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Fat Transfer or Fat Injections

Fat Transfer or Fat Injections2019-03-03T14:57:01+00:00

Fat Transfer or Fat Injections

What is Fat Transfer?

Fat transfer is known by a variety of names, of which the commonly used are fat transfer, fat injection, fat transfer, and autologous fat injection. The word autologous means material (fat) is harvested from one area and donated to another in the same individual.

Although Fat transfer has been utilized in medicine for more than 100 years, the concept of injecting human fat back into the patient as an effective means to fill in wrinkles and loss of tissue throughout the body and face has been popular only since the mid1980s.

Autologous fat transfer has become an increasingly important method of facial rejuvenation both as a standalone procedure as well as in combination with traditional rejuvenation methods, like face-lifting, brow lifting, and blepharoplasty.

What are the Benefits of Fat Transfer?

The aged face is the consequence of several concurrent factors, including skin laxity, soft tissue ptosis, and volume loss. We accept that with age fat redistributes on the body. Slim hips become rounded, breasts droop, knees deposit fat medially, and lower abdomens protrude. Why then are we so reluctant to apply the same cause and common- sense treatment to the aging face?

The young face is full, with an even, ample distribution of superficial and deep fat. It appears homogenized and balanced without demarcation of the cosmetic units. In contrast, the old face shows compartmentalization, with a “hill and valley” topography. There is vivid demarcation of the cosmetic units, which leaves the face unbalanced.

Aging as viewed on a cellular level occurs as a result of a decrease in adipocyte cell size, function, and differentiation. In addition, redistribution of facial fat and atrophy of muscles and bone leads to the structural changes in the face as one senesces. It is also accompanied by loss of underlying connective tissue and reduced collagen causing sagging of skin.

Improving the condition of the skin is most commonly done with resurfacing procedures, laser and light therapy, daily skin care, and ultraviolet (UV) protection.

Correction of soft tissue ptosis is usually surgically treated with a brow lift, mid face lift, and lower face rhytidectomy or non-surgically by energy-based technologies such as radio-frequency or ultrasound. it was obvious that to recapture youth the lost volume must be restored by means at our disposal —prostheses made of silicone, bone, cartilage or recently by fillers or fat injection.

We cannot deny Sub-dermal fat give soft contours to our ugly underlying musclo-skeletal structures and that impart an aesthetically pleasing look to our eyes and interpreted by our mines as health and vitality.  Getting rid of your own fat and then injecting it in your wrinkles to eliminate them does sound like the best of all world!!!

Fat transfer is particularly suited for restructuring the proportion of the face. Normal facial structures can also be aided, by adding constructive elements to correct a broad range of perceived facial deficiencies. For example, a stronger jawline creates a youthful, more powerful-looking face; by eliminating the hollowness of lower lids helps eliminate that tired, sad appearance; and fuller lips create a more youthful, attractive appearance. Fat transfer is also used for augmenting body contours, such as the breasts or buttocks.

In certain respects, fat injection stands in contradistinction to previous efforts at rejuvenation in which the face is augmented with tissue rather than subtracted by lifting, pulling, and excising. A simple analogy to understand the benefits of fat injection is looking at a full and ripe grape that becomes prune-like (wrinkled, puckered) over a period like a convex, youthful face that undergoes contraction and involution with age. Rather than remove what appears to be redundant tissue and transform that raisin into a pea, perhaps it would be better to re-inflate that tiny raisin back into a grape.

The minimally invasive technique using autologous Fat transfer has become a standard procedure in facial rejuvenation. It is simple, inexpensive, permanent, and effective. It is considered safe because of the autologous property and fat transfer longevity. Other indications include congenital, traumatic defects, or surgical defects and scars.

Why Fat Injection  is Superior to Filler Injections?

Autologous fat injection meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, and avoids non-auto graft disease transmission or incompatibility, not likely to illicit immune response, least reported complications and longer survivability. Considering these facts, autologous fat transfer provides a very appealing resource for soft tissue volume augmentation in both small and large volumes.

Other areas where fat injection techniques considered superior to synthetic fillers in terms of the total volume required to perform larger aesthetic corrections include the buttocks and breast.  Prof. Moawad and many others insist on the dynamic unique quality of fat as it will age as we age. This unique quality of fat is perfect in soft tissue augmentation since facial structures changes as we age, and a permanent filler will be out of proportion if used. Furthermore, fashion and trends changes, and what is accepted now as beautiful may be not accepted at all later.

The best of all is fat injection is forgivable while the mistake of permanent filler is permanent!!! ,” Prof Moawad says. The only relative drawback of fat injection has been the resoption of some of the fat transfer. However, with proper technique, approximately 30–70% of the fat is retained Prof Moawad says. In my opinion the Disputes about longevity and the technique variation has postponed the announcement of fat as the perfect filler, added Prof. Moawad.

Nevertheless, its use remains relatively limited compared to commercial fillers. It also appears that surgically trained and oriented cosmetic practitioners are far more likely to use fat, and often as a complement to other surgical procedures such as face–neck lifts and blepharoplasty.

In sheer numbers, less surgically aggressive dermatologists, and now a wide array of non-surgically trained “cosmetic practitioners” – not to mention non-physician “extenders” such as physician assistants and nurse practitioners, and even simple registered nurses – inject the bulk of commercial filler. While synthetic fillers can smooth out wrinkles and folds, it cannot restore fullness that is naturally lost as fat and bone diminish and it is not for everyone.

Some individuals are allergic to synthetic materials and may develop an allergic reaction. Furthermore, synthetic materials cannot be used in large quantities to restore body deformities, to augment breast or buttocks or even hands due to high cost, making fat injection a much more desirable and economical treatment option.

Who is the Best Candidate for Fat transfer?

Patient selection plays a vital role in success or failure of any procedure. It never pays to operate on patients with unrealistic expectations, as they are never satisfied with the outcome. It is vital to have detailed history including their past, personal, and psychiatric history.

In people with severe depression, facial outlook acts only as a part of the problem and probably will only help but not treat the cause of depression. It is noticed during consultation that some patients are not sure what the most appropriate procedure is for them. For those and others the procedure should be explained to them in nonmedical terms, along with its potential complications and alternatives.

An ideal candidate will be an individual in good health, with no active or preexisting medical condition, who is not on any immunosuppressive or anticoagulation therapy, and who has realistic expectations. Fat fat injection could be considered ideal for those areas where you really need a lot of filler, such as in those patients who have full-face lipoatrophy.

Individuals who are allergic to bovine collagen (animal origin) or other synthetic materials, but want youth-enhancing results, are good candidates for Fat transfer. People with “contour deformities” may benefit from Fat transfer as well. By contour deformity, we mean a large surface area of skin which is sunken or otherwise uneven as the result of a traumatic injury or surgery, for example after liposuction.

Another indication could be the atrophy typically seen in the aging dorsum of the hands, Prof Moawad says, offering a more lasting treatment solution for this cosmetic thorn.

