Structural fat grafting in plastic surgery.

Fat Grafting in plastic surgery.

1. Structural fat grafting Dr Nishish Vishwakarma

2. Introduction The concepts of rejuvenation are changing, placing more emphasis on volume loss and volume restoration as well as improving the quality of aging and sun damaged skin. Fat grafting provides a long-lasting, minimally invasive means to restore volume and rejuvenate the face, hands, or body.

3. Since the, 1890s when fat grafting first began, there has been controversy regarding the predictability and consistency of results of the fat grafting Fatty tissue contain adipocytes, adipose-derived stem cells (ADSCs), mesenchymal stem cells (MSCs), endothelial cells and their progenitor cell lines. These cells are multipotent and have the potential to aid in tissue regeneration.

4. Functions of ADSCs: differentiate into many different cell types in culture, including ectodermal, mesodermal, and endodermal lineages. ADSCs have been shown to induce blood vessel formation, mitigate fibrosis, promote bone formation and wound healing. This particular population of cells within a fat graft may be a major contributor to the therapeutic potential of the graft.

5. History 1893 by German surgeon Gustav Neuber : transplanted adipose tissue harvested from the arm to correct a depressed facial scar that had resulted from osteomyelitis. 1895 Vincenz Czerny, who transferred a fist sized lipoma from the buttock to the breast.

6. 1890s, Robert Gersuny and Leonard Corning were using paraffin, either injected alone, with petroleum jelly, or with a combination of petroleum jelly and olive oil, into facial defects. Initially, the paraffin and petroleum jelly filled in soft-tissue defects nicely, providing a soft, natural-appearing contour. But unfortunately, after a time, complications such as paraffinomas, or hard local swellings, began to emerge.

7. In 1919, Erich Lexer published a book on technique of fat grafting. He presented technique of fat grafting a wide variety of conditions such as depressed scars, breast asymmetry, knee ankylosis, tendon adhesions, and micrognathia and the successful results after treatment with fat grafting.

8. In 1950s Lyndon Peer studied the gross and microscopic appearance of transplanted fat. He discovered: adipose grafts lose weight and volume approx. 45% at 1 year due to cell rupture and subsequent death. The fat cells that do not rupture , however, will survive and volume will be maintained. Improper handling of the fat prior to and during transplantation was also found to decrease the survival of the fat. The large size fat graft was found to lose volume more rapidly than multiple smaller grafts of similar weight, due to the increased surface area of the smaller grafts. Revascularization , as seen microscopically, was noted to be essential for fat graft survival.

9. Coleman standardized the technique (1990s), called Lipostructure , emphasizes gentle extraction of fat, centrifugation , and microparticle injections in multiple tissue planes and documented the longevity and stability of fat grafting performed in this manner.

10. Aging and atrophy Over time there is loss of elasticity of the tissues, which results in descent and sagging of the skin because the tissue starts to sag is lack of support, or lack of volume beneath it due to loss of fat, collagen, elastin, hyaluronic acid, etc., that are involved. The goal is to replace the missing fullness and enhance the quality of the skin. If there is a tremendous amount of sagging or excess skin, then manual resuspension and trimming may be necessary. Comparing the patient’s photographs when they were young to their current state, determine how it has changed.

11. Temples are flat and her brow and glabella are unfurrowed Upper eyelids are beneath the brow short distance between the ciliary margin and the lid crease . The lower eyelids are smooth and there is minimal hollowing medially. Cheeks are round with the zygomatic arches well covered with soft tissue . Minimal nasolabial folds Lips are full, pouty, and everted Lower lip is slightly larger than the upper lip. Jawline and chin are well-defined and smooth.

12. As the age increases, Hollowing of the temples with skeletonization Wrinkles become obvious in the forehead and glabella secondary to loss of youthful fullness over areas of muscular activity The fullness present beneath the brow is diminishes and the upper eyelids appear to either collapse and fold anteriorly or collapse posteriorly to reveal the hollow orbit . There may be a real excess of skin, but there may also be merely the illusion of excess skin that disappears when the volume is restored .

13. Lower eyelids begin to deflate, making the orbital rim more apparent and elongating the lid–cheek junction. The tear trough extends diagonally into the anterior cheek and accentuating the nasolabial folds. Zygomatic arches lose their soft tissue covering to reveal the bony outlines. Vermillion of the lips becomes thinner Lips begin to invert Posterior aspect of the jawline , the mandibular border becomes less defined Lower face slides forward to accentuate the jowls and perimental hollows/ prejowl sulci.

