Advances in Plastic & Reconstructive Surgery © All rights are reserved by Rui Filipe Meneses de Lima et al.

*Address for Correspondence: Dr. Rui Filipe Meneses de Lima, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal, Tel: +351 927710628; E-Mail: rui.lima29@gmail.com

Received: May 22, 2019; Date Accepted: June 27, 2019; Date Published: June 28, 2019.

Lima Rui1, Matos Eduardo C2, Medeiros Rui3, Fernandes Victor4

1Plastic Reconstructive and Aesthetic Surgery Resident (Hospital Santa Maria - Lisbon)2Assistant of Plastic Reconstructive and Aesthetic Surgery (Hospital Santa Maria - Lisbon)3Plastic Reconstructive and Aesthetic Surgery Resident (Hospital Santa Maria - Lisbon)4Chair, Department of Plastic Surgery (Hospital Santa Maria - Lisbon)

AbstractThe use of autologous fat grafts is increasingly common in Plastic Surgery. In this way, the pharmaceutical industry has created different high quality fat processors. However, these processors have the disadvantage of being very expensive. As an alternative, we present a new low cost fat processing system.

The Tuga Grafter System is a closed, simple and fast system that perform different surgical techniques using autologous fat grafts, with low adipocytes damage and low infectious risk. This system perform the fat harvesting, decantation or centrifugation and lipofilling, using reusable material and disposable material with a very low cost, approximately 300-500 mL of processed fat with a disposable material cost of 3,78€ for one surgery.

Keywords: Fat Grafting; Fat Processing System; Adipocyte; Low cost

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Research Article ISSN: 2572-6684

Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System

Introduction The vast majority of plastic surgeons use or have already used

autologous fat grafts in their surgical practice and this technique is increasingly common in Plastic Surgery [1]. This concept was born in 1893, when the German surgeon Franz Neuber used fat extracted from lipomas of the forearm to correct facial defects due to tuberculo-sis [2]. From then onwards, the technique became more and more used, and there is a broad range of applications concerning both cosmetic procedures, such as breast augmentation, facial rejuvenation and augmentation of the buttocks, as well as reconstructive procedures, including facial and breast reconstruction [3-5].

According to the global statistics of the International Society of Aesthetic Plastic Surgery of 2016, liposuction is the second most frequent surgical procedure (14%), being in the top five requests by women and also by men. In this procedure, subcutaneous fat is aspirated from a certain site on the patient’s body (nowadays usually the flanks or the abdomen) and transplanted into other fat depot where volumization is desired [6].

In this way, the pharmaceutical industry has created different high quality fat processors. However, the perfect system does not exist and these processors have the disadvantage of being very expensive. With the budgetary constraints of any health system associated with an ongoing demand for patients, the plastic surgeons were forced to idealize other alternative systems with lower cost [7].

The aim of this study is presenting a safe and easy alternative fat processing system that allows the autologous fat harvest, decantation, centrifugation and lipofilling with the lowest cost described.

Material and Methods Material

We decided to separate the material in two different groups: the disposable material and the reusable material. In the first group, the reusable material group, we use simple and common material present in any operating room, which is two saline bags of 100cc, one abbocath 14, one luer lock syringe of 20 cc, one luer lock syringe of 5 cc, 50 cm extender, three-way tap and one blood system [Figure 1]. The disposable material is used for only one surgical procedure, but is important to refer that we can refill the two saline bags of 100 cc with fat several times and perform volumes of lipofilling bigger than 200 cc. The second group, the reusable material, consists of one cannulafor liposuction and posterior lipofilling and (according to the surgeonpreference) a manual centrifuge [Figure 2].

MethodsSystem Assembly [Video 1]

One of the goals of our system is to perform the liposuction and subsequent lipofilling through a closed system, because in this way we waste less fat, the surgical procedure is more clean and is decreased the risk of the fat graft contamination.

First we use the abbocath for completely empty the two 100 cc bags.

Second to create a closed system we use the two ends of a blood system, one is adapted to a fifty centimeters extension and this in turn

Adv Plast Reconstr Surg, 2019 Page 256 of 258

Lima R, Matos E, Medeiros R, Fernandes V. Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System. Adv Plast Reconstr Surg, 2019; 3(1): 256-258.

Figure 1: Reusable material group - Two saline bags of 100cc, one abbocath 14, one luer lock syringe of 20 cc, one luer lock syringe of 5 cc, 50 cm extender, three-way tap and one blood system.

