AUTOLOGOUS FAT TRANSFER, BREAST LIPOMODELLING AND FAT TRANSFER TO THE FACE: CURRENT GOLD STANDARDS AND EMERGING NEW DATA

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Authors: Streit L. M. D. ^1,2; R. Lhotsky ³; O. Mestak ⁴
Authors place of work: Department of Plastic and Aesthetic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic ¹; Centre for Plastic Surgery and Hand Surgery, University Hospital Ostrava, Ostrava, Czech Republic ²; Hand and Plastic Surgery Institute, Vysoké nad Jizerou, Czech Republic ³; Department of Plastic Surgery, 1st Faculty of Medicine, Charles University, Prague, Czech Republic ⁴
Published in the journal: ACTA CHIRURGIAE PLASTICAE, 59, 2, 2017, pp. 97-108

INTRODUCTION

Autologous fat transfer is a surgical technique that is used to transfer adipose tissue in an injectable form from the donor area to the areas where adipose tissue is needed for tissue augmentation or for its regenerative properties. The method is often referred to as lipofilling, fat grafting, lipotransfer or autologous fat transplantation. In plastic and reconstructive breast surgery is the lipomodelling term probably the most accurate, because it reflects significant shaping potential of the technique on the breast. Whatever the method is called, however, the basic principles remain the same. Fat transfer may be used separately as a major surgical technique, or it may be an integral part of combined surgical procedures.

Fat transfer can be categorized according to the volume of transferred tissues to high- and low-volume fat grafting. High-volume fat grafting is performed primarily in order to supplement missing volume or to increase the size of the treated area. Typical examples of high volume fat grafting include breast lipomodelling in both reconstructive and aesthetic indications or correction of congenital chest deformities such as pectus excavatum ^1-7.

In case of low-volume fat grafting, there is also the regenerative potential of fat utilized apart from its volume replenishment and contouring effects, especially in certain indications. Low-volume fat grafting is used in the treatment of radiation-damaged skin ⁸, in the treatment of scleroderma ⁹ or for the correction of the scars after burns ^10,11. It was also recognized as an optimal surgical strategy in the correction of the progressive hemifacial atrophy ¹². Finally, low-volume fat grafting is commonly used in aesthetic surgery for rejuvenation of the face ^13-17, neck or hands ¹⁵. The regenerative effect is expressed as an improvement in skin elasticity, texture and colour and as improvement in tissue vascularity.

Fat transfer consists of three consecutive steps: 1) fat harvesting, 2) fat processing, and 3) fat graft injection. All these steps may differ significantly depending on what is the main goal of the surgery and whether it is a high or low-volume fat grafting. Also the preference of the surgeon plays a role.

FAT HARVESTING

Adipose tissue is harvested by liposuction from subcutaneous fat deposits in the areas where fat is in excess. During fat harvesting, the main goal of harvested areas infiltration is not tissue tumescence but only tissue saturation with epinephrine. Therefore, lower volumes of the solution are used compared with tumescent liposuction for cosmetic reasons. The amount of aqueous components in lipoaspirate is also rather a disadvantage because these aqueous components are to be eliminated during fat processing. Furthermore, when higher volume of infiltration solution is used, harvesting time is extended because of higher number of manipulations, which may also correspond with a higher consumption of material, e.g. sampling syringes. It is also recommended to use infiltration solution without local anaesthetics since they have been shown to have toxic effects on adipocytes and preadipocytes ^18,19. For all these reasons, if the whole surgery is scheduled under general anaesthesia, we use low-volume infiltration with normal saline and higher concentration of epinephrine (2:1,000,000) and we recommend infiltration of harvesting areas by local anaesthetics when harvesting is finished.

