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© 2000 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0512/00/$15.00/0 • Dermatol Surg 2000;26:1159–1166
Current Concepts of Fat Graft Survival: Histology of Aspirated Adipose Tissue and Review of the Literature
Boris Sommer, MD and Gerhard Sattler, MD
Rosenparkklinik Darmstadt—Cosmetic Dermatologic Surgery—Darmstadt, Germany
background.
Controversy remains about the longevity ofcorrection in autologous fat grafts and its relation to adipocytesurvival. Reported long-term fat graft survival rates differwidely, depending on harvesting method, means of reinjection,injection site, and evaluation methods.
objective.
To demonstrate histologic findings of aspirated adi-pose tissue and compare the findings to the reports in the literature.
methods.
Review of the literature and the histology of trans-planted fat 7 years after subcutaneous implantation and trypanblue staining to determine the vitality of defrosted adipocytes.
results.
Fat cells survive aspiration with a suction machine or
syringe equally well. Use of a liposuction cannula or 14-gaugeneedle gives comparable results. Local anesthesia or tumescentlocal anesthesia is recommended for the donor site, preferablywith addition of epinephrine.
conclusion.
Clinical longevity of correction after autologousfat transfer is determined by the degree of augmentation result-ing from the amount of fibrosis induced and the number of via-ble fat cells. Survival of aspirated fat cell grafts depends mainlyon the anatomic site, the mobility and vascularity of the recipi-ent tissue, or underlying causes and diseases, and less on har-vesting and reinjection methods.
THE HISTORY OF autologous fat transplantationbegins in Europe. The first communication about fattransplantation was presented by Neuber
1
to the 22ndCongress of the German Surgical Society in 1893, fol-lowed by Czerny,
2
Lexer,
3
and Rehn.
4
Transplantedfat was used for a variety of surgical procedures, in-cluding thoracic surgery,
5
abdominal surgery,
6
neuro-surgery,
7
orthopedic surgery,
8
and breast surgery.
9,10
In 1911, Bruning
11
was the first to inject autologousfat into the subcutaneous tissue for the purpose of softtissue augmentation.
With the advent of liposuction surgery the harvest-ing process became an easy outpatient procedure. Inthe 1980s, Illouz
12,13
and Fournier
14
developed an easyapproach to fat transfer by syringe harvesting, called“microlipoinjection” by Fournier.
15
Today there aredifferent well-described techniques for fat transfer, al-though a standard procedure that is adopted by allpractitioners has not yet been developed.
Longevity as well as actual survival of the semiliq-uid fat graft is still a matter of controversy. Specifi-cally the following questions need to be addressed: thesurvival of fat cells after harvesting, the role of anes-thesia of the donor site, the role of the cannula or nee-dle used in harvesting and reinjection, the role ofblood in transplanted fat, trauma during cleaning pro-
cess, exposure to air, contamination of graft, histo-logic fate of reinjected fat, durability of the correction,and the relation between longevity of augmentationand fat cell survival.
Studies are difficult to compare, as different authorsuse different harvesting techniques, reinjection tech-niques, and means of evaluating the outcome. In Table1, an attempt is made to give an overview of the cur-rent state of findings in regard to the above mentionedquestions.
Anesthesia of the Donor Site
Although many authors consider local anesthesia tohave a counterproductive effect,
16–21
review of the lit-erature shows similar survival rates for aspirated fat,whether or not local anesthesia is applied. While it isargued that reduced blood supply by local applicationof epinephrine is going to have a harmful effect on thegraft, this view cannot be supported by clinical evi-dence from any study. On the contrary, vasoconstric-tion before extraction will help tissue to maintain via-bility through reduced bleeding. Tissue necrosis bylocal application of epinephrine is not a side effect ofany simple excision and patients being operated on intumescent technique are not left behind with dead adi-pocytes after liposuction surgery. Moore et al.
