AUTHOR AND EDITOR INFORMATION

Section 1 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

History of the Procedure

Although the popularity of fat transplantation is a relatively recent development in plastic surgery, the concept of fat transfer is not new. As early as 1893, free fat autografts were used to fill a soft tissue defect. The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909. Throughout the early part of the 20th century, attempts were made to correct other conditions, including hemifacial atrophy and breast defects, but modern fat grafting did not develop until the early 1980s with the popularity of liposuction.

Illouz reported the transfer of liposuction aspirate fat in 1984. In 1986, Ellenbogen reported the use of free pearl fat autografts in a variety of atrophic and posttraumatic facial deficits. With refinements in technique, fat grafting has become the procedure of choice for an array of problems, including facial scarring, lip augmentation, and facial rhytides (such as several otherwise difficult-to-address areas such as the nasolabial fold and glabellar furrows).

Problem

Methods of addressing wrinkles and lines range from excision and redraping of excess skin to methods of skin resurfacing including dermabrasion, laser ablation, and chemical peels. Each of these modalities has limitations. Implantation of a filler substance into a deficient area is another solution. Whereas facial resurfacing can be thought of as razing the mountains, use of an implantable substance fills in the valleys. Many materials have been tried for the correction of soft tissue defects and deficits. However, the use of most of these substances has met with difficulties, including impermanence, foreign body reaction, unnatural texture, and possible disease transmission. In addition, most of the products currently available remain relatively expensive.

Some materials, such as silicone, have resulted in spectacular failures. Small volumes of liquid silicone formerly were used as free injections. Defects intentionally were undercorrected, since the ongoing soft tissue reaction created additional volume. However, the reaction of the host tissue led to late complications including chronic edema, lymphadenopathy, scarring, skin ulceration, skin thinning and discoloration, and siliconomas.

Collagen currently is used widely. Available collagen consists of purified bovine collagen. Zyderm is 95% type I collagen and 5% type III collagen. The addition of glutaraldehyde cross-linking (Zyplast) slows resorption; however, the substance nonetheless eventually is degraded by the host. While collagen works well for the correction of fine lines, results for deeper furrows are less impressive. The major drawback to the use of collagen is the short duration of the response. Within 3-6 months the collagen is resorbed completely, and the improvement is lost. Also, because the collagen is bovine derived, pretesting for an allergic response is required. The test spot should be observed for 1 full month prior to treatment.

The Food and Drug Administration (FDA) approved Gore-Tex (solid polytetrafluoroethylene) for facial plastic surgery in 1993. The result is generally predictable because the substance is nonreactive but the resulting feel of the tissue is somewhat unnatural. The substance is rigid and is not available in an injectable form. In addition, infection remains a potential problem because the substance is a foreign body. Because this substance does not become integrated into the host tissue, it is generally easy to remove.

Newer substances are being marketed. Sheets of human dermis (AlloDerm) are also available and produce a more natural result. Again, the form of this substance limits its use. Although it is derived from a human source and becomes revascularized by the host, it is not autogenous. Concerns about possible disease transmission have been expressed, although processing appears to control for this. A micronized form of human dermis has been available since 2000. While the semiliquid form of the substance gives it the versatility of collagen, the substance does not have the longevity of the sheet form. The major impediments to use of this substance remain the high cost and, although initially touted as a permanent solution, the substance is eventually degraded by the host.

Use of injectable poly-L-lactic acid (PLLA) has gained widespread popularity in Europe since its approval for cosmetic correction in 1999. PLLA is a synthetic polymer of lactic acid that is biodegradable, resorbable, and biocompatible. The large particle size of PLLA (40-63 µm) prevents it from being phagocytosed by macrophages, but it can still be used in needles as fine as 26–gauge (ga). The outcome in patients with a loss of facial volume and contours appears to be very good as judged by physicians and patients, with satisfaction rates reaching as high as 70% and 75%, respectively. One multicenter trial conducted by Laglenne and colleagues involving 110 patients reported minor adverse effects, with only 10% of patients experiencing nonspecific ecchymoses and no patients experiencing allergic reactions. However, others have reported many cases of granulomas and inflammatory reactions, which are difficult to treat.