Most often, autologous Fat transfer has been used for aesthetic purposes however, it has also been used for non-aesthetic purposes such as migraine headaches, clival chordoma surgery, congenital short palate, vocal cord paralysis, lumbar laminectomy, sulcus vocalis, vocal cord scar, hemifacial atrophy, myringoplasty, eye socket reconstruction, frontal sinus fracture, temporo-mandibular joint reconstruction, and other disorders.

For fat transfer, patients with a history of underlying current infection, smoking, anticoagulants, coagulation disorders, herpes simplex, and marked acne scarring are not ideal candidates.

Patients with gross rhytids and poor skin tone will need additional procedures for optimum results. One must be careful in dealing with patients having a history of poor or delayed wounds.

People with bleeding disorders, or those who are diabetic, are not suitable candidates for the procedure. Additionally, people who are extremely thin, with inadequate donor fat sites, should not undergo this procedure.

 Fat Transfer Consultation at MSI

During your consultation with Prof. Moawad, a complete medical history is taken in order to evaluate the general health of the patient. A careful examination is conducted; examine those areas to be worked on. You are provided full details of the procedure, including the type of anesthesia to be used (local anesthesia for donor/recipient sites usually is enough). Additionally, Prof. Moawad will cover any possible risks and/or complications associated with the procedure and discuss realistically what results you can expect. Depending on each case, Prof Moawad may advise having Botox injections to enhance results: when combined, both procedures give impressive results. Botox is effective for the upper part the face (dynamic wrinkles), while fat transfer is suitable for augmenting the nasolabial, lips chin, cheeks and areas around the eyes. Another advantage of Botox is that muscles are relaxed with less movement, thus the fat injection is maintained in areas longer.

 How do I prepare before surgery?

  • A careful examination is conducted, and areas to be worked on are meticulously marked.

  • Preoperative and postoperative photographs may be taken to serve as guide and determine the amount of improvement.

  • Preoperative instructions may include the elimination of certain drugs such as aspirin, non-steroidal anti-inflammatory, and Vitamin E supplements to minimize the possibility of bleeding. Antibiotics are prescribed one day prior to the procedure to prevent infection.

  • Topical (Red Out cream) and/or oral Vitamin K is prescribed prior to the procedure to lower the likely hood of bruising.

 How Does Fat Transfer is Done?

Fat transfer is performed at MSI, on an outpatient basis, and usually under local anesthesia. Medication to alleviate any pain will be given one hour prior to the procedure if needed.

The entire procedure generally takes one hour. Fat transfer is a two-step process, involving extracting fat cells from a body site containing enough subcutaneous adipose tissue, serving as an appropriate source for donor site (area where fat is extracted).

Generally, fat is extracted from the abdomen, buttocks, thighs or knees, and re-injected beneath the skin in areas where cosmetic correction is needed.

First the donor site is injected with tumescent anesthesia, making the process of fat extraction painless. Then a small incision is made, and fat is withdrawn using a micro-cannula (instrument used in liposuction procedure).

Unlike liposuction, fat is not withdrawn with an aspirator machine, but rather with a syringe under significantly lower pressure. The syringe method of harvesting fat appears to be the gentlest method for removing suitable fat for reinjection.

After adequate anesthesia of the donor site, the cannula (attached to the syringe) is inserted into the fat. The plunger of the syringe is pulled to create negative pressure within the fat. The cannula is then moved in a back and forth motion several times in the same area. This maneuver is repeated in a radial fashion until the entire donor site is lipo-sculptured, or enough fat is obtained.

Before fat can be re-injected, it must be processed in order to get viable fat cells. Fat is centrifuged (rapidly spins liquid down), separating pure fat tissue. Blood, lidocaine or other material is completely removed; avoiding exposure of delicate fatty tissue to chemicals or mechanical damage is essential.

Fat is then injected with a small syringe after the area is anesthetized or numbed with Emla cream, with or without local infiltration of lidocaine. It is injected in a manner described as “weaving” or “layering” in small amounts in order to achieve desired cosmetic effect, especially when treating large areas.

Prof Moawad believes fat should be injected into tiny pearls or strands of fat in targeted depths of the skin or muscle. These tiny pearls have a enough blood supply, permitting the transferred fat cells to survive in their new recipient site.

Are there Risks with Fat Injection? What about Side Effects?

Proper adherence to the described technique minimizes complications, because facial fat injection is generally well tolerated.

The most common category of complication is minor esthetic irregularities. Such complications can take the form of palpable lumps because of placement that is too superficial or placement of aliquots that are too large resulting in fat necrosis.

Fat injection in thin-skinned areas should be performed cautiously to avoid such complications.32 These irregularities can be managed by suction lipectomies using the same cannulas used for infusion, by direct open excision, or with Lipodissolve.18,33

All patients undergoing fat injection experience bruising and swelling postoperatively. Pigmentation of the lower eyelids after fat injection gives the appearance of dark tea shining through the tear trough and can be referred to as tea staining. This problem generally resolves quickly, but may persist for up to several months, or even a year, in some patients as the skin thickens. Although this should be considered an expected outcome rather than a complication, patients should be prepared for bruising that can last up to 3 weeks after fat placement.

Infection after fat injection is exceedingly rare. Despite the rarity of infections, strict adherence to sterile technique should be practiced while harvesting, processing, and placing grafts to avoid infection and subsequent fat resorption.

Oral site infusion and lip augmentation should be performed last, because these sites are contaminated with oral flora despite Betadine preparation. Patients with a history of cold sores should be receiving prophylaxis with acyclovir.

The most feared possible complication of fat injection is fat embolism from intravascular infusion. This complication is extremely rare and has never been reported with the use of blunt tip Coleman cannulas for placement. The use of an epinephrine-containing solution at the graft site also reduces the possibility of fat

What Can I Expect Following Fat Transfer?

Ice packs are applied to the recipient site immediately postoperative to decrease swelling or ecchymosed. Bandages or a special garment is required for few days, for both donor and recipient sites to prevent swelling.

When correcting the hands, patients are advised to keep hands elevated, and avoid sleeping or pressing on the back of the hands.  There is minimal pain with the procedure.

Any discomfort is controlled with Tylenol or other pain relief medication.

Patients are instructed to continue taking antibiotics for three to five days to prevent infection and apply topical Vitamin K (Red Our Cream) to lessen bruising. Patients are up and about the same day, and generally can resume normal activity after one day.

Are Results of Fat Injection Permanent?  

There are many factors recognized to exert substantial influence on the success of autologous Fat transfer. Some of these include; the patient’s systemic health, genetic predisposition for cellular fat storage from the preferred donor sites (so-called “primary” fat deposit locations), pre- and post-grafting patient nutrition, basal metabolic rate, use of minimally traumatic harvest and handling techniques, proper preparation of the recipient bed, and relative early graft immobilization in the recipient sites.

A common practice is that the amount of fat extracted is enough for at least three injections; three months apart.

Based on the experience of treating thousands of patients, Prof Moawad believes that fat injections should be repeated at least three times; three months apart. Survival of the fat appears to be around three to five years in most patients, often longer (up to 20 years) due to incorporating fat transfer into surrounding tissue and establishing its own blood supply.

Different areas of the body differ with respect to fat transfer survival, e.g. areas injected with bones, such as the back of hands, last longer and need less repetition.

