History of Fat Transfer

22.1 Introduction

The history of autologous fat augmentation gives insight into the development of fat transfer for both cosmetic and non-cosmetic problems. Transplantation of pieces of fat and occasionally diced pieces of fat advanced to removal of small segments of fat by liposuction after the development of technique by Fischer and Fischer reported in 1975.

22.2 History

Neuber [1] reported the use of small pieces of fat from the upper arm to reconstruct a depressed area of the face resulting from tuberculosis osteitis. He concluded that small pieces of fat, bean or almond size, appeared to have a good chance of survival. Czerny [2] used a large lipoma to fill a defect in the breast following resection of a benign mass. The transplanted breast, however, appeared darker in color and smaller in volume than the opposite breast. Verderame [3] observed that fat transplants solved the problem of shrinkage at the transplant site. Lexer [4] reported personal experience with fat transplants and found that larger pieces of fat gave better results. Bruning [5] used fat grafts to fill a post-rhinoplasty deformity by placing fat in a syringe and injecting the tissue through a needle.

M.A. Shiffman

17501 Chatham Drive,

Tustin, California 92780-2302, USA e-mail: shiffmanmdjd@yahoo.com

Tuffier [6] inserted fat into the extrapleural space to treat pulmonary conditions. Biopsy of the fat 4 months post transplant showed most of the fat was resorbed and replaced by fibrous tissue.

Straatsma and Peer [7] used free fat grafts to repair postauricular fistulas and depressions or fistulas resulting from frontal sinus operations. Cotton [8] used a technique of broad undercutting and insertion of finely cut fat which was molded to fill defects.

Peer [9] noted that grafts the size of a walnut appear to lose less bulk after transplanting than do smaller multiple grafts. He also found that free fat grafts lose about 45% of their weight and volume 1 year or more following transplantation due to the failure of some fat cells to survive the trauma of grafting as well as the new environment. Fat grafts are affected by trauma, exposure, infection, and excessive pressure from dressings [10]. Peer [10] stated that microscopically, grafts appear like normal adipose tissue 8 months after transplantation.

Liposuction was conceived by Fischer and Fischer in 1974 [11] and put into practice in 1975 [12].

Fischer and Fischer [13] first reported removal of fat by means of 5 mm incisions using a “rotating, alternating instrument electrically and air powered.” This allowed aspiration of fat through a cannula. Through a separate incision, saline solution was injected to dilute the fat. In 1977 [14] they reviewed 245 cases of liposuction with the “planotome” for treatment of cellulite in the lateral trochanteric areas. There was a 4.9% incidence of seromas despite wound suction catheters and compression dressings. Pseudocyst formation, which required removal of the capsule through a wider incision and the use of the planotome, occurred in 2% of cases.

The advent of liposuction spurred a move toward using the liposuctioned fat for reinjecting areas of the

body for filling defects or augmentation. Bircoll [15] first reported the use of autologous fat from liposuction for contouring and filling defects. Illouz [16] claimed he began to inject aspirated fat in 1983. Johnson [17] stated that he began in 1983 to use autologous fat injection for contouring defects of the buttocks, anterior tibial area, lateral thighs, coccyx area, breasts, and face. Bircoll [18] presented the method of injecting fat that had been removed by liposuction. Krulig [19] asserted that he began to use fat grafts by means of a needle and syringe. He called the procedure “lipoinjection.” He began to use a disposable fat trap to facilitate the collection process and to ensure the fat’s sterility. Newman [20] stated that he began reinjecting fat in 1985. The idea of utilizing the aspirated fat, which was otherwise wasted, was an attractive idea and other surgeons began to make use of the aspirate to augment defects and other abnormalities.

The American Society of Plastic and Reconstructive Surgery (ASPRS) Ad-Hoc Committee on New Procdures produced a report on September 30, 1987, regarding autologous fat transplantation [21]. The conclusions were:

1.Autologous fat injection has a historical and scientific basis.

2.It is still an experimental procedure.

3.Fat injection has achieved varied results and longterm, controlled clinical studies are needed before firm conclusions can be made regarding its validity.

4.Fat transplant for breast augmentation can inhibit early detection of breast carcinoma and is hazardous to public health.