22
haveshown that lidocaine potently inhibits glucose trans-port and lipolysis in adipocytes and their growth inculture; that effect, however, persisted only as long aslidocaine was present. After washing the cells wereable to fully regain their function and growth regard-
B. Sommer, MD and G. Sattler, MD have indicated no significant fi-nancial interest with commercial supporters.Address correspondence and reprint requests to: Boris Sommer, MD,Rosenparkklinik Darmstadt, Heidelberger Landstr. 20, 64297 Darm-stadt, Germany.
1160
sommer and sattler: fat transfer: histology and literature review
Dermatol Surg 26:12:December 2000
Tab
le 1
.
Stu
die
s o
n G
raft
Su
rviv
al a
nd
Lo
ng
evit
y in
Au
tolo
go
us
Fat
Tran
sfer
Refe
renc
eY
ear
Hum
an/
Ani
mal
/in
Vitr
o st
udy
Ane
sthe
sia
Har
vest
ing
Tech
niqu
eFa
t Pr
oces
sing
Rein
ject
ion
Tech
niqu
eSi
te o
f In
ject
ion
Eval
uatio
nH
isto
logy
Long
evity
Con
clus
ion
of A
utho
rsC
omm
ents
2619
97H
uman
,
N
5
176
Tum
esce
nt lo
cal
anes
thes
ia 0
,1%
lid
ocai
ne w
ith
epin
ephr
ine
Syrin
ge,
1,5–
2 m
m
cann
ula
or
14-g
auge
ne
edle
Was
hing
with
sa
line.
Gra
vity
se
para
tion.
Fr
eezi
ng
2
20
8
C
16–1
8-ga
uge
need
le.
Ove
rcor
rect
ion
30–5
0%
Subc
utan
eous
(s.c
.)C
linic
al, h
isto
logy
2 w
eeks
aft
er
inje
ctio
n: L
ivin
g fa
t ce
lls, s
ome
colla
psed
.
Up
to 8
yea
rs
clin
ical
lyBe
st r
esul
ts in
fac
ial
hem
iatr
ophy
, sc
ars
and
post
trau
mat
ic
atro
phy.
Liv
ing
fat
cells
eve
n af
ter
defr
ostin
g,
dem
onst
rate
d by
tr
ypan
blu
e st
aini
ng. M
etho
d of
cho
ice
Impo
rtan
t st
udy
with
hig
hnu
mbe
r of
docu
men
ted
patie
nts
with
diff
eren
tin
dica
tions
.G
ood
desc
riptio
n of
tech
niqu
e. L
ong
docu
men
ted
follo
w-u
p.Im
port
ant:
Hig
hnu
mbe
r of
vi
able
cel
ls
even
aft
erde
fros
ting
5419
92H
uman
,
N
5
4Lo
cal a
nest
hesi
a 0,
5% L
idoc
aine
w
ith e
pine
phrin
e
Syrin
ge, 3
mm
ca
nnul
a, o
r 14
-gau
ge
need
le
Was
hing
with
rin
ger.
Gra
vity
se
para
tion.
18-g
auge
nee
dle.
O
verc
orre
ctio
nSu
bcut
aneo
us (s
.c.)
Clin
ical
Non
e”S
igni
fican
tau
gmen
tatio
npe
rsis
ts”
afte
r3
year
s.
Mul
tiple
re
inje
ctio
ns.
Pers
iste
nce
of 3
0–50
%
each
ses
sion
Met
hod
of c
hoic
eC
linic
al o
bser
vatio
n w
ith g
ood
desc
riptio
n of
te
chni
que
1619
96Ra
ts,
N
5
120
i.m.,
gene
ral
Shar
p ex
cisi
on
and
cutt
ing
of g
raft
Non
e14
-gau
ge n
eedl
e,
no lo
cal
anes
thes
ia
Subc
utan
eous
and
in
tram
uscu
larly
His
tolo
gyI.m
. inj
ectio
n:
Surv
ival
of
all o
f th
e in
ject
ed
adip
ocyt
es. S
.c.
inje
ctio
n:
Surv
ival
of p
art o
f th
e gr
aft.
Ver
y di
ffic
ult
to
iden
tify
or
sepa
rate
fro
m
pree
xist
ing
fat.
ly
mph
ocyt
e m
igra
tion
and
stro
ng f
ibro
tic
proc
ess.