Liposuction is performed most commonly manually using “luer-lock” syringes to connect the cannula or “Toomey” syringes with conical tip type of cannula. Vacuum is created by continuous movements of the syringe plunger or by using a holder for the plunger. Another option is usage of lipoaspirate collectors where output is connected to the aspirator and input to the cannula. The collectors are used more often, particularly when high volume fat grafting is carried out more frequently in the department. The advantage of using the collector is the fact that the vacuum can be defined more precisely. However, there is no study showing that higher values of negative pressure would significantly affect the viability of harvested adipose tissue ^20-22.

Harvesting technique significantly affects the quality of fat graft. Cannulas differ in the number, size and spatial arrangement of openings in the tip and also in diameter and length. Cannulas for low-volume fat grafting are thinner and they usually have multiple openings with a diameter below 1 mm (Figure 1). Tonnard et al. have demonstrated significant differences in adipose tissue viability depending on the size of the openings in the tip and on the number of passages through the “luer-lock” syringes. Adipose tissue viability was significantly higher after fat harvesting using 3mm cannulas with three openings of 2x7mm in the tip then after using 3mm cannulas with multiple circular sharp holes of 1-mm diameter in the tip (microfat grafting technique). Furthermore, their study has shown that adipose tissue viability is further decreased by repeated passages between the syringes via “luer lock” connector (nanofat grafting technique). On the contrary, usage of a cannula with small openings in the tip or repeated passages through “luer lock” connector had no negative impact on the concentration and characteristics of stem cells in harvested adipose tissue that are associated with regenerative effect after fat grafting ²³.

Fig. 1. Harvesting cannulas and syringes. From the right to the left: 1) 60 ml “Toomey” syringe – part of PureGraft™ set, 2) 30 ml luer-lock syringe – used in our department for breast lipomodelling, 3) 10 ml luer-lock syringe – used in our department for harvesting for facial fat grafting or for application during breast lipomodelling, 4) harvesting cannula with a diameter of 3.5 mm and length 17cm with 6 openings on the apex (PLA187 model, Pouret Medical, France) – used for breast lipomodelling, 5) Tulip harvesting cannula for microfat grafting, Sorensen type – reusable, and 6) single use harvesting cannula from “St’rim” set from the Thiebaud company used for microfat grafting

Liposuction system, which allows infiltration of harvesting area with tumescent solution by water jet and simultaneous harvest of adipose tissue has been recently developed (“water jet assisted liposuction”). An essential part of this system is a two-way cannula with an opening for the water jet in the tip with openings for lipoaspirate suction on its sides.

FAT PROCESSING

Harvested adipose tissue (lipoaspirate) is a mixture of adipose tissue fragments, lipid droplets, cellular debris, infiltration solution and blood. The quality and ratio of the individual lipoaspirate components is defined by harvesting technique. The aim of lipoaspirate processing is to obtain a purified cell mixture, which has a minimal extent of volume absorption and/or maximal regenerative effect.

For the surgeon, a large number of technical options exist for fat processing. The most commonly used techniques for lipoaspirate processing in clinical practice include 1) decantation; 2) centrifugation with different speeds, diameters, volumes, and tube shapes; and 3) filtering through a simple membrane (mesh) or filtering through a membrane combined with washing in more sophisticated devices such as PureGraft^TM.

Decantation is the oldest method that is still used by some surgeons because it is simple and cheap, although time consuming. Lipoaspirate processing is based on decantation also in recent lipoaspirate collectors that seem to be more effective as they are directly connected to the aspirator and to the harvesting cannula.

Centrifugation is the most commonly used technique for processing of lipoaspirate. It was popularized by Coleman, who described in detail the processing techniques using 3-minute centrifugation with a relative centrifugal force of 1286 g. Lipoaspirate is divided by centrifugation into four clearly distinguished layers: 1) the upper oily layer, 2) the middle adipose layer, representing most of the adipose tissue, and 3) the lower aqueous layer, consisting mainly of tumescent solution, and 4) the pellet at the bottom of each tube (Figure 2). Centrifugation is carried out usually directly in the harvesting syringes with luer lock connector. The effect of centrifugation on the biological properties of adipose tissue has been described in many studies^13,24-29. In our department, we centrifuge lipoaspirate at a relative centrifugal force of 1,200 g directly in the harvesting 10-ml syringes for low-volume fat grafting and in 30-ml syringes for high-volume fat grafting. We believe that usage of 30ml syringes reduces significantly the number of manipulations and thus operating time.

