FAT GRAFTING gives an overview if the fat fragting

healthcare

1. FAT GRAFTING Dr Raghvendra Singh Plastic surgery 2nd year resident

2. Autologous Fat Grafting Four Categories: Autogenous Fat Grafting Dermis-Fat Grafting Free Fat Flaps Fat Injection Micro lipo injection Lipostructure Autologous fat filler

3. History of Fat Injection 1893 Franz Neuber First to use fat injection Transferred 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

4. 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

5. 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-come

6. 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

7. Surgical Anatomy Harvest site Three levels of fat: Two layers of Subcutaneous fat Superficial layer Deep layer – “ The target layer- for harvesting fat ” Third: Visceral layer

8. Common sites: Abdomen Gluteal region Thighs

9. Surgical Anatomy Recipient 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

10. 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

11. 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

12. 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

13. 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

14. 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 & cheeks

15. 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

16. Post-liposuction depressions’ correction: abdominal wall, flanks, buttocks, back, or thighs

17. Correction of depressions or fatty deficits due to Lipodystrophy syndromes and atrophic areas HIV Diabetes Dermatomyositis Chronic malnutrition / anorexia nervosa Genetics, diet, alcohol, tobacco

18. Augmentation of the paralyzed vocal cord In cases of Unilateral cord palsies May require secondary procedures

19. 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

20. 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

21. 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

22. The Procedure Steps: Harvesting Selection of harvesting sites & Planning incisions Anesthesia & Infiltration technique Suction Processing & Refinement Centrifugation / Sedimentation Re-implantation Injection (of the refined, concentrated fat)

23. Step-1 Harvesting 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

24. Harvesting (cont’d) Access incisions should be planned in: Crease lines, previous scars, stretch marks, or hirsute areas

25. Harvesting (cont’d) Anesthesia Local – most common Spinal, Epidural or General For removal of larger volumes When multiple sites are used for harvesting

26. Harvesting (cont’d) 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

27. Super-wet & Tumescent techniques ( Injectanct to harvest ratio >1) Discouraged here (in contrast to liposuction ) Disrupt the parcel of fat cells & decrease survival

28. Harvesting (cont’d) 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

29. Harvesting (cont’d) Coleman harvesting cannula

30. 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

31. Step-2 Processing & Refinement Syringe with harvested fat Cannula disconnected Capped with “Luer-Lok plug” Placed in centrifuge

32. Processing & Refinement (cont’d) Separation techniques: Sedimentation ( Force:1g ) Centrifugation High speed 3000rpm for 3 minutes ( Force:3-5 g ) Manual ( Force:1-2g )

33. The material separates in 3 layers: Top – oil (🡪decanted) Middle – the fat cells (🡪to be injected) Bottom – blood, injectant solution (🡪to be drained)

34. Transference: Refined & concentrated fat to 1-3ml Luer-Lok syringe

35. Step-3 Re-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 contact

36. 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

37. Instruments’ set: Different from harvesting set Smaller gauze (17 or 18 G) One holed cannula For varying sites varied cannula Diameter, Length, Shape, Curves

38. 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

39. Injection volume per withdrawal Face: 0.1ml Eyelids: 0.02 – 0.03ml Breast: 1-2ml

40. Injection Techniques Mapping Technique Linear threading Fanning Cross hatching Reverse-liposuction Technique

41. Fate of Fat Phenomenon of Variable resorption With fat grafting, anywhere from 10% to 90% of the fat may be absorbed by the body

42. 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

43. dr sumer yadav , mch plastic surgery, [email protected]

44. 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

45. 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

46. Complications Aesthetic: Under correction Not enough material Resorption Over correction More difficult to solve Irregularities Asymmetry Others: Edema Infection Migration Perforation Necrosis

47. Site-specific complications Face: Embolism of Internal carotid artery / Middle cerebral artery (Retrograde) Blindness Stroke Aphasia Skin necrosis

48. Breast augmentation: Liponecrotic psuedocyst with calcifications Groin defect correction: Cyst formation Penile augmentation Mushroom shaped penis

49. Donor site complications Edema Infection Seroma Hematoma Skin necrosis Fat embolism Perforation

50. Comparison with other Fillers Advantages Natural Biocompatible, Non immunogenic Large volume augmentation Cheaper Disadvantages Unreliable resorption Donor needed for harvest

51. Results Depend Upon Biologic boundaries Other surgery Patient age Recipient site Injection Technique Processing & Storage Harvest technique Harvest site Result

52. 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

53. Thanks