The face and lips, with strong facial movement, need more repetition for a longer lasting effect. According to scientific literature and the experience of Prof. Moawad in treating thousands of patients at MSI the greatest chance of fat cell survival is achieved utilizing a-traumatic harvesting, low injection pressures and multilayer thin infiltration.

The recent advances in fat injection includes, plasma rich platelets (PRP), adipose tissue derived stem cells (ADCs) or collagenase digest fat shows great promise with prolongation of fat transfer.

Fat can be stored in disposable syringes for up to one year or more, without contamination or deterioration in its ability to survive.

Frozen fat is a way to gradually improve the patient and avoid a long initial downtime. It also affords the chance to “touch up” areas where the fat may have dissipated or been under-corrected

Surgical Face Lift (Rhytidectomy) and Fat Transfer

For years, face-lifting procedures were advocated and liberally used in those seeking rejuvenation to a more youthful appearance. It is now understood that the aging face is not simply as a result of gravity, but also as a result of volume loss secondary to the atrophy of tissues.

The treatment goal now is one of volume replacement. The minimally invasive technique using autologous Fat transfer has become a standard procedure in facial rejuvenation Autologous fat can be used to augment facial structures, rejuvenate rhytids, or fill depressed scars or defects of the face.

The areas of the face that can be enhanced include the cheeks (malar, sub-malar), lips, and chin (mentum). The brows may be lifted with fat transfer to the forehead and indentations can be improved in almost any area of the face. Rhytides in the glabella, nasolabial fold, and marionette lines can be improved.

Any area of the face can have a depressed scar elevated by subcision and fat transfer.  At the current time, structural autologous lipo-augmentation is the most effective way to change the framework of the aging face. Prof. Moawad adopts pan facial technique that allows for even and complete volume replacement with minimal downtime and superior results.

Although many surgeons have approached fat fat injection as the only correct method to rejuvenate the face (and have demonstrated wonderful results by doing so), Prof Moawad contend that fat fat injection can serve more effectively as a complement to other rejuvenation techniques.

Fat fat injection could then be combined simultaneously with face-lifting to enhance the mid-facial, periorbital, and pre-jowl depression to attain an overall improved aesthetic result.

Despite the excellent surgical results obtained from the midface lift, we found that our rejuvenation procedures needed to evolve to include the correction of facial volume loss. Fat transfer in patients undergoing a midface lift was specifically utilized because the key areas of volume loss are centered around the midface (the tear trough and infraorbital complex, the malar eminence, the Sub-malar region, and the nasolabial crease).

These are the areas where volume loss is most prominent. Additional areas where volume loss is present in some patients include the temporal fossa, the jawline, the glabella, the lateral brow, and the perioral.

Furthermore, fat fat injection should be used as a preventive step in facial re-contouring as soon as it is needed and not only as a treatment option when the aging process is advanced.

Periorbtial (around the eyes) Rejuvenation  with Fat Injection

The periorbital region is one of the first facial regions to show signs of aging. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume.

This volume loss is accentuated by brow lifts and blepharoplasty procedures that alter brow position and remove fat, further skeletonizing the patient.  Suboptimal results, however, have led surgeons to reassess their approach to the periorbital area. Prof Moawad is a pioneer in rejuvenating the periorbital region through volume restoration using autologous Fat transfer.

A conservative trans-conjunctival blepharoplasty or skin-only upper blepharoplasty combined with fat fat injection can provide reliable rejuvenation and limit morbidity associated with higher volumes of fat fat injection that would otherwise be necessary without concomitant excisional-based surgery. Fat transfer to the forehead is an excellent method to lift the eyebrows.

Through fat augmentation, the brow is directed in an outward and is able to support the overlying skin without raising the brow to an unnaturally high position.

Furthermore, by placing fat into the lower eyelid region, the transition from the eyelid to the cheek is shifted up, and the convexity of the youthful eye is restored. Lower-lid volume replacement is also effective in treating dark circles under the eyes by reducing shadows and the appearance of blood vessels under the skin.

Prof Moawad uses the “Pearl” technique with small quantities of fat tissue injected through a 1-mL Luer-lock syringe and a 20-gauge microcannula with one hole for better control. In a novel approaches platelet rich plasma is added to collagenase digested fat were injected giving a very promising natural result.

Non surgical Rhinoplasty (nose job) Fat Injection

Fat injection to the nose is an effective method for complementing rhinoplasty procedures or for reshaping congenital or acquired deficiencies.

Patients who elect to undergo augmentation rhinoplasty often present with concerns of a low dorsum and a short nose.

Both autologous grafts and synthetic implants can result in acceptable outcomes of rhinoplasty. In general, synthetic implants are associated with higher rates of complications, such as displacement and extrusion. Structural fat injection to regions with thin skin, such as the periorbital area, must involve the delivery of minute fat parcels.

The nasal dorsum is characterized by relatively thin skin and limited space, so the implantation of large fat parcels is more likely to lead to dislodgement of the implant, nodulation, and skin irregularities. Therefore, often, micro-Fat transfer is used to correct the profile of the nose.

Special attention should be placed on the glabella and nasion, which have the most loss of fullness. The use of epinephrine is useful to decrease the chance of emboli. Incisions are usually made in the central forehead, medial eyebrow, cheek, or alar base.

The dorsum, lateral nose deficiency and tip are approached first with a curved cannula through the forehead incision. The columella and alar base can be approached through incisions in the upper lip, nasal tip, or alar groove.

The cannula of choice is a 19-gauge (mini cannula) Coleman style III cannula for injection. Fat is layered from the periosteum/ perichondrium to the intradermal, subcutaneous, and intramuscular levels; a significant layer can be placed into the muscles of the upper nose and glabella, and it can also be placed posterior to the cartilage to help expand the nasal valve, as a spreader graft. The volume placed varies from 0.4 mL in the alar rim to as much as 9.0 mL in a saddle nose deformity. The most common problem is under-correction. Blistering that occurs 3 to 4 days after injection is most likely an intravascular event.

Lip Augmentation by Fat Injection

Lip enhancement indications can be divided into two categories: lip volume and lip definition. For lip volume enhancement, most of the fat will be delivered.

The lips are typically treated after all other areas of the face have been fat grafted but before the facelift is begun because it requires the surgeon to insert his or her fingers inside the mouth.

A 5 cm long, 0.7-mm (22-gauge) cannula is used to infiltrate fat into the lips. Injection is made from access incisions at each stomal angle, and fat is generally infiltrated superficially and submucosally into the lip.

The priority of injection consists of the upper lip white role, lower lip white roll, lower lip tubercles in both sides (oblong balls), central lower lip, frenulum of the lower lip, and finally the central portion of the upper lip have been injected.

The white roll can be enhanced with a 21-gauge sharp needle injection or a blunt 0. 7 mm cannula inserted immediately sub-dermally. threading the roll and injecting upon withdrawal. On the average a volume of 1 cc is injected in the white roll of both the upper and lower lip. The philtral columns can be enhanced by sharp needle intradermal fat transfer (SNIF) with the same needle. An average volume of 0.25 cc per column is used.