**Fig. 2. Fat processing by centrifugation in 30-ml syringes for high-volume fat grafting**

The third basic principle of lipospirate processing is filtration through a membrane. Perhaps the simplest option is filtration and washing with saline solution through a filter membrane positioned on top of the surgical bowl ³⁰. The disadvantages are obvious, the tissue is prepared on open air and the number of manipulations is relatively high. Nevertheless, due to its simplicity and cost it is still used, especially for low-volume fat grafting procedures. More sophisticated devices that are based on the filtration principle are also available. These devices can be designed like canisters connected directly to the aspirator and harvesting cannulas. The outlet portion for the liquid components of lipoaspirate can be constructed as a single outlet at the base of the container, or it can be connected also with the aspirator. Another membrane-based tissue filtration system is PureGraft™, which is designed for manual sampling liposuction syringes with “Toomey” tip. The device consists of a plastic bag, which is divided inside by double filtration membrane into the inlet and outlet parts. Valves for the lipoaspirate installation orifice together with input for Ringer solution into the inlet part; outlet part is connected to the waste plastic bag (Figure 3). Advantages of these more sophisticated devices may be lower number of manual manipulations during fat preparation and the design as a closed system. On the other hand, their disadvantage is that it can eliminate undefined substances, such as cytokines and/or growth factors, that may augment the regenerative effect of lipoaspirate application ³¹.

**Fig. 3. Fat processing by washing and filtration through a membrane using PureGraftTM devices**

Streit et al. recently comprehensively compared these preparation techniques in vitro. Morphology of each preparation was assessed by electron microscopy and overall cell viability by live/dead assay. Number of adipose derived stem cells (ASC) was determined and their stem cell character was assessed by the presence of cell surface molecules and by their capacity to differentiate into adipogenic and osteogenic lineages. They have demonstrated that 1) decantation is a very gentle technique that best preserves components of the extracellular matrix, but the product of decantation is to some extent contaminated with oil droplets and residues of disrupted adipocyte membranes; 2) centrifugation isolated the highest concentration of ASC from the upper two-thirds of the adipose layer of centrifuged fat (low-density fraction). Centrifuged fat was almost completely devoid of contaminating oil droplets and debris, and it retained considerable amounts of the fibrillar components of the extracellular matrix; and 3) centrifuged fat compared with membrane-processed fat contained about the same concentration of ASC with similar viability. Although filtration also effectively removed oil droplets and cell debris, membrane-processed fat again retained a substantial part of the fibrillar components of the extracellular matrix. Finally, the watery component was minimal in membrane-processed fat ²⁹. Because the differences were not dramatic, authors concluded that centrifugation and membrane-based tissue filtration are equivalent techniques and superior to decantation in clinical practice.

In the selection of processing technique for clinical practice, another criteria such as practicability for the individual surgical settings (close vs. open system, number of manipulations, price, required time, etc.) remain crucial for the surgeon ³¹.

Cell assisted lipotransfer is used to increase engraftment and decrease liponecrosis in the recipient tissue. This technique is based on enrichment of fat graft with stem cells or stromal vascular fraction cells ³². Core factor affecting absorption is cell apoptosis due to inflammatory condition after transplantation and the lack of angiogenesis. Stem cells may improve fat survival in three ways - they release growth factors and help the surrounding tissue to resist hypoxia and ischemia; they differentiate into adipocytes and regenerate the adipose tissue and they promote vasculogenesis. However, there is absolutely no statistical evidence that proves this assumption ^33-36.