An ideal substance would be readily available, inexpensive, long lasting, natural feeling, and would not cause adverse immunologic reactions. Autologous tissue meets these requirements. Several types of tissue can be transferred. Fascia and dermis require longer scars for harvesting. Ideally, dermis can be harvested from the area of a previous incision, such as a cesarean section or abdominal scar, to avoid a new donor site defect. Strips of these tissues can be useful for larger areas and deeper defects but do not have the flexibility of a liquid or semiliquid substance. Fat can be harvested through inconspicuous stab incisions. The harvesting does not leave a defect, and the removal of fat is often desirable. Fat tissue is soft and feels natural. It can be introduced to correct a variety of deficiencies, it is not immunogenic, and it is readily available and inexpensive.

Autologous fat transfer has been used for correction of facial scarring, including acne scars. Enhancement of facial volume also can be achieved for disease processes such as hemifacial atrophy and for patients with aesthetic concerns, such as those requesting lip augmentation. Signs of facial aging also can be improved. Rhytides that are too deep to be addressed by resurfacing modalities and areas poorly addressed by traditional lifting procedures (eg, nasolabial folds, glabellar creases, tear troughs) can be treated with grafted fat.

Etiology

Aging skin is characterized by decreased thickness, elasticity, and adherence to underlying tissue. In the epidermis, the number of melanocytes and Langerhans cells decreases. The rete pegs interconnecting the epidermis and dermis flatten, causing increased susceptibility to shear forces. The dermis atrophies as loss of ground substance, elastic fibers, and collagen occurs. Sun exposure leads to distinct damage to the skin. Elastosis (ie, deposition of thickened, irregular, partially degraded elastic fibers in the dermis) is characteristic of sun damage.

Cigarette smoking also is associated with changes in the skin. Posttraumatic scarring, acne, and the repetitive action of underlying muscle result in predictable histologic changes. Failure to properly evert skin edges during wound closure can result in a depressed scar. Repeated weight fluctuations can contribute to wrinkling. A genetic contribution also is present.

Clinical

Older patients may present for correction of specific areas or for overall facial rejuvenation. The anatomic areas not addressed by traditional rhytidectomy, auxiliary lifting procedures, or facial resurfacing often are ideal for fat grafting. Patients of all ages may present for facial enhancement; lip augmentation is the most common request. Often patients have obtained information from friends or media sources such as the Internet. Patient education and understanding are crucial to obtain optimal results.

This procedure can be performed on an outpatient basis with local anesthesia. The preoperative consultation is crucial. By far, the most important part of the preoperative workup is an extensive discussion identifying areas to be treated. In addition, details of the procedure, postoperative care, expectations, and possible adverse outcomes should be discussed.

Photographic documentation is critical to planning and evaluation of this surgery. Lighting, angle, and expression should be standardized to allow for accurate delineation of detail and adequate comparison of preoperative and postoperative views. The patient should not wear makeup for preoperative or postoperative photographic documentation. Digital photography is useful for the patient to indicate areas of concern during the consultation. Photographs are also useful for postoperative comparisons.

INDICATIONS

Section 3 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Aging and scarring result in loss of subcutaneous tissue, which is amenable to replacement by fat grafting. Indications for fat grafting include correction of atrophy due to aging or scarring and enhancement of facial elements (eg, to provide a fuller, more voluptuous lip; to correct glabellar frown lines). Areas of the face not well treated by procedures such as rhytidectomy include nasolabial folds, glabellar creases, and tear troughs. Lip augmentation may improve the appearance of fine perioral lines and increase the amount of vermilion show.

RELEVANT ANATOMY

Section 4 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Despite early views that fat is a relatively inert and isolated tissue, fat has been demonstrated to be a well-vascularized tissue with high metabolic activity. In addition to its structural role, fat tissue serves as a reservoir for energy storage. The number of fat cells generally is assumed to be stable after the completion of adolescent growth. 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. Cells shrink with overall weight loss and in fact may dedifferentiate. However, subsequent weight gain causes redifferentiation of the cells with an increase in volume.

Fat tissue consists of fat cells, which have thin cell membranes enmeshed in a fibrous network. Without the supporting fibers, the cells tend to collapse. An additional supporting network of connective tissue structure creates the lobules of fat, which can be observed grossly. Harvesting fat while maintaining as much supporting structure as possible preserves structural integrity of the tissue and helps the tissue retain bulk in the transplanted site. Almost any site can be used for harvesting; however, the abdomen is easily accessible, and stab incisions can be hidden within the umbilicus or in the hair-bearing skin of the pubic area.