If more lip protrusion is desired, additional fat is placed submucosally beneath the dry vermillion. If more vertical lip show is desired, more fat can be placed submucosally along the wet-dry junction of the vermillion on the inner aspect of the lip. A total of 1 to 1.5 mL (upper) to 1.5 to 2 mL (lower) is usually placed in each side of each lip for a total of 2 to 3 mL in the upper lip and 3 to 4 mL in the lower lip.

Bi-digital palpation is used to check the homogenous distribution of the injected fat. Minor irregularities can be corrected by gentle bi-digital massage. The puncture holes are not closed. Average volumes are 0.5 to 2.0 cc per half lip. Thus, the total volume for a complete mouth rarely exceeds 8 cc.

Treating the lips with fat has distinct advantages and disadvantages but, if the procedure is successful and graft take is good, patients are spared the inconvenience, discomfort, and expense of having to undergo repeated filler treatments and the many problems associated with lip implants and a variety of other types of lip grafts.

Fat transfer also produces a soft, natural-appearing improvement, and usually an under-correction that is arguably appropriate and desirable for typical patients having facelifts who need some improvement in their mouths.

Fat transfer the lips has the disadvantage that it usually produces a large amount of swelling that is slow to resolve, and that the take of the graft varies from patient to patient.

Patients seeking a quick recovery, a specific lip size or shape, or nuanced changes are not optimal candidates for the procedure. Patients should also be advised that when using fat, it is generally not possible to create the highly stylized cover-girl lip appearance seen in fashion magazines. These appearances are best obtained using non-autologous fillers.

In the Prof Moawad’s experience, lip augmentation with fat is rarely permanent. However, occasionally, the results are surprisingly good; for that reason, patients are often encouraged to augment the lips if they are also doing other areas of the face. When performing several procedures, the lips are saved for the very last step to avoid contaminating the other areas of the face.

Experience with combined dermabrasion or laser resurfacing and perioral fat injections suggests that healing and the overall outcome are better when resurfacing procedures are combined with fat grafting, beyond the improvement gained by simple volume addition, and this may be attributable to a “stem cell effect”.

When injecting the perioral area, care must be taken not to mistakenly overfill the white upper lip (area between the base of the nose and the vermillion-cutaneous junction) in a well-intended but misguided attempt to reduce upper lip wrinkles because patients’ upper lips can be lengthened, dental show can be reduced, and abnormal convex simian contours in profile can result.

A better strategy is to concentrate efforts on and near the white-roll area, where the wrinkles are typically the deepest and appear most objectionable and place the  fat in this area. Less fat is then placed more superiorly.

Perioral (around the mouth) with Fat Transfer

The principal areas of the lower face that benefit from fat augmentation are the pre-jowl sulcus, labio-mandibular recess, labio-mental sulcus, lateral jawline, and anterior central mentum. Of these five areas, the pre-jowl sulcus can be considered the most important for enhancement in order to provide maximal straightening of a descended jawline.

The perioral region is very amendable for improvement with millifat, microfat, and nanofat. The addition of SVF and PRP may also be beneficial. In addition, pyriform augmentation with millifat will have some effect on lifting the upper lip. The canine fossa is therefore grafted routinely with 1 mL of fat with the intention of lifting the lateral alar area of the base of the nose in the pre-periosteal plane. 1 mL is then placed in each nasolabial fold and 1 mL in the upper perioral cutaneous lip.

Although perioral grafting has had limited success with long term results, the benefit of a short-term result with the possibility of some long-term benefit warrants grafting in this area.

Pre-jowl groove Fat transfer

the pre-jowl area creates a strong, uninterrupted aesthetic line from chin to the posterior mandible (like the effect of a pre-jowl implant), which cannot be achieved by lifting the jowl alone, and results in a highly desirable improvement on both the male and female face.

Fat transfer of the pre-jowl is typically performed with a 4 cm long, 0.7-mm (22-gauge) injection cannula from injection sites over the mandibular border and on the perioral area.  Fat is placed in all tissue layers between the periosteum and skin. From 1 to 3 mL of fat are typically placed on each side in the pre-jowl area, depending on the size of the depression present, but occasionally more is indicated.

A generous amount of fat can be placed into the pre-jowl sulcus without risking contour deformity. Placement of fat should be made along both the anterior and inferior aspects of the mandibular body in order to achieve a three-dimensional, cylindrical reshaping of the pre-jowl depression.

When injecting the perioral area, care must be taken not to mistakenly overfill the white upper lip (area between the base of the nose and the vermillion-cutaneous junction) in a well-intended but misguided attempt to reduce upper lip wrinkles because patients’ upper lips can be lengthened, dental show can be reduced, and abnormal convex simian contours in profile can result.

A better strategy is to concentrate efforts on and near the white-roll area, where the wrinkles are typically the deepest and appear most objectionable and place the most fat in this area. Less fat is then placed more superiorly.

Buccal recess area Fat transfer

Buccal atrophy is consistently seen in the fourth decade of life and beyond, as is buccal hollowing caused by previous overzealous excision of buccal fat, or human immunodeficiency virus–associated facial wasting.

 Fat transfer of the buccal hollow is typically performed with a 4 cm long, 0.7-mm (22-gauge) injection cannula from injection sites situated on the midface and medial lower cheek and fat is placed subcutaneously and in sub-SMAS (buccal space) locations.

Between 2 and 5 mL of fat are typically placed on each side in the buccal recess area, depending on the degree of the problem, but occasionally more is indicated. Often an asymmetrical placement of fat is also required on the right and left sides because of the common occurrence of buccal asymmetry seen preoperatively in many patients.

Chin Fat transfer

Fat transfer can correct age associated loss of chin volume, loss of chin projection, and loss of vertical chin height, and in some cases can rival the kind of improvements obtained when small chin implants are placed.

Fat transfer of the chin can also correct an atrophic and feeble appearance that occurs as the chin shrinks with age by broadening and strengthening it, and filling in the labio-mental and submental creases when indicated. Typically, treatment of the chin must be undertaken in conjunction with the PRE-JOWL, and the 2 areas overlap each other in most cases.

Fat transfer of the chin is typically performed with a 4cmlong, 0.7-mm (22-gauge) cannula from injection sites slightly lateral to the area being treated. Occasionally a third incision is used near the midline of the lower lip. Fat is typically placed in all tissue layers from periosteum and skin

Jawline Fat transfer

Although not intuitively obvious, strengthening the jawline and posterior mandibular border makes the patient appear more youthful, fit, and attractive, and is an artistically powerful adjunct to a facelift that helps avert the deficient, frail, and lackluster mandibular contour typically seen in aging and elderly faces that is usually made worse when a facelift is performed

Fat transfer the jawline is particularly useful in patients having secondary facelifts and in patients with long faces seeking facial rejuvenation or improvement. Fat transfer of this area allows the face to be broadened, and overall proportions improved. Fat transfer the jawline area is intermediate in difficulty

of the jawline can enhance patients’ facial shapes and produce the kind of improvements obtained when mandibular border and Taylor-style mandibular angle implants are placed.

Fat transfer along the mandible can also correct an atrophic and feeble appearance that occurs as the mandibular border shrinks with age by broadening and strengthening it. Treatment of the jawline typically must be undertaken in conjunction with the PRE-JOWL and the two areas overlap in most cases.