I.m.:
Ver
y go
od
surv
ival
aft
er 3
, 6,
9, a
nd 1
2 m
onth
s. S
.c.:
Failu
re o
f m
ost
adip
ocyt
es t
o su
rviv
e tr
ansp
lant
atio
n
Goo
d su
rviv
al in
m
uscl
e be
caus
e of
hig
her
vasc
ular
ity t
han
in
subc
utan
eous
tis
sue
Larg
e an
imal
stu
dy
with
suf
ficie
ntly
hi
gh n
umbe
rs.
Ani
mal
stu
dies
m
ay n
ot
be f
ully
co
mpa
rabl
e w
ith
hum
an s
kin,
th
ough
5519
96H
uman
,
N
5
140
Perid
ural
blo
ck.
Salin
e an
d ep
inep
hrin
e lo
cally
Can
nula
3–
5 m
mW
ashi
ng w
ith
salin
e. G
ravi
ty
sepa
ratio
n.
Can
nula
s 3
mm
Subc
utan
eous
dee
p pl
ane
of le
gsC
linic
al
obse
rvat
ion
Non
e”A
bout
80%
” pe
rsis
tenc
e of
fa
t as
obs
erve
d ov
er 5
yea
rs
Low
abs
orpt
ion
rate
be
caus
e le
g is
not
hi
ghly
vas
cula
rized
Goo
d de
scrip
tion
of
tech
niqu
e. O
ther
st
udie
s ha
ve
show
n th
at lo
w
abso
rptio
n ra
tes
are
due
to
intr
amus
cula
r in
ject
ion,
no
t hi
gh
vasc
ular
izat
ion
5619
90H
uman
,
N
5
50
Tum
esce
nt lo
cal
anes
thes
ia 0
,25%
lid
ocai
ne w
ith
epin
ephr
ine
Syrin
ge,
14-g
auge
ex
trac
tion
cann
ula
No
was
hing
be
caus
e of
tu
mes
cent
flu
id.
18-g
auge
nee
dle
Subc
utan
eous
(s.c
.)C
linic
al
obse
rvat
ion
Non
e6
mon
ths:
“S
ubst
antia
l”
degr
ee o
f co
rrec
tion.
3
year
s: a
t le
ast
50%
au
gmen
tatio
n re
mai
ning
Trea
tmen
t of
cho
ice
for
augm
enta
tion
of f
acia
l lin
es
Goo
d de
scrip
tion
of
tech
niqu
e.
(con
tinue
d)
Dermatol Surg 26:12:December 2000
sommer and sattler: fat transfer: histology and literature review
1161
Tab
le 1
.
Co
nti
nu
ed
Refe
renc
eY
ear
Hum
an/
Ani
mal
/in
Vitr
o st
udy
Ane
sthe
sia
Har
vest
ing
Tech
niqu
eFa
t Pr
oces
sing
Rein
ject
ion
Tech
niqu
eSi
te o
f In
ject
ion
Eval
uatio
nH
isto
logy
Long
evity
Con
clus
ion
of A
utho
rsC
omm
ents
5719
90H
uman
,
N
5
25
Tum
esce
nt lo
cal
anes
thes
ia 0
,07%
lid
ocai
ne w
ith
epin
ephr
ine
Syrin
ge,
14-g
auge
bl
unt
min
ican
nula
No
was
hing
. G
ravi
ty
sepa
ratio
n
With
tro
car,
di
amet
er n
ot
stat
ed
Dee
p su
bcut
aneo
usC
linic
al
obse
rvat
ion
Non
eN
ot e
xact
ly
dete
rmin
ed”G
ratif
ying
”G
ood
desc
riptio
n of
te
chni
que
3119
93H
uman
,
N
5
4Tu
mes
cent
loca
l an
esth
esia
0,0
5%
lidoc
aine
with
ep
inep
hrin
e
Syrin
ge,
14-g
auge
ne
edle
Cen
trifu
ge a
t 10
00 r
pm f
or
1 m
in.