CONTRAINDICATIONS

Section 5 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Contraindications to fat grafting include the presence of any disease processes that adversely affect wound healing and poor overall health status of the individual.

The use of free fat grafting for the treatment of contour abnormalities resulting from breast biopsy or for breast augmentation is generally contraindicated. The grafted fat can cause both palpable nodules and calcifications, situations that may hinder a diagnosis of breast cancer or cause unnecessary intervention.

Almost all candidates have some fat for harvesting; however, some individuals are unwilling to have a procedure performed at a distant site.

WORKUP

Section 6 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Lab Studies

• No specific laboratory studies need to be ordered for patients undergoing this procedure unless clinically indicated (ie, patients with history of easy bleeding or bruising should have coagulation parameters and platelets checked).

Imaging Studies

• No specific imaging studies are required for this procedure. However, if concern exists as to the presence of an abdominal hernia, obtaining an ultrasound to exclude this diagnosis is prudent to avoid a potentially devastating bowel injury.

TREATMENT

Section 7 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Medical therapy

Skin care regimens such as glycolic acid peels (minipeels) and at-home products such as glycolic acid lotions and Retin-A–type products are useful adjuncts for the treatment of facial aging. Other management options for the treatment of rhytides include traditional lifting procedures such as facelifts and brow lifts as well as chemical peels, laser resurfacing, and dermabrasion. Often these modalities can be used in conjunction with fat grafting.

Surgical therapy

The most important principle in the surgical management is the atraumatic transfer of fat. Trauma to fat in the process of harvesting or placing fat affects the survival of the graft. While a nonviable graft initially may appear to have corrected the problem, eventual resorption of the tissue negates the result. Any blood that remains in the harvested fat also facilitates rapid degradation of the transplanted lipograft. The 3 parts of the surgery are harvesting the graft, transferring the graft, and placing the graft.

Preoperative details

• First, carefully mark the recipient site with the patient's agreement while he or she is in the upright position.
• Sterilely prepare and drape both the harvest site and the recipient site.

Intraoperative details

Harvesting

• The technique is designed to harvest the fat in parcels of readily transferable size. Common donor sites include periumbilical, lumbar, and trochanteric areas; the thigh; and medial sites of the knee and arm.
• Use local anesthesia to anesthetize the site for a small stab incision. Through this incision, use a long syringe to introduce tumescent fluid for anesthesia of the region. The same site serves as the access for harvesting.
• The choice of tumescent fluid varies. A standard solution consists of 1 mg of epinephrine, 200 mg of lidocaine, and 5 mEq of sodium bicarbonate in 1 L of normal saline. Dosages of lidocaine up to 35 mg/kg can be used for the tumescent technique, although substantially less is required for simple fat harvesting.
• Following infiltration of the region to be harvested, use an aspiration cannula (eg, Mercedes) connected to a syringe. Alternatively, a 14-ga needle can be used, as this causes no reduction in survival of fat harvested. Suction by hand or with a mechanical vacuum. Use a gentle passing motion for aspiration. Small syringes are recommended to avoid creation of negative pressures greater than 1 atm. Increasing the power suction from -.5 atm to -.95 atm has been experimentally demonstrated to result in the breakage and vaporization of fat cells, destroying their ability to be successfully transplanted.
• For visible tarsal plates and tear-trough or nasojugal fold improvements, a combination of pearl fat grafting and sparse fat injection may provide optimal results. Pioneered by Ellenbogen, this technique employs small pearls (5-8 mm in diameter) excised from fat and placed in saline. These pearls are then stacked on top of each other through an incision in the depressed area. This technique is not useful for nasolabial folds, labiomandibular folds, or chin augmentation.

