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R. Calderon
30.23 Conclusions
Once this protocol is followed, you avoid predictable complications and minimize infections; thus, circumferential
Fig. 30.15 A 31-year-old
postbariatric woman with
BMI of 30, underwent dual
plane II periareolar
augmentation mastopexy and
extended abdominoplasty (a)
preoperative view and (b)
three months postoperative
view
a
body lift is a powerful procedure for achieving dramatic and
natural body contouring changes in the MWL patient
(Fig.30.15).
b
30 Circumferential Body Lift withBreast Procedures
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467
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weigth loss: the plastic-bariatric surgery simbiosis. Aesthetic Plast
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2. Shrivastava, etal. Body contouring surgery in a massive weight loss
patient: An overview. Indian J Plast Surg. 2008;41:s114–29.
3. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J.
2008;28(4):452–5.
4. Song A, FernstromMH. Nutritional psychological considerations
after bariatric surgery. Aesthet Surg J. 2008;28(2):195–9.
5. Rubin JP, Nguyen V, Schwenker A.Perioperative management of
the post-gastric-bypass patient presenting for body contour surgery.
Clin Plast Surg. 2004;31:601–10.
6. Nemerofsky RB, Oliak DA, Capella JF.Body lift: an account of
200 consecutive cases in the massive weight loss patient. Plast
Reconstr Surg. 2006;117:414–30.
7. Novaes W, Cavalcanti R, Alves R, Porto da Rocha R.Classication
for indications of lipoabdominoplasty and its variations. Aesthet
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8. Roxo AC, Roxo CD, Garcia R. Endocrine-metabolic response in
patients undergoing multiple body contouring surgeries after massive weight loss. Aesthet Surg J. 2019;39(7):756–64.
9. Stahel PF, Smith WR, Moore EE. Role of biological modiers regulating the immune response after trauma. Injury.
2007;38(12):1409–22.
10. Huiku M, Uutela K, van Gils M, et al. Assessment of surgical stress
during general anaesthesia. Br J Anaesth. 2007;98(4):447–55.
11. Douglas RG, Shaw JH. Metabolic response to sepsis and trauma. Br
J Surg. 1989;76(2):115–22.
12. Amiri F, Ghomeishi A, Aslani SM, Nesioonpour S, Adarvishi S.
Comparison of surgical stress responses during spinal and general
anesthesia in curettage surgery. Anesth Pain Med. 2014;4(3):e20554.
13. Franchimont D, Kino T, Galon J, et al. Glucocorticoids and inammation revisited: the state of the art. NIH clinical staff conference.
Neuroimmunomodulation. 2002–2003;10:247–60.
14. Weissman C. The metabolic response to stress: an overview and
update. Anesthesiology. 1990;73(2):308–27.
15. Salo M. Effects of anaesthesia and surgery on the immune response.
Acta Anaesthesiol Scand. 1992;36(3):201–20.
16. Colwell AS, Borud LJ. Optimization of patient safety in postbariatric body contouring: a current review. Aesthet Surg J.
2008;28(4):437–42.
17. Small KH, Constantine R, Eaves FF, Kenkel JM.Lessons learned
after 15 years of circumferential bodylift surgery. Aesthet Surg J.
2016;36(6):681–92.
18. Herman CK, Hoschander AS, Wong A. Post-bariatric body contouring. Aesthet Surg J. 2015;35(6):672–87.
19. Barone CM, Okoro SA, Chatter-Cora D, Helling ER.Outpatients
extended abdominoplasty in patient with massive weight loss.
Aesthet Surg J. 2007;27(2):129–36.
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weight loss patient: the eur-de-lis approach. Aesthet Surg J.
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21. Steven WG, Macias LH, Spring M, Stroker DA, Chacon CO,
Eberlin SA.One -stage augmentation mastopexy: a review of 1192
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615 consecutive patients. Aesthet Surg J. 2014;34(5):723–32.
22. Messa CA IV, Messa CA III.One-stage augmentation mastopexy:
a retrospective ten-year review of 2183 consecutive procedures.
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23. Mickatyn TM, Tenenbaum MM. Mastopexy and mastopexyaugmentation. Aesthet Surg J. 2018;38(4):374–84.
