fat grafting

FAT INJECTIONfat grafting

Dr Sumer yadav

dr sumer yadav , mch plastic surgery,

sumeryadav2004@gmail.com

Autologous Fat Grafting

Four Categories: 1. Autogenous Fat Grafting2. Dermis-Fat Grafting3. Free Fat Flaps4. Fat Injection

Micro lipo injection Lipostructure Autologous fat filler

History of Fat Injection

1893 Franz Neuber First to use fat injectionTransferred 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 Hollander

First described a technique for using a needle & 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 & Benzaquen

Described injecting suctioned fat into the face

1986 Illiouz & Teimourian

Described injecting fat into iatrogenic liposuction deformities

1990 Sydney R.Coleman

Developed the method of reliable Fat injection

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-

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 AnatomyHarvest 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 AnatomyRecipient 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 Facial Augmentation

Facial atrophy

Facial Rejuvenation Ageing face

Augmentation of Breast Hand dorsum

Restorative / Reconstructive Correction of the “Under-

corrected” Liposuctioned areas

Filling of depressed zones resulting from injury

Correcting the wasting after Triple therapy for HIV+ patients

Augmentation of 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 &

cheeksdr sumer yadav , mch plastic

surgery, sumeryadav2004@gmail.com

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-1Harvesting

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

Harvesting (cont’d) 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-2Processing & 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-3Re-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 contactdr sumer yadav , mch plastic

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: Minimizing swelling of the

recipient tissues (2-4 weeks)

Stabilizing the area to avoid migration

Attained by: Elevation Cold therapy Light touch (Encourage

lymphatic drainage) 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: Under correction

Not enough material Resorption

Over correction More difficult to solve

Irregularities Asymmetry

Others: Edema Infection Migration Perforation Necrosis

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 Natural Biocompatible, Non

immunogenic Large volume

augmentation Cheaper

Disadvantages Unreliable resorption Donor needed for harvest

Results Depend Upon

Biologic boundaries

Othersurgery

Patient age

Recipientsite

Injection Technique

Processing& Storage

Harvesttechnique

Harvestsite

Result

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

Thanksdr sumer yadav , mch plastic

fat grafting

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