Transfer and purification

• Once harvesting is complete, the aspirate then is transferred sterilely through multiple syringes using the tulip connections to 1-mL tuberculin syringes. The liquid fraction of the graft is gently washed free of oil, lidocaine, and blood with this transfer.
• An alternative to gentle hand tipping is use of the centrifuge. Although Chajchir found that use of the centrifuge machine at high or low speed completely destroyed the adipose cells, other groups have reported good results with use of the centrifuge. The aspirate divides into 3 layers. The top layer is free oil from ruptured fat cells. This layer is decanted or blotted gently. The bottom layer contains variable amounts of tumescent fluid and blood and is drained. The middle layer consists of fat cells for grafting. More vigorous washing or straining may damage the fragile cells and decrease the viability of the graft.
• Inspired by a yogurt concentration method used in Anatolia, Kuran had recent success transferring aspirated fat to a sterile cup dressed with gauze. Five washes of lactated Ringer's solution rinses local anesthetic solution and blood from the fat. The aspirate is left to dry and the concentrated product is transferred to small syringes. Most groups favor a closed technique for sterility issues, but no published data exist for higher risk of infections in open procedures. The advantage of open technique is the option that allows the surgeon to manipulate fat to produce a graft that is easier to inject.
• The choice of fluid for fat suspension is controversial. Most commonly, normal saline or lactated Ringer solution is used. Serum free culture medium is also available, although it is more expensive. Some groups advocate additives such as heparin, insulin, vitamin E, and nonsteroidal anabolic hormones. The contribution of lidocaine is also debatable.
• In anticipation of future lipografts, adipocytes may be frozen to -30°C and reused. A high number of viable cells exist even after defrosting. Slow freezing and thawing is the method of choice to retain the maximal number of live cells.

Placement

• Regional nerve blocks are the most useful because adequate anesthesia can be provided without obscuring the defect to be treated.
• The goal with any grafting procedure is to gently apply the graft to a well-vascularized bed to maximize graft take. Every part of the graft should be within 1.5 mm of living, vascularized tissue. If a large area is grafted, the central area, which is most removed from the blood supply, may not survive. Still, some clinical evidence shows good lipografting survival in some tissues that are not well-vascularized (ie, hemifacial hemiatrophy and posttraumatic scars).
• Also, creating small tracks for the grafts helps keep the grafted fat adherent to the recipient site. Keeping the tracks independent prevents the fat from leaking out of the tunnel. Also take care to avoid overfilling the track. Overfilling can adversely affect graft survival and graft location.
• Insert the cannula either over a bevel-tipped needle or through a 1-to 2-mm stab incision by an 11 blade. Guide the needle or cannula superficially under the rhytid or scar and inject fat in a controlled method gently upon withdrawal. Slight overcorrection is important because some absorption of the liquid carrier occurs. Some groups recommend a 30% overcorrection.
• Level of fat grafting varies with the structure being augmented. Fat is grafted from the deep layer to the superficial layer.
• Kuran's technique calls for injection in parallel and crossing directions and at subcutaneous, intramuscular, and supraperiosteal levels for malar, buccal, and mental areas. Injections are only made parallel to the line for wrinkles and nasolabial sulcus corrections.
• With lip augmentation, grafting near the mucosa increases the amount of vermilion show. Grafting near the white roll tightens perioral rhytides. Gatti describes injection of 3 mL into the upper lip and 4 mL into the lower lip, although much larger amounts have been reported.
• Serial injection may be performed at 3-month intervals. Generally, 3 procedures should be anticipated. Even distribution of the injection is crucial. Excess bulk in a particular area may isolate the fat in the central region from the new blood supply.

Postoperative details

• Discourage massage and excessive facial animation immediately following fat grafting. These restrictions are to prevent migration of fat away from the desired areas of treatment.
• Compression dressings to prevent migration have been described; however, they are often difficult to maintain and probably add little to the final result. If the fat has been placed in an appropriate tunnel, minimal concern about migration should exist.
• Ice compresses are applied for 24-48 hours to minimize inflammation.

Follow-up

• Patients should be seen in the first week postoperatively to check the donor and recipient sites. Some edema and a minimal amount of bruising may be apparent; reassure patients.
• An additional follow-up appointment should be made for approximately 6-8 weeks. At this point, most of the edema has subsided, and early results can be assessed.
• If a repeat procedure is to be performed, a waiting period of 3 months is prudent to allow the first graft to revascularize and to allow any edema to resolve.

COMPLICATIONS

Section 8 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

The major complications of fat grafting are undercorrection and overcorrection. Undercorrection can be the result of the placement of less than the required amount of fat or from the resorption of some of the graft.