Coleman and Saboeiro [22] reported success in fat transfer to the breast and concluded that it should be considered as an alternative to breast augmentation and reconstruction procedures. Two of 17 patients had breast cancer diagnosed by mammography, one 12 months and one 92 months after fat transfer to the breast.

Now fat transfer to the breast area is being used outside the breast itself, into the pectoralis major muscle and behind and in front of the muscle. The fat is also being used to augment tissues around the breast following treatment for breast cancer.

Although most of the fat transfer procedures are for augmentation of tissues, there has been a surge of the use of fat for non-cosmetic procedures.

References

1.Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir. 1893;22:66.

2.Czerny V. Plastischer ersatz der brustdruse durch ein lipoma. Chi Kong Verhandl. 1895;2:126.

3.Verderame P. Ueber fettransplantation bei adharenten knochennarben am orbitalrand. Klin Monatsbl Augenh. 1909; 47:433–42.

4.Lexer E. Freie Fettransplantation. Deutsch Med Wochenschr. 1910;36:640.

5.Bruning P. Cited by Broeckaert TJ, Steinhaus J. Contribution e l’etude des greffes adipueses. Bull Acad Roy Med Belgique. 1914;28:440.

6.Tuffier T. Abces gangreneux du pouman ouvert dans les bronches: hemoptysies repetee operation par decollement pleuro-parietal; guerison. Bull Mem Soc Chir Paris. 1911; 37:134.

7.Straatsma CR, Peer LA. Repair of postauricular fistula by means of a free fat graft. Arch Otolaryngol. 1932;15:620–1.

8.Cotton FJ. Contribution to technique of fat grafts. N Engl J Med. 1934;211:1051–3.

9.Peer LA. The neglected free fat graft. Plast Reconstr Surg. 1956;18(4):233–50.

10.Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg. 1950;5:217–30.

11.Fischer G. The evolution of liposculpture. Am J Cosmet Surg. 1997;14(3):231–9.

12.Fischer G. Surgical treatment of cellulitis. Third Congress International Academy of Cosmetic Surgery, Rome, 31 May 1975.

13.Fischer G. First surgical treatment for modeling body’s cellulite with 35 mm incisions. Bull Int Acad Cosmet Surg. 1976;2:35–7.

14.Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosmet Surg. 1977;2(4):40–3.

15.Bircoll M. Autologous fat transplantation. The Asian Congress of Plastic Surgery, February 1982.

16.Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg. 1986;78(1):122–3.

17.Johnson GW. Body contouring by macroinjection of autologous fat. Am J Cosmet Surg. 1987;4(2):103–9.

18.Bircoll MJ. New frontiers in suction lipectomy. Second Asian Congress of Plastic Surgery, Pattiyua, Thailand, February 1984.

19.Krulig E. Lipo-injection. Am J Cosmet Surg. 1987;4(2): 123–9.

20.Newman J, Levin J. Facial lipo-transplant surgery. Am J Cosmet Surg. 1987;4(2):131–40.

21.American Society of Plastic and Reconstructive Surgery Committee on New Procedures. Report in Autologous Fat Transplantation, 30 Sep 1987. Plast Surg Nurs. 1987; Winter:140–1.

22.Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg. 2007;119(3): 775–85.

23.1 Introduction

Fat transfer (autologous fat grafting) has increased in popularity for soft tissue augmentation despite perceived drawbacks of unpredictable results. In facelifting and facial rejuvenation, it has improved the author’s aesthetic results tenfold as it addresses the soft tissue loss and atrophy that accompanies aging that a standard facelift does not address (Fig. 23.1). This has many advantages over the list of injectables both permanent and nonpermanent on the market.

Fat grafting is a concept that existed since 1893. It gained popularity over last two decades with the development in liposuction techniques. It also gained recognition for being the natural approach to restore a youthful look to face. It can be performed as an isolated procedure or in conjunction with different types of facial rejuvenation surgical and nonsurgical procedures. Despite the clinical optimism associated with fat transfer, there remains an uncertainty among practitioners regarding the viability of transferred fat.