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Complications ofFat Transfer
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SoaSantareno, JavierPalacios Ferat, MohanThomas,
CesarVelilla, ReneCalderon, SandraKnight, EdwinZara,
andGregoryAlouf
31
Fat grafting is known as the most valuable weapon in plastic
surgery: it has opened the limits of malleability and contouring in aesthetics, allowing surgeons the art of sculpting bodies by adding shape and volume. However, this technique is
not only about favorable results: complications are possible.
So, in order to master the art of fat transfer, the plastic surgeon must be aware of the possible complications, how to
prevent them, and how to manage them.
A proposed classication of fat transfer complications is
detailed in Table 31.1. Major complications are the ones
which involve the possible need for surgical intervention or
hospitalization. Minor complications are the ones the surgeon is able to manage at the ofce, and don’t offer risk to
life or a major deformity as an outcome.
The majority of complications are related to aesthetic
appearance, both on the donor (irregularities, entry-site
divot) and recipient sites (over or undercorrection, bruising,
hyperpigmentation, irregularities, migration). Other possible
complications include damage to the underlying structures
such as nerves, muscles, glands or organs; liponecrosis, calcications, oil cyst and fat embolism [1].
The scientic data available prove that the complication
rates in fat grafting are by far lower than most of the open
surgical techniques and that these events decrease with the
plastic surgeon’s experience. Actually, this issue has been
debated frequently; however, a scientic review undertaken
in the year 2015 states that the rapid increasing number of
publications and citations on this topic is possibly responsible for this effect [2]. Yiwen etal. reported in 2015 a total
complication incidence of 7.2% (28 of 387) in all 387 cases
included in their systematic review [3]. Overall, oil cysts
(5.2%, 20 of 387) were the most common complication, followed by calcications (0.8%, 3 of 387) and nodules (0.5%,
2 of 387). Fibrosis (0.3%, 1 of 387), fat necrosis (0.3%, 1 of
387), and infection (0.3%, 1 of 387) each happened in only
one case. Complication incidence between different recipient sites (breast versus face) was similar; all the oil cysts
occurred in the patients in whom the recipient site was the
breast, and the incidence of cyst formation was similar in the
two groups (p=0.545).
The ability to select the patient based on the physical and
psychological features is one of the most challenging aspects.
The perfect candidate is the one who is aware that possible
touch-ups are needed and that, apart from mastering the
technique, the plastic surgeon is never capable of assuring
the survivability of the grafted fat. An informed consent that
includes the details about the procedure, the expected outcomes, the post-operative rehabilitation and the patient’s
responsibility during the recovery, possible complications,
and the need for touch-ups is paramount.
S. Santareno (*)
Plastic Surgery - The Dr Pure Clinic, Lisbon, Portugal
e-mail: soasantareno@thedrpure.com
J. Palacios Ferat
Cosmetic Plastic Surgery, Veracruz, Mexico
M. Thomas
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y.
Patil University, Mumbai, Maharashtra, India
C. Velilla
Evolution, Miami, MD, USA
e-mail: drvelilla@evolutionmd.com
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_31
R. Calderon
Cosmetic and Aesthetic Surgery, Tijuana, Mexico
S. Knight
Harmonyhealth cosmetic clinic, Kingston, Jamaica
E. Zara · G. Alouf
Cosmetic Surgery, Salem, VA, USA
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Table 31.1 Classication of fat graft complications
Major complications Minor complications
Donor site – Infection (major with sepsis/DICV or atypical
mycobacterium infection)
– Chronic seroma (with bursa and infection)
– Major irregularities
– Asymmetry
Recipient
Site
– Active Bleeding
– Hematoma
– Infection (with abscess, sepsis/DICV or atypical
mycobacterium infection)
– Damage to underlying structures (nerves, vessels,
muscles, glands, organs)
– Fat embolism syndrome
– Embolization with infarction by intravascular injection
(blindness, stroke or neurologic decits, skin/mucosa/
conjunctiva necrosis)