Figure 2: Manual centrifuge.

is adapted to a three-way tap. The other end of the blood system is adapted to the 100 cc bag of empty serum (autologous fat graft reservoir). Posteriorly we adapt the cannula to the three-way tap that is already adapted to a syringe of 20 cc and to a 50 cm extender.

In this way, we have a closed system that connects and transfers fat graft from the cannula to the 100 cc saline bag, which means that the fat is transferred from the cannula through the three way tap to the syringe, three way tap again, extension, blood system and finally reaching the saline bag. The transfer of fat can occur in the opposite direction.

Fat Harvesting [Video 2]

We perform the hand-held syringe lipoaspiration to the luer lock syringe of 20 cc. When the syringe is full, using the three-way tap as a pivot, we perform the transfer of fat in a controlled manner. The auto-

logous fat graft is transferred from the syringe, passing the 50 extender and reaching the 100 cc bag of empty serum. We repeat this procedure until the bag is full.

Fat Decantation [Figure 3] or Fat Centrifugation According to the surgeon preference we can proceed to the fat

decantation or fat centrifugation. The decantation is performed by placing the 100 cc bag filled with autologous fat graft in a vertical position during thirty minutes. The centrifugation is performed using a manual centrifuge which minimizes the risk of lipolysis, [Video 3] because with this type of centrifugation it´s impossible to perform forces bigger than 3000 rpm (1200g). With the manual centrifuge we start to rotate the two saline bags until we verify that they are positioned in a horizontal position in relation to the ground and then we maintain with this low centrifugation speed during ninety seconds.

Figure 3: fat decantation - decantation is performed by placing the 100 cc bag filled with autologous fat graft in a vertical position during thirty minutes.

Lipofilling [Video 4]

After fat processing, the fat stored in the 100 cc bags is used to perform the lipofilling. The autologous fat grafts are transferred from the 100 cc bags, passing through the 50 cm extender and reaching the 20 or the 5 cc syringes (according to the lipofilling volume and anatomical region). Using the three-way tap as a pivot is possible to perform the last step, which is the transfer of the autologous fat graft from the syringe passing the cannula and reaching the final receptor.

Results and Discussion We demonstrate a clinical case of a patient that was previously

submitted to breast reconstruction with an implant and needed lipofi-lling to correct contour deformities. We perform the improvement of the superior pole contour of the left breast with lipofilling of 250 cc using the Tuga Grafter. This improvement maintains after 12 months of follow up, confirming the low reabsorption rate of the fat used with this system [Figure 4].

Adv Plast Reconstr Surg, 2019 Page 257 of 258

Using this system, we verified that is possible to perform the harvesting, processing and lipofilling of small volumes of fat using simple material with a very low cost [Table 1]. It was demonstrated that is possible to perform a surgical procedure using approximately 300-500 cc of processed fat with a disposable material cost of 3,78€.

The most traditional liposuction technique is the suction-assisted liposuction (SAL). However, alternatives have been developed throu-ghout time. For instance, ultrasound- assisted liposuction (UAL) uses ultrasonic energy for a more selective tissue lipolysis. Power-assisted liposuction (PAL) relies on a rapidly vibrating cannula and decreases the operator fatigue. Other options are laser-assisted liposuction (LAL) and water-assisted liposuction (WAL) [8]. Concerning the PAL, a vacuum pressure of -700 mmHg (1atm) causes some peripheral fat cell damage (approximately 10-15%) [9]. In another study, UAL aspirate revealed a thermal liquefaction of mature adipocytes. Currently does not exist one technique that is clearly superior to another in therms of cell viability, but according to the literature, it seems that the pressure with lower absolute value is beneficial for harvesting fat with maximal cell viability [1]. The Tuga Grafter System has the advantage to use the hand-held syringe lipoaspiration, exposing the adipose tissue to less trauma and consequently provoking less adipocytes damage and more cell survival [1].

We used one 3mm cannula for the lipoaspiration and lipofilling, because harvesting with a 2.5 mm cannula or 3mm cannula does not disrupt fat cells integrity [9].

Centrifugation seems to alter the adipocytes morphology and thus their morphology [10]. Conde-Green et al. refer that the adipocyte viability is higher with decantation than centrifugation [11]. Although excessive centrifugation destroys adipocytes and adipose stem cells, appropriate centrifugation with forces lower than 3000 rpm does not diminishes the cell viability [12].

