fat transfer to the face

Fat transfer to the face$

Technique and new concepts

Melvin A. Shiffman, MDa,*, Mitchell V. Kaminski, MDb

aPrivate Practice, 1101 Bryan Avenue, Suite G, Tustin, CA 92780, USAbFinch University of the Health Sciences Medical School, 3333 Green Bay Road, Chicago, IL 60064, USA

The minimally invasive technique of using autol-

ogous fat transplantation has become a standard

procedure in facial rejuvenation. It is simple, inex-

pensive, permanent, and effective.

Injectable fillers, such as collagen and hyaluronic

acid, are only temporary and therefore have few

indications. GoreTex, which is a permanent material,

can extrude or be palpable. Since 1994, when Adatasil

(silicone) was approved by the Federal Drug Admin-

istration (FDA) for use in ophthalmic problems, the

use of silicone injected into other areas of the body is

termed an ‘‘off-label use’’ and is considered legal if it is

used for a specific patient with a specific product, and

there is no advertising. Autologous fat can be used to

augment facial structures or rejuvenate rhytides, or to

fill depressed scars or defects of the face. Since the

introduction of liposuction for body contouring in

1975, [1] there has been an easy way to obtain fat for

transplantation through very small incisions. The use

of the tumescent technique for retrieving large

amounts of fat for transfer has reduced the amount of

blood loss and made the technique safer [2].

Although some reports have shown that fat trans-

fer had disappointing results in some cases, the

success of fat transfer is operator dependent and can

be quite successful if attention is paid to the details of

the techniques of the procedure. The transfer of fat to

the face, where vascularity is excellent, has an

excellent chance for fat survival.

The only relative drawback has been the lack of

100% take of the fat graft. With proper technique,

approximately 30% to 70% of the fat is retained.

Low-speed, short-time centrifugation of the fat

decreases the fluid in the transplant and reduces the

apparent loss of graft by compacting the fat and

separating out the excess liquid. Because some of

the apparent graft loss is the resorption of fluid from

the transplanted fat, there is less fluid in centrifuged

fat and therefore more mass is retained.

A newer concept to facilitate graft retention is the

use of albumin during the harvesting and transfer

phases. Albumin reduces the colloid osmotic pressure

disparity between the low colloid osmotic pressure of

the fat graft, with saline, epinephrine, lidocaine, and

sodium bicarbonate, and the interior of the fat cells.

The higher the difference in colloid osmotic pressure

between the cells and the surrounding fluids, the more

fluid will enter the cells and the more probable the

destruction of cells. If the colloid osmotic pressure

between the fat cells and the surrounding fluid with

albumin is almost equal, the more likely that there will

be improved fat survival and retention.

History of fat transfer

Since Neuber [3] in 1893 reported that trans-

planted fat can be used to fill in a depressed area of

the face, there have been many reports [4–13] that

have shown that fat, in pieces, can be transplanted

and survive in various areas of the body. Since

liposuction was conceived by Fischer and Fischer in

1974 [14] and put into practice in 1975 [1] the fat

aspirate has been used to fill defects and for contour-

1064-7406/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.

PII: S1064 -7406 (02 )00009 -3

$ This article was originally published in Facial Plastic

Surgery Clinics of North America 9:2, May 2001.

* Corresponding author.

Facial Plast Surg Clin N Am 10 (2002) 191–198

ing [15–21]. Aspirated fat should be washed atrau-

matically in physiologic solution to remove blood,

which allows better fat survival [22].

Certain principles of fat transfer have evolved

[15–21] over the years, which include aspiration at

lower vacuum (rather than at atmospheric) pressure,

fat that is present for over 60 days after transfer

(survives and grows better), avoiding dessication of

the fat during transfer, and fat grafts surviving when

there is vascular ingrowth. The survival of free fat

used as an autograft is operator dependent and

requires delicate handling of the graft tissue, careful

washing of the fat to minimize extraneous blood

cells, and installation into a site with adequate vas-

cularity. There is evidence that fat cells can survive

and that filling of defects is not from the residual

collagen following cell destruction. There is some

loss of fat after transplant, and most surgeons overfill

the recipient site.

For a more complete discussion of these princi-

ples, the reader is referred to the references cited at

the end of this article.

Insulin

Some physicians have added insulin to the fat in

preparation for transplantation [23–25]. The theory is

that insulin inhibits lipolysis.

