Fat transfer

Fat injection reportedly started in 1893 when German physician 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 the bone.^[1]

In 1895, another German doctor, Dr. Karl Czerny did the very first documented breast augmentation when he transplanted a fatty tumor from the patient’s lumbar region, or lower back, to a breast defect.^[2]

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Overview of current techniques

In the 1980s, when the liposuction procedure became more widely available, fat also became much more easily withdrawn from the body. That development allowed more plastic, dermatological and cosmetic surgeons to offer their patients fat transfer for cosmetic reasons. Patients like fat transfer because it is their own tissue and, hence, not subject to rejection by the body and because most dermal fillers are absorbed by the body within three to nine months, making regular injections a continuing expense.

Essentially, the fat transfer procedure harvests 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 and aesthetic 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:

• Smooth and repair aged hands
• Fill wrinkled, creased faces
• Create more shapely, curvaceous buttocks
• Enlarge breasts

Procedures

Fat is withdrawn from the patient in one of three ways: with a syringe that has a large bore needle or with a liposuction cannula. The fat is prepared according to the practitioner’s favorite method and then injected into the patient’s recipient site. The preparation process clears the donor fat of blood, pain killers and other unwanted ingredients that could cause infections or other undesirable side effects. Moreover, some physicians have found that human fat outside the body is incredibly delicate. One researcher (Mendieta) found that, to obtain viable fat, the needle withdrawing the fat can’t be too narrow, the liposuction cannula can’t have too strong a vacuum pressure and the centrifuge used to clear debris from the donated tissue can’t spin too rapidly. Another researcher found that vacuum pressure on the liposuction machine could not be higher than 700 mmHg.^[3]

A few doctors excise, or cut, small strips of fat from the body and then place, rather than inject, the tissue in the recipient site, using additional small incisions.

Other uses and applications continue to develop as surgeons work with, and learn more about, fat transfer. Some of the most current and developing applications include:

• Cheek and chin implants (medicine)
• Repair of inverted nipples
• Increasing the girth of the penis

Depending on the surgeon, the patient and several other factors, the body is reported to reabsorb anywhere from 20 to 95 percent of transferred fat.

Due to the varying rates of absorption and the different lengths of time fat is reported remaining in the body, many physicians and other researchers worldwide since the 1980s have tracked success, safety and failure rates of fat transfer.^[4][5]

In most applications, fat injections are laid down through several different layers of skin and muscle to provide a better chance for the fat cells to find a nearby blood supply. Because some fat is always absorbed, most physicians inject somewhere around 30 percent too much. Physicians have learned the best donor areas are found in:

• The lower stomach
• The inner thighs
• The inner knees^[6]

Current clinical applications

Fat transfer to the hand

A wrinkled, bony hand with large veins, sun spots and deep grooves can reveal an advanced age even though the patient’s face, breasts or body have been surgically rejuvenated. Consequently, plastic, dermatological and cosmetic surgeons have developed techniques 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

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

Tiny, punch-like incisions are made at one corner of the patient’s mouth. The surgeon then takes one to two millimeter thick strips of fat from the donor site and gently works them into the upper and lower lips for a plumping effect that is reported to be safer, softer and more natural than lip augmentation with popular injectable facial fillers like Restylane or filler materials like medical Gore-Tex or, e-PTFE (polytetrafluorethylene) as the material is known to doctors.

Buttocks augmentation via fat injections

Currently, many women and a growing number of men want a curvier, rounder and shapelier rear end. While thin patients must opt for insertion of special buttocks implants to fill out their derrière, patients who can spare the fat can undergo fat injection in a surgical procedure known as gluteoplasty. Working through small incisions in each gluteal cheek, the surgeon places fat cells at dozens of levels through the patient’s rear. It’s an exacting procedure; one practitioner (Roberts) reports that a placement of fat cells the size of teaspoon will perish because that many fat cells can’t find a blood supply. Most surgeons who perform the task say the perfect deposit of fat cells is about the size of a single pearl or a pea; the drops are placed in long rows. After the procedure, the patient must wear a compression 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.

Breast augmentation via fat grafting

Fat grafting to enlarge female breasts is done, not only for cosmetic reasons, but to reconstruct deformities like a mastectomy, a breast implant collapse and or a tuberous breast, a condition in which the adult breasts fail to develop in puberty and result in extremely small, narrow and sagging breasts. Plastic surgeons Sydney R. Coleman, M.D. and Alesia P. Saboeiro, M.D., of Tribeca Plastic Surgery in New York City compiled statistics on 17 fat injection breast augmentation patients from November 1995 to June 2000 and found that long-lasting natural improvements in the size and shape of the breasts are possible with a fat grafting technique.^[7]

In that procedure, the doctors harvest donor fat, centrifuge it for refinement and to screen out impurities. Then, in a four to five hour procedure, they inject the fat into the layers of the breast through six to eight, two millimeter incisions in each breast. (One millimeter is the width of a single line drawn by a ballpoint pen.) Blunt syringes and cannulas are used to place the fat so that no damage is done to blood vessels or nerves. The fat is layered from the pectoralis major muscle up through the top of the breast; the surgeons rely on the fat injections to shape the breasts for an aesthetic, natural-looking result.

Despite the reports of some small studies, no current, standard method exists among physicians for preparing donated fat before injection back into the patient. For this and other reasons, the American Society of Plastic Surgeons (ASPS) and the American Society of Aesthetic Plastic Surgeons (ASAPS) are advising their surgeon members and the public against the fat transfer procedure, at least, fat grafting to augment breasts.^[8]However, an earlier report in 2001 by ASAPS found fat grafting “safe and effective” for augmenting buttocks.

Results

Because the surgeon usually must inject too much fat to allow for reabsorption, 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 everywhere from half a year up to eight years.

Potential risks and side effects

Fat transfer remains controversial although many plastic, dermatology and cosmetic surgeons offer various fat transfer procedures to their patients because the procedure is so well received by patients.^[9]

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. All are easily controlled and healed.

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. Doctors Summer and Sattler found that fat survives equally well when removed with suction via liposuction or when withdrawn by a syringe. The issue of survivability seems most affected by where in the body the fat is transferred, how much that site moves, how muscular it is and if disease is present.

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.

Non-injected fat grafting

A few plastic surgeons claim to offer better results when they remove strips of healthy fat and replant them into areas that need augmentation. One particular surgical fat grafting procedure process, trademarked by Dr. Brent Moelleken as "LiveFill", consists of harvesting live fat and fascia, a flat band of tough tissue below the skin that covers and separates the underlying tissues. The procedure is mostly used to plump up deep facial wrinkles and folds, to fill hollow areas and to augment lips. The donor fat is harvested in very thin strips and then placed into the target areas during a minor surgical procedure; the surgeon maintains the donor fat is fully alive, unlike the fat cells used in fat injections, which he finds are approximately only 20% alive at the time of injection, according to CT scans and other medical testing.^[10] Based on a study of 120 LiveFill patients comparing that procedure to fat injections, Dr. Moelleken in one test found an average of ten to 15 percent of injected fat surviving over the long term whereas transplanting live fat via surgery resulted in a 75 percent survival rate.

References