Fat Grafting inTraumaand ReconstructiveSurgery

Yadranko Ducic, MD, FRCS(C), FACSa,b,c,d

KEYWORDS� Fat grafting � Lipotransfer � Reconstructive surgery

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The Greeks long ago recognized the ideals ofproportion and beauty, attempting to reduce itto a mathematical formula (‘‘the golden mean’’)that could be equally well applied to architecture,art, music, and general aesthetics.1 Da Vinci andRenaissance artists attempted to solve the inter-relationships of various parts of the human formand with it, define what determined beauty. Mod-ern ideals of beauty have evolved from sharp,bold, dramatic features to softer and more subtlesoft tissue envelopes covering an adequately vol-uminous and symmetric underlying osseousstructure. The midface of youth is a full, verticallywell-supported structure. Aging brings deflationof the midface associated with vertical descent.Reversal of this volume loss with fat grafting orother fillers has become a major recognizedgoal of aesthetic surgeons today. Fat grafting inreconstructive surgery is not a new concept.Neuber2 was the first to transplant fat for recon-structive purposes, harvesting pearls of fat fromthe arm to fill a facial defect. Czerny,3 in 1895,transplanted a lipoma from the back to a breastfor augmentation. Certainly fat does fulfill manyof the features of an ideal filler by being biocom-patible, inexpensive, persistent, and available inlarge quantities, and by having no risk for rejec-tion and a low chance of infection. However,the long-term retention of transplanted adipo-cytes has been debated, and has been a polariz-ing issue in the plastic surgery community, withvarious surgeons either embracing lipotransferwholeheartedly or rejecting it as completely inef-fective. Thus, it is not surprising that a dramatic

a Otolaryngology and Facial Plastic Surgery Associates, Fb Department of Otolaryngology, University of Texas Soc Baylor Neuroscience Skull Base Program, Dallas, TX, USd Otolaryngology and Facial Plastic Surgery, JPS Health NE-mail address: yducic@sbcglobal.net

Facial Plast Surg Clin N Am 16 (2008) 409–416doi:10.1016/j.fsc.2008.05.0031064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All

range of 20% to 90% for resorption of trans-planted fat has been reported.4–7

GENERAL CONSIDERATIONSHarvesting and Graft Preparation Techniqueand Effects on Graft Retention

Commonly used techniques for fat harvest includesuction machine–assisted harvest (often as a wel-come byproduct of liposuction) or hand-assistedsyringe aspiration. Although the latter techniquewould seem less traumatic on aspirated adipo-cytes because of less mechanical disruption,Smith and colleagues8 noted no difference in graftsurvival between techniques.

In addition, several authors promote washingharvested fat in physiologic solutions beforeimplanting to help adipocyte survival.9,10 LactatedRinger’s solution and 0.9% normal saline are com-monly used for this purpose. However, laboratorystudies showed no evidence of benefit from thisstep.8 In fact, prolonged exposure to air and theincreased manipulation of washing may result inloss of adipocyte viability from oxidization.

Centrifugation

Centrifuging the fat graft separates it into three dis-tinct layers. The bottom or serous fluid layer iscomposed primarily of injected local anesthetic,tumescent solution, and serous fluid. Injectingthis layer causes temporary same-day augmenta-tion from the low yield of adipocytes. The top orfree fatty acid layer is composed of inflamma-tion-promoting triglycerides that may lead to

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Fig. 2. General appearance of harvested fat withoutcentrifugation. Note: no crisp, defined point is pres-ent between each of the layers, as noted in Fig.1.

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increased delayed resorption of transplanted fatfrom mobilization of an increased inflammatorycascade. The middle or fat layer is what is gener-ally transplanted during this process. It iscomposed of the highest concentration of viablefat cells (Figs. 1 and 2). The author prefers usingcentrifugation with minimal exposure of the fat toair or manipulation as outlined below.

How Much to Inject?

