fat Graft

FAT INJECTION
fat grafting
Dr Sumer yadav
dr sumer yadav , mch plastic surgery,

sumeryadav2004@gmail.com
Autologous Fat Grafting
Four Categories:
1. Autogenous Fat Grafting
2. Dermis-Fat Grafting
3. Free Fat Flaps
4. Fat Injection
 Micro lipo injection
 Lipostructure
 Autologous fat filler

History of Fat Injection
1893 Franz Neuber Firstto use fat injection
Transferred small piece of upper arm fat to build
up the face of a patient whose cheek had large pit

caused by a tubercular inflammation of the bone
1896 Silex Claimed good cosmetic results in treatment of

periorbital scars with grafted fat
1908 Eugene Firstdescribed a technique for using a needle &

Hollander syringe to transplant fatty tissue
1926 Conrad Millar Described infiltration of fat through metal cannula

as a substitute for the subcutaneous injection of
paraffin & Vaseline

1983 Chajhir & Described injecting suctioned fat into the face
Benzaquen
1986 Illiouz & Described injecting fat into iatrogenic liposuction

Teimourian deformities
1990 Sydney Developed the method of reliable Fat injection

R.Coleman
Stressed on Respect for handling tissues, and
on basic sound surgical techniques

Evolution of the Technique of
Fat Injection
 Autogenous fat transplantation in humans
was reported as early as the late 1800s
 Fat Injection developed as an “off-shoot” of

Liposuction - 1980’s
 But it was disappointing for many years:

 Reabsorption to great extent, unpredictable out-
come

 Perseverance of Plastic Surgeons:
 1995 onwards – autologous fat injection became
a reliable technique
 Contribution of Sydney R.Coleman
 Latest in the evolution tree:

 Tissue culture technique

Surgical Anatomy
Harvest site
Three levels of fat:
 Two layers of Subcutaneous fat
 Superficial layer
 Deep layer –“The target layer- for harvesting fat”
 Third: Visceral layer

 Common sites:
 Abdomen
 Gluteal region
 Thighs

Surgical Anatomy
Recipient site
 Face: Five distinct
tissue layers
 Skin
 Subcutaneous fibro-
adipose tissue
 Superficial musculo-
aponeurotic system
(SMAS)
 Loose areolar tissue
(spaces & retaining
ligaments)
 Parotid-massetric fascia
& Periosteum
 Soft tissue spaces in face
 Preseptal, Prezygomatic, Masticator & Oral cavity
spaces
 Within the forth layer – between ligaments
 Allow gliding movements of above facial muscles
 They become more apparent with aging laxity
 The facial nerves & vessels traverse through the
walls, but do not enter the spaces

Aging Face
 The effects of aging are the summation of the
interplay of factors that occur in all five anatomical
layers of soft tissue & in the bone
 Attenuation of the retaining ligaments at all levels

 Reduces quality of fixation of the soft tissue layers
 Volume loss (more common in the mid cheek), due

to
 Displacement of the soft tissue
 Atrophy of soft tissues & of the facial skeleton

Based on “Auto-graft” Principle
 Graft of fat cells harvested from patient’s one

site to fill in the depressions (natural or post-
traumatic) at the other site
 Fraction of Fat graft which “takes” - becomes

a living part of the body
 Though results will deteriorate as the these tissues age

Indications
 Aesthetic  Restorative / Reconstructive
 Facial Augmentation  Correction of the “Under-
 Facial atrophy corrected” Liposuctioned
areas
 Facial Rejuvenation  Filling of depressed zones
 Ageing face resulting from injury
 Correcting the wasting after
Triple therapy for HIV+
 Augmentation of
patients
 Breast
 Augmentation of
 Hand dorsum
 Vocal cord palsy
 Penis

 Facial augmentation / rejuvenation:
 M/C indication
 Includes:
 Facial atrophy
 Filling & smoothing wrinkles
 Restoration of the “fullness” of ageing face
 In complement to certain Neck & Face Lifts
 Effacement of the nasolabial folds
 Augmentation of the lips, malar region &
cheeks
 Breast
 Augmentation, Lumpectomy, Asymmetry, Mastectomy
 Injection into
 subcutaneous & pre-pectoral plane
 Not into the breast tissue
 Multiple sessions might be required
 In conjunction with Pre-expansion technique
 If not done properly may lead to Unsatisfactory results

because of fibrosis & calcifications

 Post-liposuction depressions’ correction:
 abdominal wall,
 flanks,
 buttocks,
 back, or
 thighs