FAT TRANSFER

Purified adipose tissue is usually injected with syringes (10-ml syringes for high-volume fat grafting, 1-ml syringes for low-volume fat grafting) and special application cannulas (Figure 4). The cannula is introduced through multiple entry points created by a needle or scalpel in order to achieve a honeycomb structure of multiple microtunnels. Fat is injected in small quantities in the form of fine cylinders resembling spaghetti. Each microtunnel must be surrounded by well vascularized tissue (Figure 5). Transfer is done from a deep to a superficial plane. Good spatial visualization is necessary to form a sort of three-dimensional honeycomb, to avoid creating areas of fatty pools, which would lead to fat necrosis ⁴.

Fig. 4. Application cannulas. On the left, 2mm cannulas with a length of 20 and 13 cm (PLA188 and 189 models, Pouret Medical, France). In the centre, 1.5mm cannulas with a blunt tip (Coleman™ Style 1, Mentor, USA) and “V” shaped tip to release scars (“V” Dissector Cannulae, Mentor, USA). These cannulas and similar styles are suitable for lipomodelling of the breast. On the right is an example of cannulas for fat grafting to the face, diameter 0.9 and 0.7 ml (Tulip, USA)

**Fig. 5. Principle of fat transfer into multiple layers of recipient subcutaneous tissue**

During high-volume fat grafting, it is necessary to know how to overcorrect the quantity of fat, if allowed by the recipient tissues, as absorption of about 30-40% volume may be expected. When the recipient tissues are saturated and cannot accept more fat, it is not advisable to continue, because of the risk to create areas of fat necrosis. It is better to plan an additional session than disregard saturation of the tissues. Incisions are sutured using very fine suture material.

Technique of multiple percutaneous fasciotomies performed with 17-gauge trocar or needle is one of the advancements of the lipomodelling technique. This technique is also called three dimensional ligamentous band release or “Rigottomy”. It is powerful technique for scar releasing, it allows us to move down the submammary fold and to sculpture bottom part of the breast if required (in tuberous breast) ^4,37.

External breast tissue expander (BRAVA^®) was introduced as a nonsurgical alternative to breast augmentation. The system consists of two domes with soft silicone edge and it is worn as a bra. Attached pump creates negative pressure within domes and consequently acts as an expander ^38,39. Action of negative pressure leads to 1) the enlargement of breast tissue and its vascularity, and to expansion of skin, which is advantageous especially in breast reconstruction. This results in enlarged tissue bed for fat injection. The larger is the preoperative expansion, the more volume we are able to inject. We recommend wearing BRAVA 3 weeks/12 hours per day before fat grafting. It is advisable to over-expand the breast in order to gain sufficient skin envelope for fat application. With this system we can perform mega volume fat grafting, which means we can safely achieve volumes of around 300 ml per breast. While wearing BRAVA postoperatively we decrease pressure of surrounding tissue on the graft, which does not act as an internal expander anymore and we achieve better graft nutrition. The patients wear BRAVA for 12 hours per day postoperatively, for at least 4 weeks. Patient compliance is essential since it is necessary to wear the system pre- and postoperatively for a relatively long time.

BREAST LIPOMODELLING

Breast reconstruction by autologous fat transfer

In breast reconstruction, fat transfer may be used separately as a major surgical technique, or it may be an integral part of combined surgical procedures.

Breast reconstruction by repeated lipomodelling

Capacity of the donor site to accept fat graft is closely related to the initial volume of well-vascularized donor tissues. In secondary breast reconstruction, it is essential to reconstruct or expand missing skin, which is crucial in selection of reconstructive technique, especially in an irradiated patient. Furthermore, volume absorption after fat grafting is very high when applied into the irradiated chest wall. Thus, we recommend this reconstructive technique just for non-irradiated patients, despite the availability of BRAVA enlargement system. On the contrary, breast reconstruction by repeated lipomodelling is very promising in primary reconstruction after prophylactic mastectomy, or in hypoplastic breast malformations (e.g. Poland’s syndrome). Very important aspect of the consultation is to make the patient understand about the maximal possible breast size (cup size approximately B+) and about the need of higher number of lipomodelling sessions (usually 3-5)⁴.