In 1956, Sidman found that insulin decreases

lipolysis. In 1980, Hiragun et al [26] stated that

theoretically insulin could induce fibroblasts to pick

up the lost lipid and become adipocytes [27]. In 1993

Chajchir et al found that the use of insulin did not

show any positive effect on adipocyte survival during

transplantation compared with fat not prepared with

insulin [28].

Centrifugation

Some physicians centrifuge the adipose tissue to

remove blood products and free lipids to improve the

quality of the fat to be injected [24,27].

In 1987, Asken stated that his ‘‘method of reducing

the material to be injected to practically pure fat is to

place the fat-filled syringe with a rubber cap (the

plunger having been previously removed and kept in

a sterile environment) into a centrifuge [29]. The

syringe is then spun for a few seconds at the desired

rpm and the serum, blood, and liquefied fat collects in

the dependent part of the syringe. . .’’In 1991, Toledo reported that ‘‘for facial injection

we spin the full syringes for 1 minute . . . in a manual

centrifuge (about 2000 rpm), eject the unwanted

solution, and transfer the fat . . .’’ [4].In 1993, Chajchir et al centrifuge 1 mL of bladder

fat pad from mice (both at 1000 rpm for 5 minutes

and at 5000 rpm for 5 minutes) and injected this into

the subdermis of the malar area [26]. Microscopically,

after 1 to 2 months there were macrophages filled

with lipid droplets, giant cells, focal necrosis of

adipocytes, and cystlike cavities of irregular size

and shapes. After 12 months following injection, no

recognized adipocytes could be found. Total cellular

damage was present in both groups.

In 1996, Brandow and Newman found that cen-

trifugation of harvested fat did not alter the micro-

scopic structured integrity of cells. Spun and unspun

samples were examined and were found to be

similar [28].

In 1998, Fulton et al noted that centrifuged fat

(3 minutes at 3400 rpm) works well for small volume

transfers but not for large-volume transfers into

breasts, biceps, or buttocks [30].

Albumin in improving fat cell survival

Oncotic pressure

When amolecule is greater than 10,000D (a dalton

[D] is an arbitrary unit of mass equal to the mass of the

nuclide of C12 or 1.657 x 10�24 g), it is called a colloid

and is capable of generating an oncotic pressure if it is

restricted to one side of a semipermeable membrane.

Colloid restricted to one side of a semipermeable

membrane creates an osmotic gradient measured in

millimeters of mercury. Very small molecules and ions

such as sodium, potassium, glucose, and urea easily

cross a capillary membrane and can increase osmolar-

ity toward isotonicity to prevent red blood cells from

absorbing water and bursting. Osmolarity is measured

by freezing point depression, and the greater the

number of particles in solution, the colder the solution

must be before it can freeze.

Colloid osmotic pressure

In determining the colloid osmotic pressure (COP),

the Landis Papenheimer equation [31] takes into

account that soluble proteins, whether albumin, globu-

lin, or fibrinogen, are highly negatively charged:

COP ¼ 2:1ðTPÞ þ ð0:16TP2Þ þ 0:009TP3

where COP = colloid osmotic pressure and TP =

total protein.

M.A. Shiffman, M.V. Kaminski / Facial Plast Surg Clin N Am 10 (2002) 191–198192

Positively charged sodium ions surrounding the

core protein attract and hold water thus accumulating

more fluid on one side of the semipermeable mem-

brane. The combination of the oncotic pressure of the

sodium ions, resulting in an increased pressure gra-

dient, is called the colloid osmotic pressure.

Albumin is 69,000 D; globulin is 150,000 D,

and fibrinogen, 400,000 D. Because it is the num-

ber of molecules that are held on one side of the

semipermeable membrane that creates COP, albu-

min creates the most pressure because 1 g of albu-

min has twice as many molecules as globulin and

five times the number of molecules as fibrinogen.

Starch molecules, found in hetastarch and dextran,

should not be used for fat transfer because such

molecules are too large to be evacuated through the

lymphatics and can cause localized edema in the

interstitial space.