Several consideration must be taken into accountwhen performing lipotransfer. If centrifugation isnot used, a variable and, in the author’s experi-ence, unpredictable amount of transplanted fatwill consist of serous fluid, tumescent solution,and local anesthetic, none of which results inlong-term volume augmentation. In addition,some transplanted fat will not survive because ofmechanical trauma, prolonged exposure to air, orfailure of the recipient bed to provide an adequateblood supply. A history of local trauma, radiation,or extirpative surgery can all result in decreasedrecipient supply in patients undergoing recon-structive surgery.11

Finally, recipient bed trauma from injecting thefat graft through a cannula causes edema anda sustained inflammatory response, which canobscure visual clues about the adequacy of the fill-ing. The author does not inject local anesthetic intothe recipient bed except for nerve blocks inpatients undergoing surgery with sedation. Healso prefers to minimize the passes into the defectto be filled and gently massage the multiple smallfat grafts into a smooth contour rather thanperform hundreds of passes to minimize swellingand the magnitude of the delayed and prolongedinflammatory response that may result inincreased graft resorption. Placing a smaller num-ber of fat packets in proximity allows increasedsurface area contact with the surrounding tissuesand decreased trauma from placing large fat grafts

Fig. 1. Clear distinction between the three layers ofharvested fat after centrifugation.

and massaging vigorously over a large area (to bediscouraged) or placing miniscule grafts overhundreds of passes (to be discouraged).

Added Benefits of Fat Transfer

Surgeons are beginning to recognize that trans-planted fat cells have significant beneficial effectson surrounding tissues that extend beyond simplevolume improvement. Coleman12 noted improve-ment in quality of aging skin, overlying scars, and ra-diation damage. These benefits may be related tothepresenceofpreadipocytes andadipose-derivedstem cells that have a certain undefined and some-what unpredictable ability to repair damaged tissue.This effect may have tremendous benefit in recon-structive surgery, because the contracted, scarredrecipient bed often requires more than volume toimprove appearance (Figs. 3 and 4).

Fat Graft Retains Memory

Transplanted adipocytes retain some originatingsite characteristics even when placed elsewherein the body. If a patient tends to gain weight alongthe lower abdominal wall and thighs, and this is thesource of the fat graft, the transplanted fat that hastaken can be expected to increase in volume if thepatient gains significant weight at the donor site.This occurrence may be challenging in reconstruc-tive cases, in which large amounts of fat are oftenselectively deposited on one side of the face only,as opposed to both sides being symmetricallyaugmented, as in cosmetic surgery. Therefore,patients undergoing reconstruction should becautioned about large fluctuations in weight,because this may deleteriously affect their finalaesthetic outcome.

Fig. 4. Postoperative appearance of patient in Fig. 3after releasing underlying contracture with second-stage lipotransfer. Improvement occurred in thevolume of the right cheek. In addition, note the sig-nificant favorable changes in quality and color ofthe overlying skin after lipotransfer to the underlyingtissue.

Fig. 3. Preoperative appearance of a woman who hadundergone a direct transfacial approach to an orbitalfloor fracture. She developed a tremendous amountof scarring in the entire right cheek with contraction,adherence to the underlying bone, subcutaneoustissue atrophy, and hyperpigmentation in the overly-ing skin that was not remedied with bleaching agentsor passage of time.

Fig. 5. Injection gun will deliver metered doses witheach pull of the trigger. This technique is somewhatless efficient than free-hand technique but more con-trolled in inexperienced hands.

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PERSONALTECHNIQUEOF FAT GRAFTING

After adequate Betadine (or other equivalentagent) preparation of the donor and recipient sites,a stab incision is made within the umbilicus toallow for a hidden donor scar. Next, tumescentsolution (composed of 500 mL lactated Ringer’ssolution, 20 mL 2% plain lidocaine, 1 mL epineph-rine 1:1000, and 1 mL 3% sodium bicarbonate) isinjected symmetrically into the lower abdominalwall quadrants ino the deep subcutaneous tissueplane. Graft harvest should be initiated afterapproximately 10 minutes to allow for adequatelocal anesthetic effect to occur.