Although placing too little fat obviously fails to correct the defect, increasing the amount of injected fat does not always prevent problems. Placing too much fat in a particular area can contribute to failure of revascularization of the graft. Graft necrosis may cause palpable irregularities and eventual disappearance of the grafted material. Graft migration is usually caused by infiltrating too much fat into a particular site. The graft either is forced into an undesirable area or succumbs to pressure and lack of blood supply.

When grafting scarred areas, the graft tends to move to the areas of least tension. Clumping of the graft also may occur. This may be a particular problem under thin skin. After 1 month, if clumping is still a problem, instruct the patient on how to perform scar massage.

Undercorrection is generally easier to treat than overcorrection. Additional fat may be grafted at a separate sitting to complete the correction. Removing excess graft is more difficult as the host tissue infiltrates into the graft.

Damage to underlying structures, particularly around the eye, is possible and generally is prevented using the blunt needle for infiltration. Coleman reported a case of parotid injury when grafting a scar adherent to the parotid. Sharp needles were used. Niechajev and Sevcuk reviewed complications and discovered 4 cases of unilateral blindness and 1 case of severe damage to the CNS. All of these cases involved treating glabellar frown lines with probable resultant fat embolism. Careful control of the injection to keep the fat in superficial areas as well as use of the blunt cannula should prevent these complications.

Edema usually is evident for 2 weeks after the procedure; however, as with any procedure, prolonged edema is possible and troubling to the patient.

Bleeding complications usually are limited to transient mild ecchymosis and are associated with the use of sharp needles for fat injection. Superficial ecchymosis tends to resorb rapidly. Small hematomas are more unusual and are associated with the use of sharp needles for graft placement.

Although rare, infections can occur wherever the skin envelope is violated. The most common source of infection is the oral mucosa.

Additionally, donor site scarring is a potential concern. Contour irregularities can result from overly aggressive harvesting in a small area.

OUTCOME AND PROGNOSIS

Section 9 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

The major questions regarding fat grafting are how much of the graft survives and for how long. Many groups have reported on the fate of grafted fat; however, solid quantitative results have been difficult to establish. In addition to the variations in technique of fat grafting, quantifying the results objectively has been nearly impossible. Biopsy of the areas has been performed but is not a palatable option in the cosmetic patient. Further, while histology may demonstrate the integration of the graft, the relative volume retained remains unknown.

Imaging studies, such as MRI, may yield information in a noninvasive manner; however, such studies are quite expensive and inconvenient for the patient. Also, many of these patients undergo additional procedures either simultaneously or at a later date, which may confound the results. Individual variation in aging is another uncontrollable factor, although many studies reporting poor long-term results have been published. Surgeons who routinely perform fat grafting counter that failure to maintain meticulous technique accounts for the shortcomings.

Two major theories describe the survival of grafted fat. Peer proposed the host cell replacement theory. Histiocytes phagocytize free fat and become adipocytes. This idea largely has been replaced by the cell survival theory. Circulation is restored to the grafted fat cells in a manner similar to the revascularization of a skin graft. In the first 4 days, host cells, such as polymorphonuclear leukocytes (PMNs), plasma cells, lymphocytes, and eosinophils, infiltrate the graft. Within the vessels of the graft, red and white blood cells are clumped. On or about the fourth day, neovascularization is evident. Histiocytes act only to remove fat from broken down, nonsurviving, or disrupted cells.

Chajchir et al performed biopsies on the sites of grafted fat at intervals. Three months after transfer, zones of cytosteatonecrosis, lipophagic granulomas, lymphocytes, adipocytes, giant multinucleated cells, and new vessels were found. At 6-8 months, the specimens were infiltrated heavily by PMNs in a fibrotic matrix, and at 1 year a large amount of connective tissue and fibrotic reaction was present. Some fat was still present but the authors felt that the inflammatory reaction may contribute more to the long-term result.

The key points of the theory of fat survival are (1) fat is a dynamic tissue and (2) cells that suffer trauma lose more volume. Therefore, careful handling of the graft is critical. Scarring and the added bulk of reactive tissue may contribute to the anticipated result.