Starling’s equation

In equation form, Starling’s equation [32,33] rep-

resents the hydrostatic pressure pushing fluid through

the capillary pore (Pc through d) versus COP forces

holding fluid in circulation, and the rate of fluid flow

across the gel-sol matrix (Kf is inversely proportional

to �if and back into circulation by lymphatic channels

(Qlymph). When all of these factors are combined, the

entire equation is written thus:

Jv ¼ Kf½ðPc � PifÞ � ð�c � �ifÞ� �Qlymph

where

Jv = Interstitial fluid flow

Kf = Filtration coefficient

Pc = Hydrostatic pressure in the capillary

Pif = Hydrostatic pressure in the interstitial space

d = Pore membrane size on the reflection

coefficient

�c = Colloid pressure created by total protein [TP]

in circulation

�if = Colloid pressure created by TP in the

interstitial protein

Qlymph = Lymph flow

The pressure in the capillary minus the opposing

pressure in the interstitial space is known as the

hydrostatic pressure. Central venous pressure (Pc) is

the pressure pushing fluid across the endothelial mem-

brane through the body. The total protein in circulation

creates colloid osmotic pressure (�c). At any given time

at any given pore in the vascular endothelium, there is

more protein concentrated in circulation than there is at

Fig. 1. A 55-year-old woman with flattened malar eminences. (A) Preoperative. (B) One year postoperatively, following fat

transfer to the malar eminences.

M.A. Shiffman, M.V. Kaminski / Facial Plast Surg Clin N Am 10 (2002) 191–198 193

that site in the interstitial space. The COP creates a

constant negative force holding the fluid in circulation

and keeping interstitial fluid flow to a minimum,

packing cells together and preventing edema.

Avoiding hypo-oncotic trauma in fat transfer

When Klein’s solution or any modification is used

in harvesting fat, the infranatant of the harvested fat

contains 1.1 to 1.2 g% protein. The normal level is

2.0 to 4.0 g%. When one ampule of concentrated

human albumin (12.5 g in 50 mL) is added to 1 L of

tumescent solution of 8.3 mL added to 60-mL har-

vesting syringe, the harvested fat contains 2.6 g% pro-

tein. Three washes of harvested fat also increases the

difference in colloid osmotic pressure and, therefore, it

is necessary to add 18.75 g of albumin to each liter of

washing solution. Adequate time must be allowed be-

tween eachwash to allow the fat cells to pack above the

infranatant layer. The process can be accelerated by

centrifugation. The supranatant oil must be removed

before insertion of the fat into the recipient site.

Ratchet gun for injection

In 1987, Newman and Levin designed a lipoinjec-

tor with a gear-driven plunger to inject fat tissue evenly

into desired sites [22]. Fat injected with excessive

pressure in the barrel of syringe can cause sudden

injections of undesired quantities of fat that can pour

into recipient sites. In 1987, Agris stated that a rachet-

type gun allows controlled accurate deposition of

autologous fat [34]. Each time the trigger is pulled,

0.1 mL is deposited. Asaadi and Haramis described the

use of a gun with a disposable 10-mL syringe for fat

injection [35]. In 1994, Niechajev and Sevcuk used a

special pistol and blunt cannula, with 2.3-mm internal

diameter, to inject the fat [36]. Berdeguer used to a

lipotransplant gun to inject fat into areas to be en-

hanced [37]. In 1998, Fulton et al stated that it is

beneficial for a surgeon just beginning this type of

procedure to use a ratcheted pistol for injection, be-

cause this gives a more uniform injection volume [30].

Indications for fat transfer

There are several indications for fat transfer, which

can be distilled down to the following two categories:

Fill Defects

Congenital

Traumatic

Disease (acne)

Iatrogenic

Cosmetic

Furrows (e.g., rhytides, wrinkles)

Refill of lost supportive tissue (aging)

Enhancement

Preoperative consultation

The patient should be examined carefully in

relation to the specific complaint for which he or

she has come in for consultation. A description of the

physical problem must be recorded, with appropriate

measurements. Pictures should be taken before any

procedure is undertaken and postoperative photo-

graphs taken at an appropriate interval of time, when

healing is completed.

If there are problems detected by the physician

other than that of which the patient complains, this

must be recorded and possible treatment explained to

the patient, so that steps can be taken to correct other

deficits not previously identified by the patient or so

that the patient understands that adequate correction

could require other procedures. At the same time,

however, the patient must not be pressured into

procedures that are not really desired. The patient

Fig. 2. (A) A 39-year-old with thin lips. (B) Four months

postoperatively, following fat augmentation of the lips.


may need time to think about which procedures are

necessary and to seek other consultations.