 Correction of depressions or fatty deficits due
to Lipodystrophy syndromes and atrophic
areas
 HIV
 Diabetes
 Dermatomyositis
 Chronic malnutrition / anorexia nervosa
 Genetics, diet, alcohol, tobacco

 Augmentation of the paralyzed vocal cord
 In cases of Unilateral cord palsies
 May require secondary procedures

Preparation
 Patient selection
 Clinical examination, medical history
 Patient's lifestyle, expectations, h/o prior aesthetic
procedures
 Thorough discussion with patient about
 Planned procedure
 Expected out come
 Post operative course
 Need of multiple sessions
 Photography
 For 3-D examination purpose & Comparison Records
The Technique
 Should be Sophisticated & Thoroughly planned
 Amount of fat needed
 Levels in which to be placed
 Respect for handling extremely delicate “fat

tissue”
 Fat must survive various insults outside he body e.g.
 Mechanical
 Barometric
 Chemical

 Strict aseptic precautions:
 Slightest of infection can ruin the desired results
 Quickness:
 Shorter the time gap between harvesting & re-
implantation – better the chances of fat cell
survival
 Team approach – when dealing with Large
volume fat injection

The Procedure
Steps:
1. Harvesting
 Selection of harvesting sites & Planning incisions
 Anesthesia & Infiltration technique
 Suction
2. Processing & Refinement
 Centrifugation / Sedimentation
3. Re-implantation
 Injection (of the refined, concentrated fat)

Step-1
Harvesting
 Harvesting sites:
 Should be convenient for access &
 Enhance patient’s contour
 Most common:
 Abdomen
 Gluteal region
 Medial thighs
 Others:
 Suprapubic area, anterior or lateral thighs, knees, lower
back, hips, sacrum

Harvesting (cont’d)
 Access incisions should be planned in:

 Crease lines,
 previous scars,
 stretch marks, or
 hirsute areas

 Anesthesia
 Local – most common
 Spinal, Epidural or General
 For removal of larger volumes
 When multiple sites are used for harvesting

 Dry technique: Rarely used
 Wet technique (1:1::Injectant:Fat harvested)

 Choice of Infiltration solution depends upon:
 The donor areas & on the projected volume of fat to be
removed:
 Small volume / LA: 0.5% Lidocaine + Ringer lactate
solution with 1:200,000 epinephrine
 Large volume / GA: Ringer lactate solution with 1:400,000
epinephrine

 Super-wet & Tumescent techniques
 ( Injectanct to harvest ratio >1)
 Discouraged here (in contrast to liposuction )
 Disrupt the parcel of fat cells & decrease survival

 Suction:
 Two-holed blunt Coleman harvesting cannula
 10cc Luer-Lok syringe
 Combination of
 Minimal negative pressure
 by slowly withdrawing the plunger (creating 1-2ml of space
in the syringe barrel)
 Gentle curetting action

Coleman harvesting cannula

Results: Impact of Harvesting techniques
 Less suction pressure– More viable adipocytes
 Hand-held syringe method – Less trauma to

adipocytes
 Smaller gauze syringes –Avoid clumping & to

ease in re-injection

Step-2
Processing & Refinement
 Syringe with harvested fat
 Cannula disconnected
 Capped with “Luer-Lok plug”
 Placed in centrifuge

Processing & Refinement (cont’d)
 Separation techniques:
 Sedimentation
 (Force:1g)
 Centrifugation
 High speed 3000rpm for
3 minutes (Force:3-5g)
 Manual (Force:1-2g)

 The material separates in 3 layers:
 Top – oil (decanted)
 Middle – the fat cells (to be injected)
 Bottom – blood, injectant solution (to be drained)

 Transference:
 Refined & concentrated fat to 1-3ml Luer-Lok syringe

Step-3
Re-implantation
 The most challenging part
 Should be placed in such a way so as to

encourage uniform survival, stability, &
integration
 Small pockets
 Adequately spaced
 To maximize the “surface area” of contact

 Anesthesia:
 Local, Regional, General
 Advisable to use:
 Epinephrine solution
 In face- to minimize injection into vessels
 Blunt tipped Coleman cannula
 To minimize damage to blood vessels & resulting
ecchymosis or hematomas
 Natural tissue planes

 Instruments’ set:
 Different from harvesting set
 Smaller gauze (17 or 18 G)
 One holed cannula
 For varying sites varied cannula
 Diameter, Length, Shape, Curves

 The procedure:
 Stab incisions:
 1-2mm (No.11 blade)
 Cannula inserted & advanced:
 Into appropriate plane
 Injection of the fat:
 During withdrawal through the tissues
 Fat deposited as fractions of a milliliter, like peas in a pod
 Every next injection into a new plane / layer Sequentially
from deep to superficial layer multiple passes in a 3-D
manner