– Death
S. Santareno et al.
– Infection (minor or typical agent)
– Acute or sub-acute seroma (below 6weeks)
– Minor irregularities
– Scarring or entry-site divot
– Infection (minor or typical agent)
– Edema(acute or chronic)
– Bruising or small hematoma
– Hyperpigmentation
– Undercorrection (migration, no/minimal fat retention, fat
necrosis)
– Overcorrection
– Irregularities
– Fat necrosis/liponecrosis:
– Lumps
– Calcication (micro, macro or benign)
– Oil cysts
– Fibrosis
– Scarring or entry-site divot
– Miscellaneous in the face: headache, acne, dysesthesia,
drooping
– Miscellaneous in the breast: persistent pain, induration,
abnormal breast uid, pus discharge,lymphadenopathy,
striae
31.1 Infection
An immediate post-operative infection is uncommon with
fat-grafting. Still, it may happen following fat necrosis or
hematoma. In gluteal fat transfer, infection rates vary from
0.3% to 1.96% [4, 5].
Apart from local minor infection, systemic consequences
may happen. Bruner and colleagues were the rst to describe
fulminant sepsis with or without disseminated intravascular
coagulation [6]. Oranges and colleagues reported an incidence of 0.4% of sepsis [5]. The most common bacteria were
gram-negative (Escherichia coli, Bacteroides fragilis,
Microaerophilic streptococci, Pseudomonas aeruginosa,
and Enterococci). Staphylococcus aureus was one of the
lowest, at only 1 of 150 patients. In Oranges’ work, there
was one patient with a slow-growing Mycobacterium fortui-
tum chelonei and six patients with an unknown pathogen.
In cases of delayed infection (2–6 weeks postoperatively),
with redness, induration, and signs of infection a high index
of suspicion should be maintained for mycobacterial or other
unusual infections [7, 8]. Recently, there are some reports of
atypical mycobacterial infection following the use of cryopreserved autologous fat or fresh autologous fat [9, 10].
31.1.1 How toPrevent Infection?
Bruner and colleagues were able to decrease the rate of
infection on gluteal fat transfer from 13.3% initially to less
than 2% by the adoption of their protocol. The universal key
principles of sterile technique must be applied to avoid
adverse outcomes [6]:
1. On the preoperative day, a chlorhexidine bath is
advisable.
2. Trichotomy is discouraged, only hair clipping should be
undertaken.
3. At 30–60 mins pre-operative prophylactic intravenous
injection of cephalosporin or other appropriate antibiotics
is administrated (ampicillin, gentamicin, cefazolin).
4. Patients should gargle with a chlorhexidine gluconate
0.12% oral rinse immediately before any procedure on
the face; for nasal, genital or anal areas, chlorhexidine or
iodopovidone should also be considered.
5. The operating eld must be prepared with iodopovidone,
if possible circumferential preparation; all the potentially
contaminated areas, such as the ears, nose, nipples, and
genitals should be carefully protected with steri-drape or
lap pad soaked in iodopovidone.
6. The lips are always inltrated last to avoid inoculating
other areas with bacteria. If the oral or nasal mucosa is
perforated during fat grafting near these areas, the cannula should immediately be removed off the sterile eld.
7. For each 200cm [3] of fat harvested, add 2g ampicillin,
1g sulbactam, 80mg gentamicin, and 2g cefazolin.
8. Grafting cannula must be wiped with iodopovidone
before each syringe of fat is injected.
When preparing the fat, care should be taken to avoid intro-
ducing cotton bers or other foreign bodies along with the
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grafted fat, which may result in inammation and scarring.
The Codman pads, commonly used by neurosurgeons, are recommended for wicking the oil from the fatty tissue; they sem
to unravel or release bers the least [1]. The use of frozen fat
is not advisable, since the dead tissue offers the risk of severe
infection. The use of autologous banked fat is also strongly not
recommended [11]. Also, Mercado suggest us to keep in mind
that exquisite sterilization process is paramount, since contaminated cannulas in the sterilizer may perpetuate these
events. These infections are rare with fat since fat has an antibacterial cytokine. A monthly check of the sterilizer by a third
party with registered records is advisable.
31.1.2 How toManage Infection?
A conscious surgeon must follow the patient in the immediate post-operative period and rule out local infection.
Infection must be managed with immediate dressing, drainage and antibiotic therapy. Oral and topical antibiotics,
drainage and ice packing are recommended. In case of pus
drainage, this should be sent to analysis (Fig.31.1). A proposed protocol by Palacios is presented in Table 31.2.