Moore et al reported on the effects of mechanical damage to fat cells harvested with syringe suction lipectomy versus excision with local anesthetics. The mechanical damage to tissue aspirated versus tissue that was excised was unchanged. Lidocaine inhibited the glucose metabolism and lipolysis of adipocytes in culture. The effect was maintained only for as long as the lidocaine was present.

Also, as Smahel reported, fat grafts, like other grafts, must be small enough to be revascularized but large enough to maintain structural integrity and some native blood vessels. When part of the graft is not revascularized, the fat becomes necrotic and is not simply resorbed but is broken up and removed by the cellular elements.

Outcomes of early studies yielded disappointing results.

A 1991 report by Ersek revealed a 3-year follow-up period of fat grafting that was disappointing; however, although the fat was harvested atraumatically using a blunt cannula and minimal vacuum, the fat was processed in a traumatic manner using a whisk and strainer. The range of fat resorption was reported at 20-90%. Cortese et al reported resorption of 75-98% of the graft, but some good results were obtained with multiple procedures.

The techniques of grafting fat have changed markedly since these studies were performed. Niechajev and Sevcuk reported long-term results of fat transplantation clinically and histologically. Fat harvested by low-power aspiration was used. Patients were overcorrected by approximately 50% at the time of the initial procedure. Only partial resorption had occurred 1.5-4.5 years postoperatively. The clinical impression was that 40-50% of the result was maintained long-term. Histologic sampling at 7-36 months revealed fat cells in an organized structure. Longer-lived specimens demonstrated more pronounced fibrosis and organized connective tissue. The size of the graft was demonstrated to increase with overall weight gain by the patient.

Bertossi reported on the histology of biopsy specimens from the upper lip of 99 patients. Upon examination, the structure of the transplanted adipocytes was well-preserved. In some areas, connective tissue was dense and organized; in other areas, adipocytes and reactive cells with increased vasculature were in higher abundance.

Coleman reported long-term success when the treated rhytid was compared with a control rhytid. Patients were monitored clinically with careful photographic controls for 6.5 years. However, ongoing aging and choice of control rhytid can affect the interpretation of results.

Clearly, the results depend on the technique used for the procedure and on the method of measuring results. Advances in digital photography will aid in long-term follow-up care and documentation. Presently, clinical impressions and patient satisfaction support the use of fat grafting in many different situations.

FUTURE AND CONTROVERSIES

Section 10 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Fat grafting has become a popular procedure for facial reconstruction and rejuvenation. The long-term results remain debatable. Standardized digital photography may allow more precise quantification of long-term results in a noninvasive manner. Investigations regarding pharmacologic manipulation of the graft are underway. In addition, techniques for simplification of harvesting are being developed. The ability to grow cells in culture may allow for multiple grafting procedures with a single harvest. Some groups have tested agents such as insulinlike growth factor, basic fibroblast growth factor, and a selective B1 blocker to enhance the survival of lipograft in rats. The results seem promising and may one day be used in human facial fat grafting.

ACKNOWLEDGMENTS

Section 11 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Wendy Gottlieb, MD, to the development and writing of this article.

MULTIMEDIA

Section 12 of 13  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

Media file 1:  Preoperative view demonstrates marionette lines.
	View Full Size Image
Media type:  Photo

Media file 2:  Infiltration of the abdominal fat donor site with tumescent fluid.
	View Full Size Image
Media type:  Photo

Media file 3:  Aspiration of fat.
	View Full Size Image
Media type:  Photo

Media file 4:  Layering of fat and tumescent fluid in the syringe.
	View Full Size Image
Media type:  Photo

Media file 5:  Fat in a tulip syringe.
	View Full Size Image
Media type:  Photo

Media file 6:  Transfer of aspirated fat into a small syringe for controlled injection.
	View Full Size Image
Media type:  Photo

Media file 7:  Injection of a marionette line.
	View Full Size Image
Media type:  Photo

Media file 8:  Injection of the glabellar furrow.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 13 of 13

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Acknowledgments
• Multimedia
• References