Dry tunneling is then performed with the liposuc-tion cannula. No negative pressure is applied atthis point in the procedure. The tunneling encom-passes the entire area of proposed graft harvestand facilitates less-traumatic adipocyte acquisi-tion. Liposuction cannulas (3–5 mm) attached toa syringe are used to harvest the fat symmetricallyfrom the deep subcutaneous tissue. More superfi-cial harvest may result in increased bruising, morefibrous fat, and surface irregularities, and shouldbe avoided. The donor site is closed with resorb-able suture, antibiotic ointment is applied to theumbilicus, and an abdominal binder is worn bythe patient for 2 to 4 weeks, depending on thevolume of fat harvested. The binder will minimizeswelling, maximize comfort, and allow for nicesmooth, controlled adaptation of the (liposuction)elevated pockets of subcutaneous tissue to theunderlying fascia.

The fat is then centrifuged at 3000 rpm for3 minutes. The fat graft is decanted, efficiently

and completely removing the serous fluid (com-posed primarily of blood and tumescent solution)and free fatty acid layers (oily layer superficial tothe ‘‘good fat’’). Injecting the serous layer materialcauses false augmentation that disappears in24 to 48 hours, whereas injecting the free fattyacid layer incites a delayed and prolonged inflam-matory response that expedites graft resorption.

Alternatively, the syringe may be allowed tostand upright for 15 to 20 minutes to allow theselayers to settle, but this is neither as efficient orclean as centrifugation in the author’s experience.Next, the fat graft is injected into aestheticallyhidden areas using an injection gun (Fig. 5) thatdelivers metered doses (excellent for residentteaching and supervision) or using free-hand tech-nique wherein the injection needle is attacheddirectly to the syringe.

Fig. 6. Various injection cannulas of differing sizes andcurvatures are required to facilitate access to the re-cipient site through hidden injection sites.

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Access stab incisions for fat injection are cheeks(intranasal), lips/perioral region (oral commissure),periorbital (gingivobuccal or preauricular), andforehead (hairline). The author does not favor theColeman technique, involving hundreds of tinypasses crisscrossing each other in multiple layers,because he believes it results in an inordinateamount of surgical trauma, leading to excessiveand prolonged postoperative edema thatultimately results in unpredictable graft retention.The author prefers to inject somewhat largervolumes along the path of the injection needle’swithdrawal, because he finds it allows a morecontrolled and smoother deposit of fat.

The author does not overcorrect, because hehas treated many patients who have retained allof the fat without resorption of any sort. The authorovercorrected a few patients when first using thetechnique, assuming resorption would occur tosome degree. However, he was unpleasantlysurprised when no resorption occurred, and thissmall group of patients had to undergo furtherprocedures to correct the overcorrection. Oncethe fat is injected, the author gently massagesthe surrounding tissue through a gauze (to mini-mize direct and overly aggressive pressure onthe fat graft).

When using fat grafting techniques in posttrau-matic or reconstructive surgery cases, the outlinedtechnique of harvest is unchanged. The fat shouldbe harvested immediately before implantationrather than remaining for prolonged periods ona side table. This technique minimizes exposureto air, which may cause oxidization. The intervalbetween harvest and exposure to nourishingserous fluids should be decreased at the recipientsite.

If simple loss of volume occurs, without muchscar tissue formation at the recipient site, injectionwill be similar to that in aesthetic cases. Whensignificant scarring is present, preinjection tunnel-ing with a blunt-tip 2-mm injection cannula into thearea of proposed augmentation is beneficial(Fig. 6). In cases of severe scar contracture tounderlying tissue, a V-dissector (Fig. 7) is used torelease the area of tethering before dry tunnelingthe remainder of the area with a blunt-tipped can-nula. Excessive release with the V-dissectorresults in an excessively large pocket into whichthe injected fat will be deposited. Such a large vol-ume of fat has an increased risk for resorptionbecause it will be too far away from (an inadequatescarred field) blood supply.

The fat then should be injected within the deepsubcutaneous tissue, approaching the underlyingbone in some cases. This procedure resultsin the most aesthetically favorable augmentation

in patients who have posttraumatic scars. If thesurgeon notes that excessive scarring is present,of which entire release would result in a largepocket, the tethered area should be completelyreleased and the patient returned to the operatingroom in 4 to 6 weeks for lipotransfer. If the surgeryis performed under general anesthesia, no localanesthesia is administered at the recipient site. Ifthe procedure is performed under sedation, thennerve blocks with limited amounts of anestheticare injected. This technique causes less distortionof the recipient bed tissues and minimizes inter-ruption of blood flow to the grafts onceimplanted. The author prefers to use general anes-thesia for patients who have posttraumatic scars.