The patient must understand the need for using

autologous fat as a filler substance, compared with

other fillers presently available. To conform with the

standard of care for informed consent, the patient

must have sufficient information to be knowledge-

able about the procedure, the possible material risks

and complications, and the alternatives and their

possible material risks. Someone from the surgeon’s

office must take time to explain this information, and

the physician must make sure that the patient under-

stands the procedure, risks, and alternatives and also

answer any questions about the procedure. It is

suggested that the physician include in the record

the statement that ‘‘the surgical procedure was dis-

cussed, as well as viable alternatives and all material

risks and complications.’’

Technique

Fat survival depends on the careful handling of fat

during harvesting, cleansing, and injecting. Harvest-

ing is performed by liposuction in areas of fat with

alpha-2 receptors, where the fat responds poorly to

diet (e.g., abdominal or trochanteric areas [genetic

fat]) [29]. The fat can be retrieved with liposuction,

using a cannula (2.5 mm to 3.5 mm) and suction

machine (–500 mm vacuum or less) or needle 14-to

16-gauge) with syringe (3 mL to 50 mL). Small

amounts of fat ( < 50 mL), which is usually all that

is necessary for transfer to the face, are easier to

remove with syringe and needle.

The fat must be cleansed with physiologic solu-

tion of normal saline or lactated Ringer’s solution by

gently mixing and decanting the infranatant liquid,

which consists of tumescent fluid, serum, and blood.

Fat can be concentrated with the use of centrifugation

at 3600 rpm for 1 minute. This allows less need for as

much overfilling (30% to 50%) as is usually used.

Kaminski [38] has proposed the addition of 12.5 g of

concentrated human albumin for each 1000 mL of

Klein’s solution used for harvesting and 18.5 g for

each 1000 mL washing fluid, to maintain the normal

extracellular oncotic pressure necessary to prevent the

influx of solution into the cells with possible rupture.

Fig. 3. A 45-year-old woman with depressions of the left malar eminence A, and left cheek B, and depressed scar of the left

chin C. (A) Preoperative. (B) Six months postoperatively, following subcision and fat transfer.


Alternatively, 8.3 mL of human serum albumin can

be added to a 60-mL harvesting syringe.

Injection of the fat is with a needle (18-gauge) or

cannula (1.5 mm–2.0 mm) uniformly distributed into

tunnels in multiple layers to fill the defect. With

depressed scars, the attachments to the skin should

be subcised before fat injection. The use of the ratchet

gun for injection does not damage fat cells [39].

The areas of the face that can be enhanced include

the cheeks (malar, submalar), lips, and chin (mentum,

Figs. 1 and 2). The brows can be lifted with fat transfer

to the forehead, and indentations can be improved in

almost any area of the face. Rhytides in the glabella,

the nasolabial folds, and ‘‘marionette’’ lines can be

improved. If the glabella is to be injected, the patient

should be informed of the rare possibility of blindness.

Any area of the face can have a depressed scar

elevated by subcision and fat transfer (Fig. 3).

Complications

There are very few serious complications of

autologous fat transfer. Because it is the patient’s

own tissue, there is no rejection phenomenon or

allergic reaction. Harvesting of large amounts of fat

by liposuction can trigger the complications of lip-

osuction in the donor area, but facial fat transfer is

usually with small amounts of fat. If small amounts of

fat ( < 50 mL) are retrieved, the one can expect the

possibility of bruising or infection in the donor site.

Autologous fat injection can be associated with

the following risks:

1. Loss of fat volume (the most common

problem)

2. Possible need for repeat injection(s) of fat

3. Bruising and hematoma

4. Swelling (especially with overinjection)

5. Asymmetry

6. Prolonged erythema (usually temporary, over

a short period)

7. Scar that is depressed or thickened (rare

except in the area of liposuction)

8. Tenderness and pain

9. Fibrous capsule around fat accumulation

(from too much fat injected into one area)

10. Fat cyst (mass)

11. Infection (rare)

12. Microcalcifications (has not been reported in

the face)

13. Central nervous system damage or loss of

sight from retinal artery occlusion (can occur

with injection in the glabellar area)

14. Any of the problems that can accompany lipo-

suction (if a large amount of fat is removed)

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