Fat transfer of the jawline is typically performed with an 8 cm long, 1.2-mm (18-gauge) injection cannula from injection sites on the perioral area and mandibular border and fat is placed deep in a pre-periosteal/sub-masseteric position on the surface of the bone.

Between 3 and 6 mL of fat are typically placed on each side depending on the deficiency present, but occasionally more is indicated. The jaw line and chin can take as much as 20 mL of autologous fat. Note that fat is not injected subcutaneously, into the parotid, or into the masseter muscle.

In addition, the skin of the chin may be treated with mesotherapy using nanofat to reduce pore\size and resurface the photo-damaged skin.

The jaw line is filled not only in the anterior plane but also in the inferior plane by wrapping fat around the mandible. This area is approached through multiple incision sites perpendicular to the mandible, fanning laterally and inferiorly so the fat ends 1 cm below the bony border on the superior portion of the neck. In Prof Moawad’s, this not only delineates the jaw line but also seems to borrow skin from the neck. The submental area and pre-jowl sulcus are filled in the same manner, forming a sling to support the chin and separate it from the uppermost portion of the central neck.

Acne Scars Treatment (Enhancement)

For severely atrophic disease in which there is destruction of the deeper tissues, fat remains the optimal replacement agent, first noted in 1893, to improve acne scars. The word autologous means material (fat) is harvested from one area and donated to another in the same individual.

 fat transfer meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, and avoids non-auto graft disease transmission or incompatibility, not likely to illicit immune response, least reported complications and longer survivability. Considering these facts,  fat transfer provides a very appealing resource for soft tissue volume augmentation.

Fat is not considered generally effective for individual bound down ice pick scars. However, once the scar is freed, fat may be satisfactorily injected. For widespread grossly atrophic disease in combination with deeper tissue destruction, fat should be considered as the optimal filling and volumizing agent.

Fat is an excellent deeper augmenting injectable in acne scars. When higher volumes are required, fat injections can considerably save costs for the patient. Fat can be combined with other resurfacing techniques.

Any volumization should be performed first. While patients in the teens and early 20s may infrequently require volumizing, most patients that are older do need the enhanced volume. Volumizing smoothed and rounds the overall facial contour which reduces shadowing. But the importance of overall facial volumizing is that a rounded facial contour has relatively the same shadowing in most head positions.

Issues of permanence are gradually being resolved. Fat no longer appears to be as temporary as initially considered. Accurate long-lasting  corrections can result. Various factors may contribute to fat cell survival: harvesting method, manipulation of fat, exposure to blood or lidocaine, recipient site, donor site, centrifugation, injection method including syringe and needle size and overcorrection.

Fat should be injected deeply as a three-dimensional lattice with0.1–0.2-mL aliquots. The site is gradually built up to enhance the superficial layers in a lipo-layering technique. Injections can be in any tissue plane as determined by the subcision, or within all three (intra dermal, sub dermal and subcutaneous) tissue planes.

Only micro droplets are usually needed for intra dermal or immediate sub dermal placement. Often infusion is best accomplished as the needle is withdrawn. The endpoint is a slight over correction. Although, microinjecting fat intra-lesionally within the scar after subcision, Prof Moawad still recommends instilling at least a small amount underneath to volumize the area. This helps to stretch or distend some scars making them more superficial in appearance.

Post operative care usually only requires antibiotic application to the injection sites. Post-operative pain is minimal, and oral antibiotics are not required in the author’s experience. Significant edema can be treated with a short course of oral steroids.

Approximately 50% of transplanted fat should be expected to survive. Thus, touch up procedures at 3 months may be needed. Overcorrection of about 10% is usually needed.

As with lipofilling of cosmetic defects, the procedure should be considered as a multi treatment program. Small volumes are required even if multiple scars are infused, and as such the use of frozen fat aliquots from a single harvesting will save considerable time with future injection sessions.

Fat can be stored in disposable syringes for up to one year or more, without contamination or deterioration in its ability to survive. Frozen fat is a way to gradually improve the patient and avoid a long initial downtime. It also affords the chance to “touch up” areas where the fat may have dissipated or been under-corrected.

The best of all is fat transfer is forgivable while the mistake of permanent filler is permanent!!! ,” Prof Moawad says. The only relative drawback of fat injection has been the resoption of some of the fat transfer. However, with proper technique, approximately 30–70% of the fat is retained Prof Moawad says.

In my opinion the Disputes about longevity and the technique variation has postponed the announcement of fat as the perfect filler, added Prof. Moawad. The recent advances in fat transfer includes, plasma rich platelets (PRP), adipose tissue derived stem cells (ADCs) or collagenase digest fat shows great promise with prolongation of fat transfer.

Breast Augmentation. Fat Injection

The technique of autologous fat-graft injection to the breast is applied for the correction of breast asymmetry; of breast deformities; congenital defect correction” micro-mastia, and  tuberous breast deformity, breast reconstruction: for post-mastectomy breast reconstruction (as a primary and as an adjunct technique; trauma-damaged tissues (blunt, penetrating), disease (breast cancer), explanation deformity (empty breast-implant socket).); for the improvement of soft-tissue coverage of breast implants and for the aesthetic enhancement of the bust.

The technique for injecting Fat transfers for breast augmentation allows Prof. Moawad great control in sculpting the breasts to the required contour, especially in the correction of tuberous breast deformity. In which case, no fat-graft is emplaced beneath the nipple-areola complex (NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater likelihood than is achieved solely with breast implants.

The successful outcome of fat-graft breast augmentation may be enhanced by achieving a pre-expanded recipient site to create the breast-tissue matrix that will receive grafts of autologous adipocyte fat. The recipient site is expanded with an external vacuum tissue-expander applied upon each breast. The biological effect of negative pressure (vacuum) expansion upon soft tissues derives from the ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. Because external vacuum expansion of the recipient-site tissues permits injecting large-volume Fat transfers (+300cc) to correct defects and enhance the bust

The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and capsular contracture, achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. Furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule. Recently at MSI fat injection is combined with platelet rich plasma (RP) to enhance the survival of adipocytes inside the breast tissue

How Fat Transfer Breast Implant Removal  is Done?

The autologous Fat transfer replacement of breast implants (saline and silicone) resolves medical complications such as: capsular contracture, implant shell rupture, filler leakage (silent rupture), device deflation, and silicone-induced granulomas, which are medical conditions usually requiring re-operation and breast implant removal. The patient then has the option of surgical or non-implant breast corrections, either replacement of the explanted breast implants or fat-graft breast augmentation. Moreover, because Fat transfers are biologically sensitive, they cannot survive in the empty implantation pocket, instead, they are injected to and diffused within the breast-tissue matrix (recipient site), replacing approximately 50% of the volume of the removed implant—as permanent breast augmentation. The outcome of the breast implant removal correction is a bust of natural appearance; breasts of volume, form, and feel, that—although approximately 50% smaller than the explanted breast size—are larger than the original breast size, pre-procedure.