Usually once infected and treatment started, the grafted
infected fat forms an abscess and it heals once most of the
infected fat has been extruded.
Gram staining or cultures may miss an atypical mycobacterial infection. This atypical mycobacterial infection is
highly suspect when chronic lesions are seen, or delayed redness occurs (Figs.31.2 and 31.3). In this case, proper acidfast bacilli cultures (may take up to 6–8weeks to grow), with
sensitivity as well as more sensitive tests such as polymerase
chain reaction should be performed in a timely fashion.
Until the sensitivity results are available, dual or tripe
antibiotic therapy with broad coverage is suggested. The
antibiotic regimen and its duration (if may be for months)
should be discussed with an infectious disease specialist [8].
M Thomas etal. propose 2 protocols for the management of
this condition (Table31.3), with monthly CBC count through
a blood analysis.
Other possible protocols are proposed by Velilla, referred
in Table31.4. In case of protocol 2 is applied, blood analysis
with creatinine levels each 2weeks to exclude nephrotoxicity by amikacin are mandatory; also exclusion of ototoxicity
is a must.
All the atypical bacterial infection cases resolved with
antibiotics, with or without additional surgical interventions;
471
Fig. 31.1 A 35-year-old female with a local infection of the buttocks
after fat grafting (courtesy of Palacios)
Table 31.2 Protocols for general infection management after fat transfer by Palacios
Protocol 2—Oral and
intravenous treatment (if
Protocol 1—Oral
treatment
Clindamycin
300mg each 8h
PLUS
Cefadroxil 1 g
once daily
infection resistant to
protocol 1)
Ceftriaxone PLUS
amikacin
Protocol 3—Other
actions
Intralesional
superoxidative
solutions
Intralesional ozone
gas (or at the
hyperemic area if no
abscess)
No compression
Daily dressing
they resulted in contour irregularities and scarring. This
treatment may take up to 1year.
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Fig. 31.2 A 37-year-old patient female with previous buttock fat transfer that reveled an atypical mycobacterial infection 2 weeks after a vitamin C mesotherapy (courtesy of Julian Duran, MD)
S. Santareno et al.
Table 31.4 Protocols for atypical mycobacterium infection manage-
ment by Velilla, based on Jabbour and coleagues [12]
Protocol 2—Oral and intravenous
Protocol 1—Oral treatment (6
months)
Combination of 2:
– Clarithromycin 500mg
twice daily OR
azithromycin 250–500mg
once daily
– Sulfa-trimethoprim
(Bactrim DS) twice daily
– Doxycycline 100mg twice
daily
treatment (if resistant infection to
protocol 1)
– Clarithromycin 500mg
twice daily OR
azithromycin 250–500mg
once daily
+
Combination of 2 IV antibiotics
for 2 weeks:
– Amikacin 7–10 mg/kg
daily
– Imipenem 1 g twice daily
– Cefoxitin 8–12 g daily
divided in 2–3 doses
+
Surgical drainage and
debridement
31.2 Seroma
Seroma formation is dependent on the amount of fat left
behind and the amount of denuded fascia [13]. This is similar
to the high rates of seroma from latissimus muscle aps,
which are already familiar. A seroma after fat grafting usually occurs in the fat harvest site—the lumbosacral area, specially at the sacral triangle. To create the aesthetically
pleasing shelf from the lower back to the upper buttock,
aggressive liposuction needs to be performed in the lumbosacral area. In a recent meta-analysis of all the studies to
date, the seroma rate was 3.5% [4].
Fig. 31.3 An atypical mycobacterial infection of 26 years old male
patient, 18 months after a buttock fat transfer in another facility (courtesy of Grant Hamlet, MD)
Table 31.3 Protocols for atypical mycobacterium infection management by M Thomas etal
Protocol 1—Oral
treatment (3 months)
Linezolid 600mg
twice daily
Clarithromycin
250–500mg twice
daily
Gatioxacin
400mg once daily
Protocol 2—Oral and intravenous treatment (if
resistant infection to protocol 1)
Amikacin 750mg IV daily (2 weeks)
followed by amikacin 750mg IM once per
week (6 weeks; deep gluteal injection
alternate gluteal region) + 2 of the oral
medications from protocol 1
31.2.1 How toAvoid aSeroma?
Pre-operative blood analysis to check serum protein levels
are advisable. Low albumin increases the chance of postoperative seromas. To prevent a seroma, the use of a closed
suction drain in this area is advised—the drain also help
dene the lower back upper buttock transition by decreasing
the amount of uid collection, which later turn into brosis.