Mec
hani
cal
disr
uptio
n of
ce
ll w
alls
25-g
auge
nee
dle
Intr
ader
mal
Hyd
roxy
prol
ene
to d
eter
min
e co
llage
n co
nten
t in
gr
aft.
Wes
tern
bl
ot f
or
colla
gen
diff
eren
tiatio
n. H
isto
logy
aft
er
rem
oval
At
1 w
eek:
no
inta
ct in
ject
ed
adip
ocyt
es.
Vac
uole
s (m
icro
cyst
s). A
t 1
mon
th: N
ew
zone
of
fibro
us
tissu
e at
junc
tion
retic
ular
der
mis
, s.
c. A
t 3
mon
ths:
co
nden
sed
fibro
tic s
car,
mild
de
rmal
fib
rosi
s,
derm
al e
xpan
sion
”Lon
gevi
ty o
f re
sults
riv
als
Zypl
ast.
” Lo
ngev
ity o
f ce
lls is
sho
rt.
Thes
e ar
e re
plac
ed b
y fib
rosi
s.
Cel
ls d
o no
t su
rviv
e (n
ot in
tend
ed w
ith
this
tec
hniq
ue).
Aug
men
tatio
n ef
fect
thr
ough
de
rmal
fib
rosi
s.
Safe
, eff
ectiv
e,
repr
oduc
ible
. A
nim
al m
odel
s m
ay n
ot b
e co
mpa
rabl
e to
th
e hu
man
ski
n
Thor
ough
his
tolo
gic
exam
inat
ions
. V
ery
good
de
mon
stra
tion
of te
chni
que.
Cel
l w
alls
in t
his
tech
niqu
e ar
e pu
rpos
ely
dest
roye
d af
ter
harv
est.
1719
96H
uman
,
N
5
not
st
ated
Gen
eral
Ane
sthe
sia
Suct
ion
mac
hine
and
sy
ringe
, ca
nnul
as
5–8
mm
Not
sta
ted
Not
sta
ted
Subc
utan
eous
(s.c
.)C
linic
al
obse
rvat
ion
Non
eN
ot s
tate
d ex
actly
. Var
iabl
eV
aria
ble
and
unpr
edic
tabl
e lo
ngev
ity.
Impr
ovem
ent
of
over
lyin
g sk
in. F
at
graf
t ha
s pl
ace
in
cont
our
corr
ectio
n
No
impo
rtan
t da
ta
conc
erni
ng
patie
nts
or
tech
niqu
e ar
e gi
ven.
Lar
gest
ex
trac
tion
cann
ulas
use
d.
1819
90H
uman
,
N
5
43
Der
mis
: Loc
al
anes
thes
ia.
Subc
utis
: Chi
lling
w
ith s
alin
e
Syrin
ge,
14-g
auge
ne
edle
Was
hing
with
sa
line
14-g
auge
nee
dle.
Si
de-b
y-si
de
com
paris
on o
f re
inje
cted
fat
vs.
Zy
plas
t
TM
Subc
utan
eous
(s.c
.)C
linic
al
obse
rvat
ion
and
phot
ogra
phi-
cally
usi
ng
thre
e-di
men
sion
al
optic
al
prof
ilom
etry
of
rep
lica
surf
ace
from
18
sub
ject
s
Non
eLo
ngev
ity
dete
rmin
ed
afte
r 3,
6, a
nd
12 m
onth
s. C
a.
75%
of
corr
ectio
n lo
st
afte
r 6
mon
ths.
22
% o
f co
llage
n-tr
eate
d su
bjec
ts
mai
ntai
ned
at
leas
t 30
% o
f co
rrec
tion
afte
r 1
year
. 44%
of
fat
augm
ente
d su
bjec
ts
mai
ntai
ned
at
leas
t 30
%
corr
ectio
n af
ter
1 ye
ar.
Aut
olog
ous
fat
give
s re
sults
ra
ngin
g fr
om p
oor
to s
uper
ior.
Fat
au
gmen
tatio
n ha
s m
ore
stay
ing
pow
er t
han
inje
ctab
le
colla
gen.