In every surgical and non-surgical procedure, the risk of medical complications exists before, during, and after a procedure, and, given the sensitive biological nature of breast tissues (adipocyte, glandular), this is especially true in the case of Fat transfer breast augmentation. Despite its relative technical simplicity, the injection (grafting) technique for breast augmentation is accompanied by post-procedure complications—fat necrosis, calcification, and sclerotic nodules—which directly influence the technical efficacy of the procedure, and of achieving a successful outcome. Use of additives to bioactivate the grafts and recipient bed appears to substantially improve the augmentation achieved  and reduce the incidence of lipid cysts, cellular loss, and microcalcifications.

Buttocks Augmentation Fat Injection or Brazilian Butt Lift (BBL)

The buttocks are a difficult area of the body to shape through exercise, but the shape and size of the buttocks has significant influence on the aesthetics of the torso. Buttock augmentation has gained popularity due to cultural trends around the world and in the media. Shapely, round buttocks can make the waist and thighs appear smaller, bring the upper torso into more pleasing proportion, and convey a youthful appearance in general. Fat augmentation of the buttocks has become the preferred choice for gluteal enhancement due to a lower complication rate and much easier recovery. The goal of this procedure is to provide patients of all ages with a youthful, pronounced, sprightly backside and a more arousing physique. Placing injections of your own fat into the upper quarter of your buttocks gives them a look of elevation and firmness, which enhances your appeal. Using your own body fat is very appealing as there is no implant, no chance of rejection, and no chance of capsular contracture, and no chance of “slipping” or shifting out of proper position. An additional benefit is that in removing fat from the donor site(s) to be used for the grafting, such as the abdomen, the patient also benefits from a liposuction to the donor site.

Harvesting the excess fat from the sides, above, below, and around the buttocks first enhances the curves and projection prior to the micro fat transfer and makes for shapelier derriere. Fat can be taken from numerous other areas including the abdomen, back, hips, waist, thighs, knees, and arms using syringe technique. The fat is deposited in a sterile container until an acceptable amount of fat is obtained (approximately 300 mL for each buttock). The area around the buttock is further sculpted by liposuction machine to better reshape the iliac crests and waist.

The fat is transferred to 60-mL syringes, and processed to remove blood, anesthesia and oil. The fat is injected through the prior incisions for fat retrieval into the buttocks in a fan-like fashion depositing small amounts of the fat into multiple tunnels subcutaneously over any areas that need filling. While injecting we mold the fat to obtain a regular accommodation with finger and hand pressure. This process is repeated until all the fat has been used to achieving a balanced, natural, smooth appearance of the buttocks. The procedure is designed to fill the upper quadrant of your buttocks so that the butt appears lifted and perky. We strive for the 3–3.5 cm posterior projection that can be achieved with the Brazilian silicone prostheses for the gluteus. The procedure usually takes about one and a half to two hours and is performed under IV sedation.

This procedure is an ideal option for anyone looking to raise or improve the contours of their buttocks. People who desire to supercharge their self-confidence and feel attractive, regardless of the clothes they are wearing (or if they are wearing none), can enjoy the benefits that a Brazilian Butt Lift offers.  Women considering a butt lift should have realistic expectations about the outcomes, as they should with any surgical procedure, and they should enjoy good health overall and have a healthy, comfortable weight. Patients who are at or near their ideal weight will achieve the best outcomes, and following their body contouring surgery, they will have an easier time keeping their weight steady. The amount of fat required for each buttock is an average of about 250 to 350 cubic centimeters (cc) of pure fat. Hence, for both sides, that equals about 700 cc, which is about ½ to about ¾ of a pound of fat. Hence, if you can spare the fat, then fat transfer is the best option. How do you know if you are a candidate for butt augmentation through fat transfer? Usually, if a patient is overweight or wears an eight to 12 dress size, she is probably best suited for transfer and perhaps some liposuction. Thin patients who wear size two to four dresses or severely under your ideal weight, you are usually not good candidates for fat transfer because they do not have any fat to spar. As mentioned before, very thin, or patients may not be ideal candidates for the Fat transfer augmentation of the breasts or buttocks. In those with very limited recipient site fat tissues, it is common to transfer lower volumes (such as 150 mL or less to each side), and plan on a secondary transfer in 4–6 months.

Swelling and bruising will diminish in the weeks following the surgery, and patients need to wear a compression garment beneath their regular clothes for a brief length of time during their recovery. Prof Moawad will instruct you to be mindful of how you are sitting in the weeks after your butt augmentation procedure; however, each patient’s guidelines are different, and your personalized post-operative instructions is reviewed with you during your pre-op visits.  Autologous fat will only survive if a certain amount of new circulation develops into it and, after 3–4 days if the fat has not obtained their blood supply it is re-absorbed by the body as dead tissue, while fat cells that have been supplied with new blood supply are going to survive. The recovery time for a Brazilian Butt Lift varies from patient to patient, but it is not uncommon for patients whose jobs are not highly active to return to work within seven days. Within three to four weeks, many patients resume moderate to full activity levels, though the recovery time may be longer for certain patients. One note: just after the procedure, the buttocks will swell somewhat and then subside. Thus, most patients think all the transferred fat has gone away but, it was the swelling that went down. That is why it requires three months before we can get a final resolution on how much fat remains.

Almost all rear ends look better with some added volume. Even after doing hundreds of fat transfers, I am amazed at how much nicer the gluteus looks when more volume is added. And remember, it is not always a matter of how much fat is contained in one area but where the fat is located that decides what the shape of buttocks will be. The resulting effect is a more attractive and sensuous appearance overall.

The results of your injections should be long-lasting if the fat is obtained, prepared, and placed properly, and you should not need to have any fine-tuning or additional fat injections. The surgeon’s experience has a great deal to do with the results you achieve from a Brazilian Butt Lift. Surgeons who fail to use proper methods of fat purification or injection cannot deliver long-lasting results. Most Brazilian Butt lift patients enjoy the results of their surgery for as many as 20 years afterward. While it is natural for some of the injected fat to be reabsorbed, the rest of it remains in the buttocks, preserving the aesthetic enhancement. Anyone’s body will change shape as the years pass, as a natural part of the aging process. Brazilian Butt Lift patients can help prolong the results of their procedures by sustaining a body weight that is healthy because, over the years, sharp increases or decreases in weight can change the contours and smoothness of the backside. Butt lift patients who do not smoke usually reabsorb less of the fat injected during fat injection than do butt lift patients who use tobacco.

What are the Differences Between a BBL and Buttocks Implants?

Butt implants are silicone devices that are surgically placed into the buttocks to achieve the patient’s desired shape, while a buttock lift uses injections of the patient’s own body fat to achieve their desired shape. It is much easier to achieve a more natural look and feel using the natural fat than it is using the artificial implants. By using the patient’s own fat cells to enhance their buttocks, there is a decreased likelihood of infection, and shorter or quicker recovery. Silicone implants in the butt have the same complications as silicone implants in the breast.  Artificial buttock prostheses cause patients to be incapacitated for 15–30 days after surgery. Mostly this is caused by extreme pain and the fact that the patient cannot lie down on the gluteus area. In addition, patients receiving an artificial buttock implant are forbidden to receive intramuscular injections. This raised the potential problem of having an accident that might leave the patient unconscious while someone else applied an intramuscular injection. This might rupture the prostheses, requiring a repeat of the cosmetic surgery. In addition, gluteal prostheses cause small irregularities that are easy to view through the skin and many patients are unable to wear a swimsuit in a natural way. Brazilian Butt Lift allows the patient to lie in a supine position after only 4 days and to be ambulatory as early as the same day of surgery.