Lipomodelling for the correction of sequelae of conservative treatment

Breast reconstruction after breast conserving therapy is problematic. Two factors must be considered. The first is the uneven breast shape resulting from partial mastectomy. The second is the preexisting irradiation of the breast ⁴⁰. Therefore, breast reconstruction using fat grafting is an attractive tool for treatment of this deformity with possible local filling of the defect as well as regenerative properties of the graft ⁴¹.

We perform this procedure under general anesthesia. The injection is performed very slowly with a fan-shaped technique during the withdrawal of the cannula. We attempted (as much as possible) to prevent accumulation of the fatgraft and overfilling of the tissue to prevent ischemia, necrosis, colliquation and calcification, which is more likely in irradiated tissue.

Fat grafting to breast after breast cancer has been questioned regarding higher risk of cancer recurrence. This possible risk would be higher in patients after breast conserving treatment. However, this assumption has not been confirmed in clinical studies yet ⁴².

Lipomodelling as the complement of autologous breast reconstructions

The abdominal free flaps and the latissimus dorsi flap are the two most common autologous breast reconstruction techniques today.

The abdominal free flaps are often considered to be the gold standard for autologous breast reconstruction. Defects may however also develop after their use, in particular asymmetry of volume, lack of projection, defect in the décolleté or possibly partial flap loss. In these cases, we carry out intrapectoral lipomodelling and lipomodelling of the flap (Figure 6).

**Fig. 6. A 51-year-old patient with the history of secondary breast reconstruction using abdominal flap before and 5 months after one lipomodelling session with 180 ml of fat**

The autologous latissimus dorsi flap is an ideal tissue to receive fat transfer as it is very well-vascularized and very large quantities of fat can be injected into it. Volume of 200-450 ml per breast and per session may be injected with very good results ^1,4,43. The autologous latissimus dorsi flap can now be considered as an auxiliary method that prepares the breast recipient site for future lipomodelling. We recommend performing lipomodelling quite early (after 3-4 months), before muscle atrophy is maximal, in order to take the advantage of the volume effect, which allows the area to accept sufficient amount of fat.

Breast augmentation by autologous fat transfer

There has been a boom in the demand for autologous fat breast augmentation in recent years. As our experience with this procedure extends, indications and limitations for this procedure clarify. Today, we know that autologous tissue transfer to the breast cannot replace breast augmentation using silicone implants ⁴⁴. Indications for fat grafting are different then for breast augmentation with silicone implants. Also, contrary to fat grafting to the face, we are talking about high-volume, or sometimes “mega-volume fat grafting”, since we inject volumes of around 250-300 ml. This method is suitable for patients, who require rather smaller enlargement of the breast (at about one cup size), with sufficient breast skin envelope and sufficient adiposity in the lower part of the body. Breast augmentation by fat transfer is performed in sessions if more significant breast enlargement is requested by the patient.

First modern attempts for fat grafting to the breast in 1980’ launched a wave of negative attitude on the account of fear of calcifications, which could impair breast cancer detection. Subsequently, this method was banned for several upcoming years without any scientific data.

Radiologic follow-up of breasts treated with fat grafting is not complicated and should not prevent plastic surgeons from offering this procedure ^45,46. Far more common are calcifications after different kinds of breast operations – for example reduction mammaplasty ⁴⁷. Calcification after fat grafting, in case of the use of correct technique, are localized in different areas and reveal different radiological image then those in breast cancer. The best approach is to perform radiological examination ahead of the procedure to find out existing lesions. We advise performing follow-up examination one year after the procedure.

In addition, concerns about the oncologic safety remain a controversial topic among plastic surgeons and other physicians. In vitro studies have repeatedly shown an increased activation of breast cancer cells by adipose derived stem cells; however, clinical research, although limited, continually fails to show an increase in breast cancer recurrence after breast fat grafting not only in cosmetic breast augmentation patients but also in breast cancer patients ^48-52.