 Injection volume per withdrawal
 Face: 0.1ml
 Eyelids: 0.02 – 0.03ml
 Breast: 1-2ml

Injection Techniques
 Mapping Technique
 Linear threading
 Fanning
 Cross hatching
 Reverse-liposuction
Technique

Fate of Fat
 Phenomenon of Variable resorption
 With fat grafting, anywhere from 10% to 90%

of the fat may be absorbed by the body

 Theories:
 Host replacement theory – Billings & May
 Lipid in transplanted cells  taken up by histiocytes  which
eventually replace the fat cells
 Cell survival theory – Peer

 Transplanted fat cell survive, if vascularised; and histiocytes
remove, & not replace, non vascularised fat cells
 Stem cell theory - Billings & May:

 Under nourished fat cells either necrose; or return to more
primitive cellular state  Pre-adipocyte

Post-op care
 Aimed at:  Attained by:
 Minimizing swelling of the  Elevation
recipient tissues (2-4  Cold therapy
weeks)  Light touch (Encourage
 Stabilizing the area to lymphatic drainage)
avoid migration  External pressure with
elastic tape

Final results
 Assessment at 3-6 months
 Many patients may need more than one

treatment - usually 3-6 months after the first
one
 The benefits of fat grafting can last anywhere

from 3 months to 3 years, and probably more

Complications
 Aesthetic:  Others:
 Under correction  Edema
 Not enough material  Infection
 Resorption  Migration
 Over correction  Perforation
 More difficult to solve
 Necrosis
 Irregularities
 Asymmetry

Site-specific complications
 Face:
 Embolism of Internal carotid artery / Middle
cerebral artery (Retrograde)
 Blindness
 Stroke
 Aphasia
 Skin necrosis

 Breast augmentation:
 Liponecrotic psuedocyst with calcifications
 Groin defect correction:

 Cyst formation
 Penile augmentation
 Mushroom shaped penis

 Donor site complications
 Edema
 Infection
 Seroma
 Hematoma
 Skin necrosis
 Fat embolism
 Perforation

Comparison with other Fillers
 Advantages  Disadvantages
 Natural  Unreliable resorption
 Biocompatible, Non  Donor needed for harvest
immunogenic
 Large volume
augmentation
 Cheaper

Results Depend Upon
Harvest
site
Biologic Harvest
boundaries technique
Other Processing
surgery Result & Storage
Patient Injection
age Technique
Recipient
site

Current researches
 Focus on the Cellular level
 Tissue culture / stem cell technique
 “Pre-adiposite” cell
 May be the way to achieve fat transplantation without
significant volume loss
 It’s a connective tissue cell identical to fibroblast  takes

up lipid as it matures
 Van & Roncari transplanted “pre-adiopsites” from rat

epididymis into intramuscular location pad of fat
developed there

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FAT INJECTION

dr sumer yadav , mch plastic surgery,

3. Free Fat Flaps

dr sumer yadav , mch plastic surgery,

up the face of a patient whose cheek had large pit

1896 Silex Claimed good cosmetic results in treatment of

1908 Eugene Firstdescribed a technique for using a needle &

1926 Conrad Millar Described infiltration of fat through metal cannula

dr sumer yadav , mch plastic surgery,

1986 Illiouz & Described injecting fat into iatrogenic liposuction

1990 Sydney Developed the method of reliable Fat injection

dr sumer yadav , mch plastic surgery,

 Fat Injection developed as an “off-shoot” of

 But it was disappointing for many years:

dr sumer yadav , mch plastic surgery,

 Latest in the evolution tree:

dr sumer yadav , mch plastic surgery,

 Deep layer –“The target layer- for harvesting fat”

 Third: Visceral layer

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Attenuation of the retaining ligaments at all levels

 Volume loss (more common in the mid cheek), due

dr sumer yadav , mch plastic surgery,

 Graft of fat cells harvested from patient’s one

 Fraction of Fat graft which “takes” - becomes

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 If not done properly may lead to Unsatisfactory results

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Respect for handling extremely delicate “fat

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Access incisions should be planned in:

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Dry technique: Rarely used

 Wet technique (1:1::Injectant:Fat harvested)

dr sumer yadav , mch plastic surgery,

 Discouraged here (in contrast to liposuction )

 Disrupt the parcel of fat cells & decrease survival

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Less suction pressure– More viable adipocytes

 Hand-held syringe method – Less trauma to

 Smaller gauze syringes –Avoid clumping & to

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

dr sumer yadav , mch plastic surgery,

 Should be placed in such a way so as to