Bruner and colleagues looked at 261 fat grafting patients and
found that after they started to use 2 drains they did not have
any seromas [6].
31.2.2 How toManage Seromas?
Close follow-up by the plastic surgeon with immediate inofce drainage with a 14-gauge catheter is a good strategy.
According to Calderon, if a seroma is closed and sterile, it
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473
should be drained under sterile conditions in the ofce. Then,
a new syringe should be used to inject the same volume of air
into to the cavity. The air will dry the walls of the seroma,
which will become sticky and within 1week the air will be
absorbed and the walls will adhere. Some other surgeons
inate the seroma cavity with carboxytherapy, drain the
seroma and inject 5-uouracile, triamcinolone, and doxycycline. The applied formula by Knight is: 1cc of 5FU, 1 cc
triamcinolone, and 100mg crushed doxycycline diluted in 8
cc of physiologic water. Zara postulates that diuretic medications may also help.
31.3 Edema
Swelling is the most common acute consequence of a fat
transfer. Several factors contribute for the edema, including
the amount and anatomic location of the grafted fat (more
common in the lower eyelid), the surgeon’s technique and
instruments used (a blunt canula forced through the tissues
activates the inammation cascade), and patient’s factors
(age, genetics, and medication) [7]. The edema will vary
from patient to patient, from area to area, and even from side
to side in the same patient [1].
The surgeon must prepare the patient for this outcome,
with its peak at the third post-operative day. .
can be undertaken, typically by the fourth or fth postoperative day [14].
31.4 Bruising or Hematoma
Over the donor area, the main reason for bruising and/or
hematoma is when the surgeon does not wait the planned
15 minutes after the tumescent inltration. Regarding the
recipient area, the main cause of bruising is the incorrect
washing and preparation of the fat, with some blood remaining in the graft.
31.4.1 How toPrevent Bruising?
A correct selection of the patient, and a 2-week pre-operative
suspension of oral intake of garlic, ginger, ibuprofen, aspirin
(if possible), green tea and supplements, may help. It is
important to stop smoking for at least 4weeks, 2weeks prior,
and 2weeks after the procedure. After the inltration of the
tumescent solution, the surgeon must wait a minimum of
15mins before fat harvest. Also, a correct washing and fat
preparation will avoid blood debris to be transferred to the
recipient site and bruise this area.
31.3.1 How toAvoid anEdema?
The amount of local anesthetic should be minimized to the
smallest volume that will numb the area and obtain vasoconstriction [1].Elevation, cold therapy (intermittent icing for
the rst 48–72h) and external pressure with elastic tape or
Tegaderm (3 M, Maplewood, MN, USA) help preventing
swelling [7, 14]. If fat was transferred to the face, head elevation also reduces the extent of postoperative edema. A restful
night’s sleep will also help. In addition, salt intake should be
limited because this assists in the resolution of postoperative
edema. Edema can also be reduced and/or prevented by the
use of steroids during and after the procedure. This inhibits
the inammatory cascade.
31.3.2 How toManage Edema?
Education of the patient about the importance of proper lymphatic drainage for 72h post-op is paramount. Use of electrotherapy devices for 5–7days has been found successful
for reducing swelling. Heavy exercise with increased intraabdominal pressure and bending should be avoided, but a
light isometric weight-lifting regimen with one-half to onethird the typical weight and lighter cardiovascular exercise
31.4.2 How toManage Bruising?
Certain medications (arnica montana and bromelain) and
lymphatic drainage may speed up the recovery [7].
31.5 Hyperpigmentation
Patients with a Fitzpatrick skin type IV, V, or VI tend to have
post-inammatory hyperpigmentation. Contact dermatitis or
secondary damage of the subdermal vascular plexus due to
supercial liposuction may also stimulate hyperpigmentation. The incorrect management of bruising, for instance, in
the face, may result in pigmentation that may last for weeks
or even months after hemosiderin deposits. This is particularly common in the lower eyelid [7].