We usually perform this procedure under general anaesthesia and we use methods described above for graft harvesting and processing. We infiltrate the breast from multiple entry points circularly around the breast base. We can infiltrate subcutaneous space, subglandular space and also the pectoral muscle. In order to ensure sufficient blood flow to the entire graft, we should be careful not to overfill the breast tissue. The maximal volume of graft is approximately 200–250 ml for B size breast, 300–350 ml for C size breast etc. We risk graft ischemia, absorption, necrosis and calcification with too large graft volumes. Based on authors’ experience, it is essential to overfill the size of the smaller breast in comparison with the contralateral side in cases of breast asymmetry because of the expected asymmetrical fat absorption. Relative volume resorption remains the same (30–40%), but the final volume absorption is different when asymmetrical volumes of processed fat is applied.

Preoperatively we educate the patient about the graft volume we plan to inject to the breast and about the possibility of 30–40% absorption. We do not use any compressive garment postoperatively, since it could impair blood supply to the graft. The patient should postoperatively keep stable weight, in order to prevent lowering of the volume of the augmented breast (Figure 7, 8).

**Fig. 7. Patient before and 6 months after one session of autologous fat breast augmentation**

Fig. 8. A 17-year-old patient with hypoplastic left breast and ptotic right breast before and after 2 sessions of lipomodelling on the left and contralateral vertical mastopexy with augmentation by fat grafting in décolleté area - 6 months follow-up

Simultaneous Breast Implant Exchange with Fat (SIEF)

Simultaneous Breast Implant Exchange with Fat is suitable for patients asking for breast implant removal while maintaining the volume ^53,54. The procedure can be performed in two ways – fat is injected before or after implant removal. We inject fat into all possible planes, into subcutaneous and subpectoral after breast reconstruction and also into subglandular space after breast augmentation. We take care not to inject into the capsular space. In the case of implant removal before injection, we use finger guidance in this space to prevent penetration of capsule by the cannula. We also recommend using blunt cannula for injection.

Composite breast augmentation

As mentioned above, breast enlargement by fat grafting is limited and silicone implant augmentation continues to be a gold standard. However, we can use benefits of both techniques to achieve the best results – the volume created by the silicone implant, covered by the fat graft. With this technique, we cover the visible edges of the implants in thinner women. Fat can be injected before or after insertion of the implant. We prefer injection with implant already in place to achieve better overview of the final result. For this reason, we need to use blunt cannulas, which decrease the risk of implant penetration. Motiva (Establishment Labs) recently created a cannula with special tip intended to use for composite procedures. Fat is injected especially to the décolleté region and according to specific needs to any other regions of the breast.

AUTOLOGOUS FAT TRANSFER TO THE FACE

Autologous fat transfer to the face has become a common technique to treat volume and contour abnormalities in aesthetic and reconstructive facial plastic surgery ⁵⁵. It has also been widely used for the management of facial aging signs ^16,56.

Signs of aging with regards to fat grafting

Aging process affects all facial structures. The process includes changes in the skin and its appendages, subcutaneous tissues, and bony skeleton.

Skin and appendages are influenced by intrinsic (normal aging) and extrinsic (photoaging, smoking) factors and these are manifested by the changes of skin texture (wrinkling, atrophy and increased fragility, changes of colour, etc.).

Subcutaneous tissue includes fat compartments and the SMAS system with interconnections to skin that are essential for transfer of facial expression triggered by the facial muscles to the skin surface. Aging process in subcutaneous tissue is associated with atrophy of volume (deflation), migration of fat compartments and increased soft tissue laxity with ptosis causing changes of contour.

The changes in subcutaneous tissues are further enhanced by absorption of bony skeleton in the upper face and midface such as the orbital margins, prejowl mandible, pyriform aperture and nasal spine causing reduction of support for soft tissues.