• Ayhan M, Senen D, Adanali G, et al. Use of beta blockers for increasing survival of free fat grafts. Aesthetic Plast Surg. Sep-Oct 2001;25(5):338-42. [Medline].
• Bertossi D, Zancanaro C, Trevisiol L, et al. Lipofilling of the lips: ultrastructural evaluation by transmission electron microscopy of injected adipose tissue. Arch Facial Plast Surg. Sep-Oct 2003;5(5):392-8. [Medline].
• Billings E Jr, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg. Feb 1989;83(2):368-81. [Medline].
• Bostwick John III. Augmentation Mammaplasty. Plastic and Reconstructive Breast Surgery. 2000;I:239-370 (343).
• Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg. Winter 1994;18(1):17-9. [Medline].
• Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of autologous adipose tissue processed by different techniques. Aesthetic Plast Surg. Spring 1993;17(2):113-5. [Medline].
• Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue augmentation. Plast Reconstr Surg. Dec 1989;84(6):921-34; discussion 935. [Medline].
• Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. Apr 1997;24(2):347-67. [Medline].
• Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. Sep-Oct 1995;19(5):421-5. [Medline].
• Cortese A, Savastano G, Felicetta L. Free fat transplantation for facial tissue augmentation. J Oral Maxillofac Surg. Feb 2000;58(2):164-9; discussion 169-70. [Medline].
• Ellenbogen R. Free autogenous pearl fat grafts in the face--a preliminary report of a rediscovered technique. Ann Plast Surg. Mar 1986;16(3):179-94. [Medline].
• Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg. Feb 1991;87(2):219-27; discussion 228. [Medline].
• Gatti JE. Permanent lip augmentation with serial fat grafting. Ann Plast Surg. Apr 1999;42(4):376-80. [Medline].
• Illouz YG. L'avenir de la reutilization de la graisse apres liposuccion. Rev Chir Esthet Lang Franc. 1984;9:36.
• Kulkarni RK, Pani KC, Neuman C, Leonard F. Polylactic acid for surgical implants. Arch Surg. Nov 1966;93(5):839-43. [Medline].
• Kulkarni RK, Moore EG, Hegyeli AF, Leonard F. Biodegradable poly(lactic acid) polymers. J Biomed Mater Res. May 1971;5(3):169-81. [Medline].
• Kuran I, Tumerdem B. A new simple method used to prepare fat for injection. Aesthetic Plast Surg. Jan-Feb 2005;29(1):18-22; discussion 23. [Medline].
• Laglenne S, Lalanne B, Laglenne B, Asius J. Un nouveau produit comblement des rides, entirement resorbable. Dermatologie. 2000;54:30-3.
• Montanana Vizcaino J, Baena Montilla P, Benito Ruiz J. Complications of autografting fat obtained by liposuction. Plast Reconstr Surg. Apr 1990;85(4):638-9. [Medline].
• Moore JH Jr, Kolaczynski JW, Morales LM, et al. Viability of fat obtained by syringe suction lipectomy: effects of local anesthesia with lidocaine. Aesthetic Plast Surg. Jul-Aug 1995;19(4):335-9. [Medline].
• Niechajev I, Sevcuk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. Sep 1994;94(3):496-506. [Medline].
• Niechajev I. Lip enhancement: surgical alternatives and histologic aspects. Plast Reconstr Surg. Mar 2000;105(3):1173-83; discussion 1184-7. [Medline].
• Peer LA. Transplantation of Tissue. Baltimore:. Lippincott Williams & Wilkins;1959.
• Rees TD, Aston SJ, Thorne CHM. Blepharoplasty and facialplasty (subheadings facial aging and morphologic changes). Plast Surg. 1990;3:2360-3.
• Saylan Z. Facial fillers and their complications. Aesthetic Surg J. 2003;23:221-4.
• Schuller-Petrovic S. Improving the aesthetic aspect of soft tissue defects on the face using autologous fat transplantation. Facial Plast Surg. Apr 1997;13(2):119-24. [Medline].
• Smahel J. Adipose tissue in plastic surgery. Ann Plast Surg. May 1986;16(5):444-53. [Medline].
• Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg. Dec 2000;26(12):1159-66. [Medline].
• Vleggaar D. Facial volumetric correction with injectable poly-L-lactic acid. Dermatol Surg. Nov 2005;31(11 Pt 2):1511-7; discussion 1517-8. [Medline].
• Yuksel E, Weinfeld AB, Cleek R, et al. 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. Apr 2000;105(5):1712-20. [Medline].

Article Last Updated: May 26, 2006