31.5.1 How toPrevent Hyperpigmentation?
The surgeon should avoid dressing with strong topical glues
(always prefer a lm protection like SECURA- Smith and
Nephew). The principles of bruising and hematoma prevention will help prevent the hemosiderin deposits and consequent hyperpigmentation. Some surgeons advocate the use
of arnica to treat aggressively the bruising and avoid hyper-
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S. Santareno et al.
Table 31.5 Protocol of management of Hyperpigmentation by
Mohan T etal
Weeks 1 and 2 Week 2–8
Mefenamic acid twice daily
Proton pump inhibitor once
daily
Glutathione 600mg twice a day
Sunscreen (micronized zinc
oxide or titanium dioxide)
Q-switch laser (two passes) each
4 weeks
Glutathione 600mg twice a day
Sunscreen (micronized zinc
oxide or titanium dioxide)
pigmentation. Also, Knight highlights the importance of
middle rm compression garment, since too tight garments
may compress the micro-circulation and develop a sustained
inammatory chain with hyperpigmentation. Guarino refers
to a possible role of tranexamic acid in the prevention of this
condition, since it also helps to minimize bleeding. Knight
refers HIFU to be a good weapon preventing these kinds of
complications after fat transfer to the buttocks. The science
behind it is probably a stimulation of collagen type A production with less post-inammatory hyperpigmentation
response.
Daily use of a sunscreen at the bruised areas and entry-
points will also prevent post-inammatory hyperpigmentation.
about this particular number—the percentage of fat that will
survive—the surgeon may answer “about 50%, based on
some studies, although it is impossible to predict it accurately.” [13] In fact, reabsorption may range from 25 to 80%
and is one of the disadvantages of this procedure [1]. Proper
patient selection (both based on physical and psychological
prole), proper donor area selection and careful fat harvest,
preparation and injection are essential. For facial applications, fat is usually harvested from the lower abdomen,
which is typically the best site for obtaining the necessary
volume of lipoaspirate. In slender patients, the inner thigh or
inner knee offer alternative sources of fat. If a large volume
of fat is to be grafted, other donor sites may be selected, such
as the dorsum, anks, trochanteric region, and others.
However, if fat is harvested from the anks or trochanteric
region, it is essential to aspirate it bilaterally to maintain
symmetry and to prevent the donor area from having a different contour than the contralateral side [1].
An informed consent with these data and informing the
patient about the possible need of additional touch-ups is paramount. Also, reproducible photographs with standard positioning and good lightening conditions will allow the surgeon
to compare the pre and postoperative status of the patient.
31.5.2 How toManage Hyperpigmentation?
When installed, a possible protocol advocated by Mohan T
etal. is summarized in Table31.5.
Alouf postulates that the topical use of hydroquinone,
betamethasone, and tretinoin plus at least three sessions of
carboxytherapy is also a possible approach. Keep in mind
that the topical use of hydroquinone is mostly recommended
on Caucasians—in high Fitzpatrick level patients it may
even originate severe rebound hyperpigmentation. Knight
refers also to mesotherapy with tranexamic acid (TXA) as a
good way to address it—TXA 1000mg (10 mL), with 4mm
27-gauge needle application—a grid of 2 per 2cm should be
draw over the affected area and a 0.2cc dose of TXA should
be injected at the center of each box. The protocol is repeated
each 6 weeks until it resolves.
31.6 Undercorrection
This is the most common complaint of patients after the
swelling disappears. Plus, it is the best complication to deal
with, since is the most easily correctable. In fact, being able
to predict the exact amount of volume that will survive at the
recipient’s site is almost impossible. When asked by a patient
31.6.1 How toPrevent Undercorrection?
Most surgeons seem to cite that 50% of the fat does not survive and, therefore, more than (double) the estimated
required volume should be grafted [13]. Until now, there are
no published studies that objectively addressed fat survival
in gluteal fat augmentation.
The most recent studies reported that there are several
adjunct strategies that augment fat graft survival. In the rst
3 months after fat grafting, dynamic tissue remodeling
occurs, with different degrees of adipogenesis, liponecrosis,
scarring, oil cyst formation and differentiation and proliferation of adipose-derived stem cells. Angiogenesis is a paramount factor that provides long-term graft viability [15]. In
order to favor this, the surgeon’s strategy should include:
1. Obtaining the purest fat: elimination of blood, oil, debris,
lidocaine with the least possible damage to the adipose
tissue. By lowering the percentage of debris present in the
graft, the inammatory response is lowered and so, it
won’t stimulate so much resorption. The Coleman technique is until today the most reproducible one [7].