Fat grafting may be used to address all of these changes in a certain extent, i.e. it can supplement volume and add support to tissues, replace missing bony structures and correct skin texture changes.

Technique for facial fat grafting

The technique of facial fat grafting differs from standard techniques used elsewhere in the body. It is necessary to use finer instruments to harvest smaller fat particles to be injected to the face. This prevents creation of bulges and irregularities that could develop after the standard fat grafting technique. Fat grafting to the face is referred to as microfat grafting or also low-volume fat grafting due to this difference.

Examples of such fine instruments include e.g. various Tulip cannulas with a small diameter for harvesting and various small diameter injectors for application of fat. (Figure 9, 10).

**Fig. 9. Examples of harvesters for facial fat grafting (Tonnard, Sorensen style)**

**Fig. 10. Examples of injectors for facial fat grafting. These may be curved or straight as per surgeon’s preference**

There are various application methods of microfat grafting and they include application of fat to the deep to act as a deep filler, superficially underneath the skin and intradermally into the dermis of the skin to treat fine and deep wrinkles and also a special form of fat for regenerative purposes. These various types provide different effects on target tissue.

Deep microfat grafting

Fat injected as a deep filler is used to supplement missing volume and for facial contouring. There are various areas in the face that loose volume with age and need filling (Figure 11). These include the temples, eyebrows and upper eyelids, infraorbital area, tear trough, malar area, nasolabial folds, lips, and the area of the Marionette lines.

**Fig. 11. Areas that usually need deep filling with fat during facial fat grafting**

Filling effect of fat is also utilized in reconstructive procedures, such as augmentation rhinoplasty ⁵⁷ to augment the dorsum of the nose or for correction of mandibular or maxillary hypoplasia that have traditionally been treated with orthognathic surgery ^49,57-60.

Superficial fat grafting

Fat is injected to the superficial layer just underneath the skin. This technique addresses the aging induced atrophy that is characterized by disappearance of a continuous layer of fat underneath the skin. There are areas with more pronounced deflation to be treated with deep filling, but superficial fat grafting is beneficial in areas where fine wrinkling occurs that cannot be filled intradermally and there is no deep space to fill (Figure 12). This technique is more exactly referred to as superficial microfat grafting ⁶¹. Superficially injected fat has also regenerative potential on the skin. Study performed by Charles-de-Sá et al. demonstrated that treatment with fat and stromal vascular or expanded mesenchymal stem cells modified the pattern of the dermis, representing a skin rejuvenation effect. Effects of treatment are visible in the epidermis also, even though the injection takes place in the subcutaneous region ¹⁷.

**Fig. 12. Example of area that may benefit from superficial microfat grafting**

Various modifications exist, such as superficial enhanced fluid fat injection (SEFFI) where fat is combined with platelet rich plasma for enhancement of its effect ^62,63.

Intradermal fat grafting

This technique was described by Zeltzer et. al. and popularized by Tonnard and Verpaele as SNIF (Sharp Needle Intradermal Fat grafting). Simple microfat is injected with a needle into the skin, into deep rhytides (Figure 13). This has an effect of a natural filler and smoothes wrinkles very effectively ³⁰.

Nanofat and regenerative potential of fat

The therapeutic benefit of autologous fat is partly ascribed to the presence of precursors of adipose derived stem cells (ASCs), which are progenitor cells that reside in the stromal vascular fraction (SVF) of adipose tissue. ASCs are able to differentiate into various cell lineages and seem to be suitable for repair of damaged tissue in organs and aged skin ⁶⁴. In cosmetic facial surgery, ASCs are reported to be beneficial for skin rejuvenation ⁶⁵. Special fat processing techniques, which destroy mature adipose cells are able to prepare an injectable product, which contains a high concentration of ASCs and no viable mature adipose cells ⁶⁴. The final injectable product is injected directly into the skin with a fine needle. Tonnard et. al. described the nanofat grafting technique, which is indicated for general skin rejuvenation, treatment of dark circles under the eyes, post-acne scaring, striae, etc. ⁶⁶. Typical areas for nanofat grafting are show in Figure 14.