Patients are instructed to avoid any manipulationof the grafted areas for 2 weeks other than bathing.Edema and bruising are generally mild except inthe lips and lower eyelid areas, where prolongededema lasting 2 to 3 weeks may be noted.

The author generally uses a preoperative first-generation cephalosporin and metronidazole anda single dose of intravenous dexamethasone.Postoperative oral first-generation cephalosporinsare provided for 1 week postoperatively.

Fig.7. (A, B) V-dissector allows for controlled release of scar contractures. The dissector should release the contrac-ture as deep as possible. Superficial release with the V-dissector will lead to surface irregularities after fat graftinginto the raised areas.

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DISCUSSION

As with any surgery, the technique, its execution,and surgeon experience ultimately affect patientoutcomes. Fat grafting is not different. The tech-nique should result in maximal survival of

Fig. 8. Intraoperative appearance of an orbitozygo-matic approach to resection of an osteosarcoma ofthe greater wing of the sphenoid.

transplanted adipocytes. Attention to minimizingtrauma during harvesting of fat, careful prepara-tion during transfer, and, ultimately, the nature ofinjection are important in determining graftretention.

Fig. 9. Intraoperative appearance of patient in Fig. 8showing calvarial bone graft reconstruction of theorbital rim and walls and temporalis muscle flapreconstruction of the base of the skull. Note the largedepression in the temporal fossa after flap harvest.

Fig. 11. Eighteen-month postoperative appearance ofpatient in Fig.10 after fat grafting to the right tempo-ral fossa. No overcorrection was performed.

Fig. 10. Three-month postoperative appearance ofpatient in Fig. 8. Right temporal depression is noted.

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Coleman’s technique of structural fat graftingresults in placement of tiny multiple fat strandswith multiple passes.13,14 This procedure placesthe adipocytes close to a recipient blood supply,presumably decreasing risks for resorption. Theo-retically, when fat is placed and deposited at therecipient site in large clumps, some adipocytes

Fig. 12. Intraoperative view of patient status post re-section of a recurrent myoepithelioma leaving herwith a full thickness defect of the left cheek skin,loss of facial nerve and maxillary bone.

will be situated too far from an adequate bloodsupply, resulting in fat necrosis, which may leadto variable resorption and dreaded surfaceirregularity.

The problem with this technique is that themultiple passes result in a tremendous increase

Fig. 13. Following cervicodeltopectoral flap recon-struction of the skin, nerve graft reconstruction ofthe facial nerve and bone graft reconstruction ofthe maxilla, this patient, on basal view, is left with vol-ume loss over left cheek.

Fig. 14. Frontal view of same patient prior to fatgrafting.

Fig.16. Frontal view following lipotransfer to left faceto complete her reconstruction.

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in tissue swelling, mobilizing an increased inflam-matory response. This effect not only increasesthe duration of the healing process for the patientbut also can result in increased resorption, neces-sitating overcorrection. In addition, this techniqueis labor- and time-intensive. The author prefersto inject larger volumes with fewer passes (all fatis injected as the needle is withdrawn from itstunnel) and gently massage the grafts into therecipient site. No overcorrection should be per-formed with this technique because the authorfinds that some patients experience no resorption(Figs. 8–11). Surface irregularities and healingtimes have been significantly diminished with thistechnique.

Although lipotransfer into a radiated recipientbed is associated with an increased risk forresorption, most patients will still experiencea favorable improvement.

Fig.15. Following a single lipotransfer to the left face,the patient has improvement in volume on basal view.

Figures 12 through 16 demonstrate surgicaland lipostransfer technique and outcome on a pa-tient with a full thickness skin defect.

SUMMARY

Excellent results may be achieved in mostreconstructive and cosmetic surgery cases withwell-executed lipotransfer. Attention to detail isimportant for rewarding results. Graft resorptioncan occur even in well-executed cases andpatients should be appropriately cautioned.

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