Avoidance of over manipulation of the fat is paramount.
2. Atraumatic technique: apart of all the care on this pro-
cess, the surgeon must be aware that a portion of the fat
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graft will die due to air exposure, negative pressure and
mechanical trauma. On this matter, the physical characteristics of the patient also take part: for instance, the fat
cells in thin patients are smaller, so they will probably
ow through the cannulas with less chance of rupture.
The opposite happens with heavier patients. Choosing the
right canula for harvesting and injection the graft is essencial [1]. The preferred syringe for injection is a large hole
one, like the Toomey.
3. Placement of small aliquots in retrograde fashion: this
will warranty a good bed for the graft to take, a better
contact of the graft with the recipient vessels, overcoming
the ischemia. Death of adipocytes cause brosis, calcications and oil cyst formation [7].
4. Avoid molding the fat graft after its placement: this
maneuver offers unequal access to nutrition by the graft
and may lead to a cyst, clump formation or edema.
5. Consider cell-assisted lipotransfer.
Cell-assisted lipotransfer is a technique developed to
increase fat graft survival and reduce complications [16].
Enrichment of fat grafts through vascular endothelial growth
factor-activated autologous stromal vascular fraction and
adipose-derived regenerative cells may assist with the
improvement of fat graft viability [15]. When adiposederived stem cells are added, they may improve fat survival
via the following four ways:
1. They differentiate to adipocytes and regenerate the adi-
pose tissue.
2. They differentiate to endothelial cells and promote
angiogenesis.
3. They release growth factors and help the surrounding tis-
sue to resist hypoxia and ischemia.
4. They survive as original adipose-derived stem cells.
31.6.2 How toManage Undercorrection?
In the face, additional fat harvesting and grafting can be
accomplished quickly and without difculty under local
anesthesia or limited intravenous sedation [14]. In other
body areas, a minimum of 6months interval should be held
before possible touch-ups under general anesthesia.
31.7 Fat Migration
The migration of grafted fat is more common in the face,
where muscle movement is present, as for example, at the
glabella or midbrow areas. When the patient is lying in the
operating room, the surface looks smooth, but when awake,
eventually the corrugators will move and so the fat. In cases
that the surgeon is planning to graft this area, apart from the
nanofat technique, the use of botulinum toxin in advance
(2weeks prior to the surgery) should be considered. Then,
after the placement of the graft, taping the recipient area for
3days is advisable.
When fat grafting the lips, supercial layering of fatty tissue into the submucosal plane and immediately deep to the
vermilion gives greater stability to the transplanted fat.
Placement into the lip for eversion should reduce the effects of
the powerful contractions of the orbicularis oris muscle [1].
When fat grafting other body areas, taping or kinesia
bands is also a strategy. If the surgeon has access to postoperative fat graft garment, such as the ones that offer compression to the donor areas, and molding with less pressure
over the recipient sites, then these should be worn. Sitting or
pressure over the recipient sites are not advisable for 10days.
31.8 Overcorrection
Compared with conventional fat grafting, cell-assisted
lipotransfer increases the fat survival rate from 45 to 60%
overal [3]. However, it is not superior to conventional grafting in terms of reducing complications. In facial fat grafting,
cell-assisted lipotransfer increased fat survival by 19% and
reduced the incidence of multiple operations [3]. This technique does not offer advantages in terms of efcacy or survival with fat transfer for breast augmentation, and it is
associated with higher incidence of complications such as oil
cyst formation [17]. A cell-assisted fat transfer does not offer
cancer risk to the breast—in the literature review by Yiwen
etal. no sign of cancer was found in any of the included studies [3]. All the cysts and nodules were reported to be benign
and self-limiting [18].
The use of platelet-rich plasma, which contains multiple
growth factors, can be incorporated with fat grafts to increase
survival and long-term viability [19, 20].