Hand and Feet Rejuvenation. Fat Injection

Hands, like the face, often look much older and worn than the rest of the body which is protected from the sun and wind. Hands are like face – some stay young for a long time and their shape and color do not change.

There are full hands just as there are full faces, and there are thin hands just as there are thin faces that have aged inside and out. Most often, as in any aging process, the hands shrink, the veins appear more bulging and more colored than in youth, and the complexion darkens.

The back of the hand and the fingers age but not the palm or the palm side of the fingers. Face makeup can camouflage aging, but hands have no such artifice.

Prof Moawad injects fat in order to counter the exaggerated appearance of the veins on the dorsum of the hand.  Fat is removed with a syringe and a 4-cm-long needle having a 2-mm external diameter (14 gauge), and 10 mL is injected into the entire back of the hand, although sometimes 12–15 mL is used. The hand fill is as justified as the face fill, since it corresponds to loss of tissue.  Once the result has been obtained, Prof Moawad may combine chemical peel or laser treatment to complete hand rejuvenation.

Hair Loss (alopecia) and Fat injection

The first use of adipocyte-derived stem and regenerative cells, also known as SVF, for alopecia were injected in combination with fat in 2010 for in a woman who demonstrated marked improvement in hair growth.

Presently, no approach using enzymatically digested SVF is approved in the United States. In Europe, SVF can be used to treat alopecia in men and women. Mechanically dissociated SVF, nanofat, and PRP alone or in combination with Fat transfers have been used to treat alopecia.

In aesthetics, the lower priced, easier to deploy products, providing they achieve near equivalent results, will make the most sense. Patients with earlier stage hair loss are the best candidates. Combination treatments are the standard and most patients are put on topical medications before and after treatment.

In our clinic, during facial rejuvenation, if a man or woman has mild to moderate hair loss, nanofat with mSVF or SVF enriched fat obtained from mechanical dissociation, or a combination of both are used in conjunction with microfat if the patient selects this approach.

The injection of nanofat or SVF enriched microfat is performed subcutaneously above the galea and in proximity to the hair bulb, which is the region where stem cells exist. An 18 to 19-gauge cannula is used for grafting. The fat is injected retrograde in a radial and crisscrossing fashion.

Non-Aesthetic Application of Fat  injection

Tissue Augmentation

A contour concavity is not only a tissue deficiency; there is a fibrous network tethering down its uneven surface. Simply pumping fat will not correct the defect. For the procedure to succeed, the tethering fibers need to be released by jack hammer grafting and needle meshing Overzealous release destroys the fibrovascular recipient framework and creates cavities where the graft will die. To better release tethering scars, we often place these fibers under tension by injecting tumescent fluid. The previously discussed principles and techniques of fat fat injection must then be followed. Estimate the recipient capacity and realize that some defects may require more than one grafting session. Fat is not an expander. Even with meshing, tissues can hardly accommodate a greater than 50 percent volume increase. Repeated sessions result in exponential gains.

Breast Reconstruction

Breast reconstruction is more challenging than primary augmentation because its smaller recipient site has less compliance and vascularity. Furthermore, radiation therapy and scars create a hostile environment for graft survival. Still, the same principles and techniques apply

Autologous Fat transfer is widely used in reconstructive breast surgery. Plastic surgeons and patients seeking breast reconstruction may have drastically different images in mind of what constitutes an attractive, natural, and ideal breast shape.

Lipofilling represents a simple solution to restore the correct profile of the breast after reconstruction. In fact, in the immediate or late postoperative period, secondary contour defects of the reconstructed breast can develop.

Indeed, there are important landmarks in the female breast, for example, the creation of a well-defined inframammary fold is a fundamental element in obtaining a good aesthetic result after breast reconstruction.

Lipofilling can be used after reconstruction with implants or muscle flaps with or without tissue expansion. Appropriate tissue expansion allows the use of autologous flaps or the insertion of definitive prosthetic implants for breast reconstruction. This could be carried out with the aid of a computer program to help the surgeon select the proper tissue expander while planning breast reconstruction.

Breast reconstruction with external vacuum expansion plus autologous fat transfer is in vivo tissue engineering. The expansion generates a vascularized recipient scaffold that we seed with fat. To reconstruct a mastectomy that is nonirradiated and unscarred from previous reconstruction failures usually requires three successive outpatient grafting sessions 3 months apart.

Fibrosis and Scar Treatment

Fat is the soft-tissue alternative to fibrous scar. Judicious lipofilling turns the fibrous scar into a recipient matrix. What was once a dense fibrous scar become the loose supporting fibrous scaffold for Fat transfers. The cicatrix-to-matrix concept explains how autologous fat transfer can turn tight and stiff into loose and soft. Scars

Patients with retractile and painful scars compromising the normal daily activity/mobility of the joint involved can take advantage of lipofilling treatment.

In fact, Fat transfer can be used not only to fill atrophic scars but also to reduce scar contracture as a regenerative alternative to other surgical techniques. This is made possible by the presence of ASCs in the fat tissue.

From a histological point of view, autologous Fat transfers show the ability to regenerate the dermis and subcutaneous tissue and improve the dermal and dermo-hypodermic quality in scar areas, with increasing amount of fat layer – largely destroyed in cases of thermal insults and poorly regenerated during tissue repair after any type of trauma – new collagen deposition, and local neo-angiogenesis.

The regenerative role of fat in scarred areas is thought to be attributable to the release of multiple nerve entrapments, so that neuropathic pain is improved. In addition, the improvement in neurogenic pain may be maintained by placing Fat transfers around the nerve to avoid the recurrence of scar contracture

Autologous Fat transfers allow skin to become softer and more flexible and extensible, and very often the color seems like that of the surrounding unaffected skin. Another important quality of scars release, both superficial and deep, is the improvement in the mobility of the body part involved the affected joints, eyelids, nasal valve, and mouth, as well as the possibility for the patient to have a partial restoration of facial expression.

In patients with marked skin depression, scar release by autologous fat fat injection often fills these volume deficits, leading to excellent cosmetic results and positively affecting the patient’s body image.

Scar Contractures and lipofilling (PALF)

Percutaneous aponeurotomy and lipofilling (PALF) has emerged as a regenerative alternative to flap surgery for treatment of scar contractures. Percutaneously meshing the restrictive scar and expanding the resultant microcavities with fat injection expands the cicatrix into a fat-filled matrix.

For proper three-dimensional release, nicks must be staggered in multiple planes in multiple directions wherever restrictive fibers prevent expansion.

This percutaneous meshing expands the restrictive block of scar tissue to create a larger three-dimensional recipient scaffold for autologous fat transfer.

The loosened grafted scar becomes softer and closer to the normal surrounding fat tissue. Repeating the process a few months later leads to substantial tissue volume gain and can eliminate the scar to replace it with normal fat.