Fat transfer is known by variety of names, commonly used are fat transfer, fat injections, fat grafting, micro-lipoinjection, and autologous fat grafting. It is considered safe due to the autologous property and fat graft survival duration. Though it is more invasive and expensive than available semipermanent and permanent synthetic fillers, it has least reported complications and longer survivability.

The credit of introducing the concept of fat transfer goes to Neuber [1] who used a small piece of upper arm

fat to augment the depression on a patient’s cheek caused tuberculosis. In 1895, Czerny [2] reported breast augmentation by using a fatty tumor from the patient’s lumbar region, or lower back, to a breast defect. The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909 by Verderame [3]. In 1919, Marchand [4] reported that large central portion of grafted fat is nonviable by the tenth week, with proliferation from the peripheral fat.

His study was based on histological examination of the grafted tissue in humans. The idea of fat injection came into practice from 1920. Neuhof in 1923 [5] claimed that transplanted fat adopts the similar course as transplanted bone, that is, replacement of grafted fat with fibrous tissue or newly formed cells. In 1950, a publication by Peer [6] contradicted the findings of earlier publications regarding survival of grafted fat and believed that durable fat cell are more concentrated in the center. He also noted larger percentage of weight and mass loss in that grafts sectioned into multiple small segments than single autologous fat grafts of equal size.

With the innovation in techniques of liposuction in 1980s, the idea of fat transfer for facial rejuvenation readily flourished. Illouz [7] published the idea of the transfer of liposuction aspirate fat in 1984. Later Ellenbogen [8] introduced the technique of fat transfer popularized by the name of free pearl fat autografts in a variety of atrophic and posttraumatic facial deficits. Despite all the controversial reports regarding the survivability fat graft, the basic facts remain the same, that is, patient selection, comorbid factors, blood supply of recipient site, and safe and reliable technique. Despite the lack of hard evidence regarding the survivability and longevity of fat grafting it is still widely practiced procedure in the field of cosmetic surgery.

23.2Relevant Anatomy and Pathophysiology

With refinements in technique, fat grafting has become the procedure of choice for an array of problems, including facial scarring, lip augmentation, and nasolabial fold and glabellar furrows). Although fat grafting and other types of grafting are still not perfect, they have come a long way.

The knowledge of anatomy is the key to any surgical procedure. A surgeon with sound anatomical knowledge can avoid certain iatrogenic complications related to the procedure. A detailed description of facial anatomy is beyond the scope of this chapter. However, one of the complications of fat transplant is injury to the nerves or other vital structure, namely, parotid duct.

Most anatomists agree that face has six layers, namely, skin, subcutaneous fat, SMAS (superficial musculoaponeurotic system), muscular layer, parotideomasseteric fascia, and retaining ligaments (zygomatic osteofasciocutaneous ligaments, mandibular osseocutaneous ligament and masseteric fasciocutaneous

ligaments). The face is supplied mainly from branches of external carotid (facial and superficial temporal artery) and internal carotid arteries (ophthalmic artery). The venous drainage runs along arteries. The facial vein can communicate with cavernous sinus through ophthalmic vein or pterygoid plexus. The lymphatic drainage is mainly through superficial and deep cervical nodes.

The terminal branches of trigeminal nerve division’s, that is, the supraorbital branch of the ophthalmic nerve, the infraorbital branch of the maxillary nerve, and the mental branch of the mandibular nerve emerge from corresponding foramina on the face (Fig. 23.1). A vertical line drawn from supraorbital foramen through the interval between the two lower premolar teeth will pass through infraorbital and mental foramina. The supraorbital foramina lies approximately 3 cm from midline. The infraorbital foramina lies 1 cm below infraorbital margin and the mental foramina lies midway between the upper and lower borders of the mandible in adults. In children, it lies near the lower border and near the upper border in older people.

The surface marking of the parotid duct is the horizontal line from the lower end of tragus to midway between the ala of nose and red margin of the lip (Fig. 23.1). The duct is 5 cm long and ends opposite the upper second molar tooth.

The facial nerve divides into five terminal branches, namely, temporal or frontal zygomatic, buccal, marginal mandibular, and cervical (Fig. 23.2). Among these, frontal and marginal mandibular are more at risk of

Fig. 23.2 Branches of facial nerve