This is a rare complication to occur in most of the body areas
at the rst procedure. It can more commonly happen in certain regions such as the face or after secondary procedures/
touch-ups. This condition is difcult to manage and should
be avoided at all cost.
31.8.1 How toAvoid Overcorrection?
A conservative strategy for autologous fat transfer should be
used. In the early postoperative period, it is common for
patients to be concerned about too much fat that was placed.
The surgeon must inform that signicant tissue edema may
be responsible for this illusion and that in time the resorption
of nonviable adipocytes will occur before results can truly be
appreciated.
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31.8.2 How toManage Overcorrection?
The surgeon must wait at least 6months before considering
any other surgical intervention to address overcorrection. In
the face, micro-liposuction of the areas using an 18-gauge
Klein-Capistrano micro-liposuction cannula in a crosshatched pattern is a possible technique [14].
31.9 Irregularities, Lumps, or Bulges
Surface irregularities, both visible and/or palpable, are the
most common negative outcome after fat graft. These may be
caused by the intrinsic patient’s body characteristics, the
technique used for placement and due to the migration of the
fat graft. At the donor area, the removal of fat from the subcutaneous tissue reduces its support and may result in irregularities, with increased wrinkling and depressions.
About the recipient site, lumps are small areas of excessive fat that are more likely to occur in the periorbital region
due to its soft tissue covering and the transfer of a bolus of fat
in a single pass. A bulge is a a wide contour irregularity,
characterized by palpable persistent edema or thickening and
generally manifests as an oval-shaped elevation with palpable
induration oriented parallel to the inferior orbital rim [14].
Other irregularities result either from weight variations
(to which the fat graft may respond; more perplexing, fat
grafts can grow in people with stable weight due to medications or without apparent cause) or from fat necrosis, that
lead to chronic inammation, brosis, calcication, oil cyst
formation [7]. Bruner and colleagues reported the incidence
of fat necrosis at 4% [6].Although a single dead adipocyte
(50–150 m) can be completely absorbed, signicant numbers
of oil drops are replaced with collagen matrix (cicatrization)
[21]. If the cicatrization has a central tiny oil drop (<1mm),
chronic inammation persists and a sand-like macrocalcication (0.3–2mm) can develop over the rst 5years. If fat
necrosis is large in size (>10 mm), the necrotic tissue
becomes an oil cyst within 6–12months after grafting, which
presents never-ending inammation. Oil cysts are permanently problematic; they neither become silent (this is more
common to occur after larger volume injection or bolus,
mainly in breast and buttocks) [17]. The oil cyst is a chronic
phenomenon, that induces chronic inammation (at the
beginning M1-type macrophages for phagocytosis; latter the
M2-type which are anti-inammatory and form a brous
cyst wall) and does not reduces in size or suffers reabsorption [17].
After performing fat transfer to the breast, some calcications and oil cyst may offer diagnostic difculties with breast
cancer. However, the most recent studies conrm that a good
radiologist is able to distinguish them, and that fat grafting
may be used as a great resource in the improvement of breast
reconstruction aesthetics [22].
When small fat necrosis happens at a grafted breast, a
brous deposit develops over the years into a sand-like
micro/macro-calcication (Fig.31.4) [7]. Large fat necrosis
induce an oil cyst, of which brous wall will be calcied
over time and present an egg-shell-like calcication
(Figs.31.5 and 31.6) [7]. These calcications may interfere
with mammographic evaluation and precise breast cancer
diagnosis. Still, they may be differentiated by an experienced
radiologist. The surgeon should avoid bolus injection of the
fat graft into the mammary gland.
The breast evaluation by ultrasound, 1month after the
lipoinjection is advisable to distinguish any tiny oil drops
and to learn more and improve this injection technique [7].
31.9.1 How toPrevent Irregularities, Lumps,
or Bulges?
When harvesting the fat, a 2 or 3mm cannula is preferred.
Recent ndings on the mechanism of fat graft survival and
regeneration suggested that fat particles with more than
2–3mm diameter cannot be engrafted at 100% [7]. The surgeon should extend the movements of the cannula in different directions, in a cross-pattern, in order to avoid aspirating
fat from only a specic area, which inevitably results in an
unpleasant depression that is difcult to correct.
During fat transfer to the face, prepare less dense
fat, use thin cannulas (like 21 gauge), and perform a
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