Epithelial Cells
Fig. 215-28. B. PAS -E Staining PAS -E.
Connective tissue and some peripheral capillaries.
5-8. C. PAS Staining. Cellular Membrane distruction. Membrane formation.
Fig. 215-8. D. PAS Staining. Capillaries with a preserved
structure surrounded by adipocytes.
Once the procedure is done the implanted material is manually pressed distributing it in the receiving area (modelling)
Finally a compressive bandage is indicated right after the surgery to immobilized the area and cooperate with the healing process. It is later removed after 48 hours. This will help the garft´s attachment, first by soaking and second by stimulating angiogenesis and revascularization of the area. As a prophylactic precaution, antibiotics are prescribed as well as pain killers and anti-inflammatories.
Treated areas may present edema for about a week, ecchymosis is sometimes observed. The patient must be warned beforehand to avoid unpleasant surprises.
Patients whose face is very slim and have a lack of subcutaneous tissue; fat is injected into a deeper layer (muscle).
Methodologies change depending on each person´s needs. The way this method is applied as a reconstructive therapy changes between: hemi facial atrophy, Romberg Syndrome, Barraquer Simons Syndrome, scleroderma, posttraumatic depressed scars and acne scars.
In some cases we use it as a single minimum invasive procedure: as a filler material to be used in calves, face and the back of the hand, naso labial folds, cheeks, lips and chin.
This procedure can be combined with surgeries and fat injections in surgical procedures such as: facelift, eyelid surgery, nose surgery, post surgical depressions and body shaping.
Fat graft application to the orbital region must be deep and in very small amounts, because irregularities can be seen even if the graft is placed under the orbicularis muscle .
Fig. 215-32. Intraoperative Fat Graft. Left side has already been corrected,
unlike the right side.
Fig. 215-33. Scleroderma patient. A) Presurgical. B) Immediate Post surgery. C) Presurgical
D) 5 years after the surgery.
Fig. 215-34. Bilateral facial atrophy patient A) Presurgical B) Immediate post surgery C) Presurgical
D) Post Surgery.
It is usually used in body shaping, specially in depressions such as the trochanter area, cellulite depressions, in post liposuction iatrogenic waves, knee deformation and traumatic depressions. Fat injections can be repeated as many times as necessary.
This is the method of choice for buttocks augmentation. Between 150 and 350 ce can be added to each side.
Even though there are some publications in which fat grafting is used in breasts, from the oncological point of view, this is contraindicated. In some cases we have seen calcium formations and irregular nodules that may look suspicious in a mammography.
A compressive bandage is indicated right after the surgery to immobilize the area and cooperate with the healing process. It is later removed after 48 hours. This will help the garft´s attachment, first by soaking and second by stimulating angiogenesis and revascularization of the area. As a prophylactic precaution, antibiotics are prescribed as well as pain killers and anti-inflammatories .
Compound Grafts
We have been using compound grafts as an alternative treatment with excellent long term results.
Some of the frequently treated areas are: upper lip augmentation with SMAS and fatty tissue (Fig 215-35), dermal-fat grafts that were taken from different body areas, taking the advantage of other procedures done at the same time, such as dermis and subcutaneous tissue, , taken from the periareolar area, or fascia and abdominal fat graft (Fig 215-36 ).
Complications
Complications in autologous fat grafting procedures depend mainly on the cares with which the graft was manipulated, the applied technique, the receiving area, the graft´s size, the patient´s overall situation as well as his co-morbidity conditions.
This procedure’s complications are the same ones any other surgical procedure may have: bruises caused by small injured vessels; edema because of a secondary inflammatory reaction; seromas because of injured blood or lymph vessels; pain, even though it is not intense it is constant, specially in the buttocks area; infection caused by contamination or a bad procedure; disestesia, rare and transitory, caused by nerve compression; cutaneous dyschromia consequences of bruise reabsoption; necrosis of the surrounding skin, even though it is extremely rare, it may occur after a large superficial graft is injected; irregularities caused by alteration of the graft´s balance between integration and reabsorption .
Fig. 215-35. SMAS and fat compound graft, upper lip augmentation.
Fig. 215-36. Dermo-fat compound graft removed during Mastopexy to be used in an upper
lip augmentation procedure.
Fat hypertrophy
One of the most common questions that this method triggers is: what happens with the graft when a slim patient gains weight?
We only had three cases of fat hypertrophy in patients where fat was suctioned and later re-injected and relocated. In two of these patients, we used the tissue as a filler to improve periocular shape. The patients had depressed lower eyelid. We used the traditional technique to obtain the graft and to re-inject it. After some years, patients showed a located thrust in the treated area that was removed surgically (Fig 215-37)
The third case was a patient that had had facelift, blefaroplasty and fat graft facial filler. After 10 years the patient gained weight presenting a facial asymmetry caused by fat atrophy. We provided treatment by performing liposuction to remove the extra fat (Fig 215-38)
In general histological follow ups show that, two years after the procedure 40 or 60% of the injected material is reabsorbed, still the reabsorption index depends on the chosen method.
There are very few articles written about the changes fat suffers after it is re-injected. Truth is that fat is susceptible to volume changes depending on patient´s weight changes, hormonal conditions and fat´s revascularization.
Some authors claim that because of it vasclarization, the graft grows and that that growth depends on hormonal and nutritional facts.
These cases, in which there is an important volume augmentation trigger the following question: did survival adipocytes go through a transforming period from pre-adipocyte to a mature adipocyte? Or did they survive because of re-vascularizationof the tissue´s stroma and therefore were able to grow?
May be one answer to this question is related to the graft´s growth as a consequence of many different factors: hormonal factors, growth factors, stem cell´s presence; or to the place from where the graft was obtained, making these cells capable to respond independently from the place they were injected to, keeping their receptors (a2, b1) properties unchanged.
We think that this rare fat graft complication is unpredictable in a long term period. It depends on many conditions (besides the one we have already mentioned) such as: gender, age and the quality and quantity of he injected cells .
Fat Graft, GF and Stem Cells
Even though today there are not many clinical studies with significant follow ups that confirm it, it has been seen fat graft survival improvement when associated to GF, as well as a discreet volume augmentation and a skin improvement just by infiltrating platelet rich plasma. This might be justified because an augmentation of the GF concentration causes a greater and faster re-vascularization of the graft and stem cell reproduction (Fig 215-39).
Fig. 215-37. Fat hypertrophy of the lower eyelid eight years ago. It required surgical removal.
The removed fatty tissue is highly vascularizated.
Stem cells obtained from sternum’s bone marrow are diluted in GF highly concentrated plasma. This preparation is added to fatty tissue before injecting it. GF stimulate stem cell´s differentiation towards adipocytes as well as stimulating neo-vascularization. This will cause great attachment and will extend the graft´s duration. In addition GF low concentrated plasma is injected in the receiving are causing an injury that will trigger an inflammatory process that will procedure in situ GF.
We have been using this technique in aesthetic and reconstructive facial surgery to obtain fat filler. (Fig. 215-40 to 215-444)
This technique has also been used in body shape surgery, specially to redistribute body fat to the trochanter area, buttock augmentation and filling cellulite secondary depressions (figs. 215-44 to 215-48 ).
Fig. 215-38. A) and B) pre and post facial surgery combined with blefaroplasty and fat graft. C) Fat hypertrophy 10 years later after gaining weight. D) After fat hypertrophy correction using liposuction. E) and F) Highly vascularizated fatty tissue.
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