This system presents different ways to process the autologous fat grafts by centrifugation and decantation. A review study didn´t find differences between the two techniques in relation to cell viability [1].

1. Gir P, Brown SA, Oni G, Kashefi N, Mojallal A, Rohrich RJ. Fat grafting:evidence-based review on autologous fat harvesting, processing, reinjection, andstorage. Plast Reconstr Surg. 2012; 130: 294-258. [Crossref]

2. Zhu M, Zhou Z, Chen Y, Schreiber R, Ransom JT, Fraser JK, et al.Supplementation of fat grafts with adipose-derived regenerative cells improveslong-term graft retention. Ann Plast Surg. 2010; 64: 222-228. [Crossref]

3. Cleveland EC, Albano NJ, Hazen A. Roll, Spin, Wash, or Filter? Processing ofLipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review ofthe Literature. Plast Reconstr Surg. 2015; 136: 706-713. [Crossref]

4. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in theaging face. Plast Reconstr Surg. 2007; 120: 89S-97S. [Crossref]

5. Kanchwala SK, Holloway L, Bucky LP. Reliable soft tissue augmentation: aclinical comparison of injectable soft- tissue fillers for facial-volume augmentation. Ann Plast Surg. 2005; 55:30-35. [Crossref]

6. Perez-Meza D, Ziering C, Sforza M, Krishnan G, Ball E, Daniels E. Hair follicle growth by stromal vascular fraction-enhanced adipose transplantation in baldness.Stem Cells Cloning. 2017; 10:1-10. [Crossref]

7. Sorin T, Rausky J, Rem K, Ozil C, Nguyen Van Nuoi V, Revol M, et al. A newcost-effective and fast method of autologous fat grafting. Ann Chir Plast Esthet.2016; 61: 237-240. [Crossref]

8. SM Shridharani, JM Broyles, and A Matarasso. Liposuction devices: Technology update, Med Devices. 2014; 7: 241-251. [Crossref]

9. Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of harvest and transfer methods on adipocyte viability and review of the literature. Dermatol Surg. 2001;27: 819-826. [Crossref]

10. Condé-Green A, Baptista LS, de Amorin NF, de Oliveira ED, da Silva KR, PedrosaCda S, et al. Effects of centrifugation on cell composition and viability of aspiratedadipose tissue processed for transplantation. Aesthet Surg J. 2010; 30: 249-255. [Crossref]

11. Condé-Green A, de Amorim NF, Pitanguy I. Influence of decantation, washing and centrifugation on adipocyte and mesenchymal stem cell content of aspirated adipose tissue: a comparative study. J Plast Reconstr Aesthet Surg. 2010; 63: 1375-1381. [Crossref]

12. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, et al. Influences of centrifugation on cells and tissues in liposuction aspirates: optimized centrifugationfor lipotransfer and cell isolation. Plast Reconstr Surg. 2008; 121:1033-1041. [Crossref]

Lima R, Matos E, Medeiros R, Fernandes V. Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System. Adv Plast Reconstr Surg, 2019; 3(1): 256-258.

Adv Plast Reconstr Surg, 2019 Page 258 of 258

Is important to refer that the centrifugation is not faster in relation to the decantation, because the surgeon can potentiate the thirty minutes needed for the decantation, performing more lipoaspi-ration or lipofilling while the fat harvested is being decanted. Another point important to discuss, is that this system is a closed system, with less fat waste, cleaner and with less contamination risk.

Conclusions

The pharmaceutical industry offers several quality fat processing systems, however with a very high cost. In this way we decided to create our own fat grafting processor, the Tuga Grafter that in our opinion achieve the four necessary goals of really good system. First is composed by simple disposable material available in every operating room and is really simple to use, second it´s faster because is a closed system, third it has a very low cost and fourth allows to perform the liposuction, decantation, centrifugation and lipofilling. In surgical procedures that require small volumes of fat, approximately 300-500 mL, this system achieves satisfactory results with a fastsurgical time and with long lasting results.

DeclarationsNot applicable

References

The manual centrifuge offers the possibility of low speed centrifugation (lower than 3000 rpm) which are correlated with less adipocyte damage.

Table 1: Tuga Grafter s reusable materials cost.

Figure 4: Improvement of the superior pole contour of the left breast one year after the lipofilling (250 mL) using the Tuga Grafter.