**Fig. 14. Red dotted areas represent examples of areas typically treated with nanofat for regenerative purposes**

Survival of fat in the face

Survival of fat in the face varies and is influenced mainly by the mobility of the target area. Mobile areas such as glabella or lips are associated with lower retention of fat compared with less mobile areas, such as malar and lateral cheek ⁵⁵. Stabilization of the graft may be considered after 4 months from the surgery.

Complications of facial fat grafting

Complications following fat grafting to the face are rare. The most common complications include irregularities in the donor area after fat harvesting, and asymmetry, irregularities, bulges, under-filling and overfilling in the target area. Rare complication is fat embolism to the ophthalmic artery and cerebral arteries with subsequent blindness and cerebrovascular accident that have been reported after fat injection mainly to the glabellar area ^67,68.

Postoperative course and management

The postoperative course after facial fat grafting is associated with very low morbidity. There are signs and symptoms from the donor area, which is the most disturbing for the patient and it is similar to smaller liposuction. In the application area, there is usually swelling and bruising that subsides quickly after surgery, usually within 1–2 weeks. Pain is not a common symptom after facial fat grafting. In the postoperative management we usually do not use any special garments for the donor area, as the harvested volume is very low. It is advisable to provide antibiotic cover to the patient perioperatively.

Combination of facial fat grafting with other facial rejuvenation techniques

It is convenient to combine facial fat grafting with other facial plastic surgery techniques such as face-lifting, upper and lower blepharoplasty, chemical or laser resurfacing, etc. The effects multiply and the final cosmetic result of the combined surgery is potentiated ^69,70.

Complex facial fat grafting

Complex facial fat grafting is a combination of several or all of the fat grafting techniques to treat various problems that are present in the face in the same time. These may be performed in one session. There is usually enough fat to be harvested to perform complex treatment, i.e. deep filling, superficial microfat grafting, intradermal fat grafting and possibly take the advantage of regenerative capacity of fat on facial skin (Figure 15). This is a great difference compared with artificial fillers based on hyaluronic acid, which are usually very costly, the quantity is limited mainly by price and it lacks any regenerative potential. The usual quantity of fat that is needed for complex fat grafting is 20–30 ml of processed fat or more.

Fig. 15. A case of a 45-year-old female patient with profound deflation of the face seeking rejuvenation. Originally she requested filler injection but was offered facial fat grafting. The figure shows pre- and postoperative photographs. There was a total of 24 ml of microfat injected and included deep filling of malar, tear trough area and nasolabial folds, superficial fat grafting to the cheeks. Note mainly the change of contour of the malar area on the 45° view

CONCLUSION

Autologous fat transfer techniques have experienced tremendous boom in the recent years. High-volume fat grafting is performed primarily in order to supplement missing volume, low-volume fat grafting has also a regenerative potential apart from its volume replenishment and contouring effects, especially in certain indications.

Lipomodelling is a major development in plastic, reconstructive and aesthetic surgery of the breast, and we consider it as one of the major advances of the last 20 years. The technique is now well codified and the complication rate is very low. Because of the very good results obtained and the excellent acceptance of the technique by the patients, lipomodelling has considerably modified our indications in plastic, reconstructive and aesthetic surgery of the breast.

Facial fat grafting is an effective and rather mini-invasive procedure that is able to provide very interesting effects in the treatment of overall facial aging signs. It has a filling as well as regenerative potential and may be combined with other facial procedures to achieve enhanced results. It may be performed under local anaesthesia with mild sedation and the postoperative course is very smooth.

Corresponding author:

Libor Streit, M.D., Ph.D.

Department of Plastic and Aesthetic Surgery

St. Anne’s University Hospital

Berkova 34

612 00 Brno, Czech Republic

E-mail: liborstreit@gmail.cz

Zdroje

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