14. Diagnosis, patient presentation, indications Aging: Generally, over 40 years of age with loss of facial fullness, elasticity and thinning of the skin, resulting in skin laxity, wrinkles, or a gaunt, skeletal appearance. Younger patient: who is unhappy about the shape or proportion of a facial feature, such as the cheeks, chin, or jawline.

15. Patients with congenital deformities such as hemifacial microsomia and Treacher Collins syndrome. Patients who have sustained previous trauma resulting in significant scarring or tissue loss. Patients who have undergone previous facial cosmetic surgery often present with iatrogenic deformities.

16. Facial atrophy due to drug related lipodystrophy seen in patients taking antiretroviral and protease inhibitor therapies. These patients often present with a maldistribution of facial fat and body fat . With excess of fat over dorsal hump on the upper back/lower neck, and the face usually appears hollow in the temples and buccal cheeks, creating an appearance pathognomonic for the drug-related lipoatrophy.

17. Deformities as a result of liposuction ranging from very slight irregularities, to large indentations, to even full- thickness skin loss. The large and complex tissue deficiencies often require several operative procedures, with the occasional release of adhesions, to restore the necessary volume and smoothness.

18. Patient selection Contraindication Poor patient health prohibiting anaesthesia . Small areas of fat grafting can be performed under local anaesthesia, but anything involving more than a few millilitres of fat usually requires sedation. Patients with unrealistic expectations are not good candidates Extremely thin patient who does not have sufficient fat for transfer.

19. For fat grafting to the hands, breasts, or body, significantly more fat is usually needed, and often there is a limit as to the correction that can be made given the paucity of fat in some patients. Asking the patient to gain weight prior to the procedure only makes sense if the patient is willing and able to maintain that weight afterwards.

20. In aging patients with a tremendous amount of loose, excess skin, fat grafting can be disappointing. These patients are either left with residual skin excess or if completely filled, may have an unusual appearance to their face. Therefore it is advisable to first tighten the skin with a traditional facelift and then to add volume with fat.

21. Younger patients usually do not have as much facial atrophy and sagging of the skin, but the overall appearance of the face can be changed drastically with a shift in facial proportions.

22. The patient is an example of a chin augmentation in a younger patient to improve the overall facial proportions.

23. The patient is an example of an upper and lower lip augmentation. Filling the lips gives her a much softer appearance.

24. Patients with more severe deformities e.g., Treacher Collins syndrome are excellent candidates for fat grafting, even though the condition is complex, with both bony and soft-tissue abnormalities. The unusual facial contours in this patient would be very difficult to address with anything other than fat, as different volumes can be tailored to the specific defects to create a more normal appearance.

25. The patient demonstrates the loss of volume in the dorsum of the hand due to aging. The hand has a wasted appearance, with poor quality skin. After fat grafting to the dorsum of the hand, the veins and tendons are less visible and the quality of the skin appears improved.

26. The patient has irregularities created by liposuction. Grafted fat is really the only option to correct areas of significant deficiency, whereas small depressions can occasionally be corrected with temporary fillers.

27. The patient is an example of atrophy that has occurred in the temple secondary to radiation therapy. After grafting fat to the region, the area is filled in and with more normal texture and consistency.

28. Treatment and surgical technique The process involves harvesting the fat gently to preserve the delicate architecture refining the fat with centrifugation to remove non-viable components and provide a predictable volume placement of the fat in small aliquots to increase the surface area and ensure a blood supply to the grafted tissue. These principles are to be followed for a relatively predictable and safe procedure as it provides high percentage of survival and near-normal adipose cellular enzyme activity.

29. Harvesting The choice of donor site for fat grafting is dependent on the desires of the patient and accessibility of the fat, No conclusive differences in viability or “graft take” have been seen from one site to another. In general, the love handle, posterior hip, back, and lateral thighs are more forgiving and do not have as much potential to wrinkle as the abdomen and medial thighs.

30. If possible, incisions should be hidden in creases, scars, stretch marks, or hair-bearing areas. Through these incisions, local anaesthetic solution is infiltrated using a blunt Lamis infiltration cannula. For local cases, the local anaesthetic solution consists of 0.5% lidocaine with 1:200000 epinephrine For general anaesthesia cases, where larger volumes of fat are harvested 0.2% lidocaine with 1:400000 epinephrine is used. The amount of solution infiltrated is essentially equal to the amount of fat removed.