The Rigottomy is useful when grafting fat into scarred tissue to correct a volume deficiency. It transforms a restrictive cicatrix into a regenerative matrix.

Dupuytren and Other Hand Contractures

Needles preferentially cut tensed fibers while leaving intact the looser structures. Forceful digital extension tenses the Dupuytren cords before healthy neurovascular structures become tight.

The key to the procedure is a strong digital extension retractor that places the restrictive fibers under tension. The selective cutting of a needle for structures under tension divides the Dupuytren fibers that prevent extension while preserving the neurovascular bundles.

The procedure is safe and particularly suited for multidigit contractures. Lipofilling the meshed cord treats the subcutaneous atrophy and helps prevent recurrence of the fibrosis.

Multiple percutaneous aponeurotomies mesh-expand the fibrous cord and turn it into a recipient for fat. Furthermore, abdominal fat has been shown to be inhibitory to Dupuytren fibroblasts.

Scleroderma/Systemic Sclerosis

Subcutaneous perioral microfat injection in patients with systemic sclerosis is beneficial in the treatment of facial handicap, skin sclerosis, mouth opening limitation, sicca syndrome, and facial pain. Effects on scleroderma of the hand are also impressive

Burns

Regenerative medicine using stem cells is an efficient, low-morbidity, and high-quality therapy for skin coverage in burns, mainly due to the regeneration of skin appendages and the minimal risk of hypertrophic scarring.

Subscar and intrascar fat fat injection are relatively recent techniques that improve scar quality. Lipofilling allows a dramatic change in this status, making the tissue much more like healthy tissues from a histological point of view. Serial fat transplant sessions may be required to improve scarred recipient sites.

To enhance the therapeutic response after stem cell treatment in burns patients, intense tissue engineering with the development of 3D scaffolds or matrices is of vital importance as well as improved preconditioning cell treatments and optimized culture conditions.

Radiation Damage

Radiation kills cancer cells but also kills the adipose-derived stem cells responsible for tissue upkeep and for engraftment capacity. Fat is rich in adipose-derived stem cells.  Although initially poor to engraft because of the hostile environment, the little graft that takes in the first round makes it easier for more to engraft in the second round.

From there on, the advantage is exponential, with more grafting rendering the tissue richer in normal cells and more like nonirradiated tissue. Autologous fat transfer is best immediately after radiation treatment while the tissues are still inflamed and before fibrosis sets in; it tends to soothe the inflammation and reduce the fibrosis.

Radiation dermatitis is caused by prolonged exposure of the skin to ionizing radiation. It can be seen in patients receiving radiation therapy, with or without adjuvant chemotherapy. Inflammation of the skin after exposure to radiotherapy (radiodermatitis) can be classified into three specific types

New Trends in Fat  injection

The future of autologous Fat transfer may lie in stem-cell research, specifically adipose stromal cells. Mature tissues, such as adipose contain some number of stromal cells. Stem cells are smaller, more resilient cells that may be more viable than their mature fat cells. Stem Cells are capable of differentiation to mature fat cells. Developing technology to expand out clones of adipose stromal cells would provide a source of filler material for patients that do not have adequate fat for transfer. Other future research endeavors include the development of pre-adipocyte transplants, hormonal manipulation of Fat transfers, and the use of growth factors added to harvested tissue to increase survival of transplanted adipocytes.

Fat transfer and Platelet Rich Plasma (PRP) or Stem Cell Fat Transfer

In our experience, one of the most important influences of grafting adult lipocytes plus stimulation of the very rich mesenchymal stem cells found within adipose tissues is the addition of platelet-derived factors added to the harvested graft materials prior to graft placement. The PRP is added to the autologous graft materials in an approximate ratio of 10% in small volume cases and 0.5–1% of the total graft prepared for large volume transplantation.  PRP enhances the survival and quality of Fat transfers. Although several mechanisms may be responsible for this result, the most important mediator of the survival of Fat transfers is induction of angiogenesis. PRP contains mitogenic and chemotactic growth factors important in angiogenesis, including VEGF and EGF. These factors promoted angiogenesis during the growth of the fat.  A second potential mechanism by which PRP enhances Fat transfer survival is greater proliferation of adipose stromal cells (ASCs) or stimulation of ASCs to differentiate into adipocytes.  PRP treatment increases graft weight and volume and improves graft quality in small and large volume applications.

Stem cell-enriched fat fat injection or Cell Assisted Lipotransfer (CAL)

The concept of regenerative medicine, using the body’s own stem cells and growth factors to repair tissue, is an alternative therapeutic strategy for damaged tissue repair.

Adipose adult stem cells (ASCs) have been used as a cell source for adipose tissue engineering because they could be readily differentiated into adipocytes with specific induction factors. It has been suggested that the pre-adipocytes and adipose stromal cells are the cells that are the most likely components of surviving grafts.

These cells are more resistant to trauma and have lower metabolic requirements compared to mature adipocytes. Adipose tissue–derived stem cells (ADSCs) can be commonly obtained from adipose aspirates after conventional liposuction.

Cell assisted fat transfer ASC-poor fat is converted to ASC-rich fat by supplementing with cells freshly isolated from the adipose tissue during preparation of the injectable material. The procedure of ASC-enriched fat fat injection had excellent feasibility and safety.

Results indicate that ASC graft enrichment could render lipofilling a reliable alternative to major tissue augmentation, such as breast surgery, with allogeneic material or major flap surgery. Furthermore, ADSCs and their secretory factors show promise for application in cosmetic dermatology, especially in the treatment of skin aging.

Collagenase digested Fat Transfer

Collagenase is used to dissociate the connecting fibrils between the fat cells in fat lobules to create a suspension of fluid containing smaller clusters of digested fat cells. Using this method, the fat is transformed into a fat cell suspension that can be injected using small gauge syringes.

The harvested fat was centrifuged at 1,500 9 g for 3 minutes. Cellular debris at the bottom was drained, and the oil layer was removed using a sterile pad. The remaining fat layer was mixed with collagenase type II.

These techniques are used to improve longevity of the transplanted fat due to increase surface area contact with nutrient bed. The digested fat can pass through small-bore (25- to 27-gauge) needles which is less traumatic and allow for a more precise delivery into the superficial layer of the skin, such as the dermis, which has become the preferred location for several nonfat filler substances to treat superficial wrinkles and scars.

Autologus Collagen Micro-injections

While injectable bovine collagen, and other synthetic materials, can smooth out wrinkles, it is not for everyone. Some patients are allergic to bovine collagen or may develop an allergic reaction over time. Alternatively, autologus collagen is a safe, natural and non-allergenic material. Several techniques are applied to extract autologus collagen from fat; adding sterile, distilled water to extracted fat, breaking it down by mechanical manipulation to render it in a non-viscous form, and centrifuge (spin) it at 1000 revolutions per minute to separate the oily infranate composed of triglycerides that allows fat extracted to be injected through a small gauge needle intradermally.

Material collected is injected through a 25-gauge needle into the papillary dermis to correct fine lines and wrinkles and superficial scars. As in fat transfer, longevity of results may depend on multiple injections

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