31. Fat is then harvested using a two-hole Coleman harvesting cannula attached to a 10-cc syringe. This harvesting cannula is designed to harvest intact fatty tissue parcels that are large enough to survive, but small enough to pass through the standard infiltration cannula (17 gauge). The plunger of the 10-cc syringe is pulled back only a few milliliters during suctioning, so as not to create too much negative pressure and rupture the fat cells. Incisions are closed with interrupted nylon sutures

32. Refinement The the first few syringes of harvesting, the infiltrated local anaesthetic is more than later. As the suctioning continues, many of the later syringes contain less infiltrate and more blood. After the 10-cc syringe is full, the cannula is disconnected from the syringe and a Luer -Lok plug is used to cap the syringe. The plunger is then removed, and the syringe is placed into the centrifuge in a sterilizable central rotor and sleeves. The Centrifugation is done for 2 min.

33. The concentrated fat is separated from the aqueous components (the local anaesthetic and blood) can be removed and discarded by releasing the Luer -Lok plug. In addition, any ruptured fat cells that release their oil can be decanted off the top and/or wicked away with Telfa pads. The fat is then transferred to a 1-cc syringe for placement into the face and hands or a 3-cc syringe for placement into the breasts or body.

34. The uncentrifuged sample will sediment and separate the fat from the oil and aqueous component to some extent, but it is more time consuming and has less of a concentrating effect than centrifugation. And this sample will initially appear to provide the proper correction, but only for a short period of time, much of it will be reabsorbed and the procedure will have been considered a failure.

35. Placement Incision sites are anesthetized with 0.5% lidocaine with 1 : 200 000 epinephrine, and small stab incisions are made for the placement of fat through one of three Coleman cannulas.

36. Into the face, 0.5% lidocaine with 1:200 000 epinephrine are usually infiltrated for Vasoconstriction of the vessels Reduction of bruising Decreases the chance of accidental intravascular embolization of the fat.

37. Maximizing the contact surface area of the fat graft with the surrounding tissue, such that a blood supply can be restored to the newly grafted fat. Placement is performed during the withdrawal of the cannula and is placed in different layers to build up the structure.

38. Transferring large globules of fat can result in central necrosis of the mass with subsequent resorption and loss of volume, or development of cyst.

39. Fat can be placed at different levels to accomplish different effects. Fat grafting beneath the dermis improves the quality of the skin, decreases wrinkles, decreases pore size and even reduces scarring. While placing it superficially, irregularities are more apparent in this plane, especially in areas that have thin skin, e.g. lower eyelid. In the face or body that is relate to the underlying bony skeleton, fat can be placed above the periosteum.

40. The fat grafting is done with tiny aliquots of fat rather than attempting to insert larger aliquots and then mould the tissue after it is placed. Moulding may displace the fat or cause necrosis of the fat, resulting in an uneven contours. The incisions used to place the fat are closed with single interrupted nylon sutures.

41. Postoperative care All areas of the face, except the upper eyelids is covered with Tegaderm, which is more flexible, tolerable, and socially acceptable. Around the eyes, dressings must be applied so as not to pull the lower eyelids down. Cold therapy is recommended for up to 72 h postoperatively.

42. The hands are dressed with Microfoam tape. The donor sites are dressed with a compression garment or abdominal binder. The dressings are usually left in place for 3–4 days. On day 5, the dressings and the facial sutures should be removed. Body sutures at the donor sites and on the hands are usually removed at 5–7 days.

43. Complications Swelling and Bruising is the most common complications, or side effects, of fat grafting. It occurs due to the multiple passes of the cannula during the procedure. Bruising generally resolves in 2–3 weeks, but there have been a few cases of prolonged subcutaneous pigmentation that is easily visible through the thin skin of the lower eyelids. This has the appearance of “tea staining” and can take many months to resolve.

44. Subcutaneous irregularities visible through the skin (can occur in both the recipient and donor sites). In the recipient sites, excess grafted fat will appear as a lump beneath the skin due to the result of placement of a too large volume beneath thin skin, e.g. in the periorbital region. These bits of unwanted fat can be difficult to remove; therefore, caution should be employed when grafting into this area.

45. Irregularities in the donor sites can also be problematic, particularly if too much fat is removed. The most potential complication is an intravascular embolization, (extremely rare). Can occur when fat is inadvertently injected under pressure into a small artery, with retrograde filling of the vessel. This intra- arterial fat can embolize to an end arteriole resulting in tissue ischemia. This has never been reported when using a blunt cannula; therefore, sharp needles are discouraged.

46. Infections in the recipient or donor site: they can result in resorption of the grafted fat and loss of the desired correction. Strict sterile technique should be employed during fat grafting, and cannulas that penetrate the oral mucosa should be considered contaminated. Lip augmentation, should be performed last if fat grafting is performed elsewhere on the face.

47. Significant changes in weight can result in concomitant changes in the size of the area grafted; Therefore, patients are encouraged to have the procedure performed when they are at their ideal body weight and to maintain that weight, if possible.

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