In
ject
able
co
llage
n gi
ves
mor
e pr
edic
tabl
e re
sults
Ver
y in
tere
stin
g si
de-b
y-si
de
com
paris
on o
f au
tolo
gous
fat
vs
. inj
ecta
ble
colla
gen
(Zyp
last
TM
)
5819
92H
uman
,
N
5
43
Loca
l ane
sthe
sia
Suct
ion
mac
hine
w
ith f
ilter
tr
ap. 3
-mm
bl
unt
cann
ula
No
was
hing
. G
ravi
tatio
nal
pool
ing
15-g
and
18-
gaug
e ne
edle
sSu
bcut
aneo
us (s
.c.)
Clin
ical
ob
serv
atio
n an
d pa
tient
as
sess
men
t qu
estio
nnai
re
Non
eLo
ngev
ity
dete
rmin
ed
afte
r 3,
6, 9
, an
d 12
mon
ths.
D
epen
ding
on
unde
rlyin
g co
nditi
on,
rem
aini
ng
augm
enta
tion
was
bet
wee
n 30
and
50%
at
12 m
onth
s w
ith
linea
r m
orph
ea
havi
ng t
he le
ast
amou
nt o
f fa
t re
sorp
tion
Thig
h is
idea
l don
or
site
. Aut
olog
ous
fat
tran
spla
ntat
ion
is
safe
and
ef
fect
ive.
Lo
ngev
ity a
s cl
inic
ally
and
pa
tient
ass
esse
d,
is s
atis
fact
ory
Long
fol
low
-up,
so
me
case
s 48
m
onth
s. R
esul
ts
are
disc
usse
d as
“g
raft
via
bilit
y,”
a te
rm t
hat
may
on
ly b
e us
ed
afte
r hi
stol
ogic
as
sess
men
t
(con
tinue
d)
1162
sommer and sattler: fat transfer: histology and literature review
Dermatol Surg 26:12:December 2000
Tab
le 1
.
Co
nti
nu
ed
Refe
renc
eY
ear
Hum
an/
Ani
mal
/in
Vitr
o st
udy
Ane
sthe
sia
Har
vest
ing
Tech
niqu
eFa
t Pr
oces
sing
Rein
ject
ion
Tech
niqu
eSi
te o
f In
ject
ion
Eval
uatio
nH
isto
logy
Long
evity
Con
clus
ion
of A
utho
rsC
omm
ents
1919
96H
uman
,
N
5
45
Not
sta
ted.
Pro
babl
y G
ener
al
Ane
sthe
sia
Suct
ion
mac
hine
and
sy
ringe
. 3–
5 m
m
one-
to
thre
e-ho
le
cann
ulas
Was
hing
with
sa
line.
A
ntic
oagu
lant
ag
ent.
C
entr
ifuga
tion
1000
rpm
, 5
min
.
Not
app
licab
leN
ot a
pplic
able
Not
app
licab
leH
&E
stai
ning
. D
emon
stra
tion
of a
ll ce
llula
r,
hum
oral
and
st
ruct
ural
co
mpo
nent
s of
fa
t. T
issu
e da
mag
e su
gges
ted
by fr
ee
fat,
hem
oglo
bin,
an
d cl
ots.
Not
app
licab
leTi
ssue
dam
age
afte
r bo
th m
achi
ne
and
syrin
ge
harv
estin
g le
ads
to r
elea
se o
f in
flam
mat
ion
med
iato
rs.
Was
hing
el
imin
ates
fre
e fa
t an
d bl
ood,
thu
s de
crea
sing
in
flam
mat
ory
resp
onse
to
graf
t
Thor
ough
rep
ort
of
tech
niqu
e an
d ne
gativ
e pr
essu
res
used
. Tu
mes
cent
an
esth
esia
w
ould
hel
p to
de
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ject
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Dermatol Surg 26:12:December 2000
sommer and sattler: fat transfer: histology and literature review
1163
less of whether the exposure was as short as 30 min-utes or as long as 10 days.
22
In vivo exposure tolidocaine has no effect at all, so that harvesting underlocal anesthesia can be done to obtain subcutaneousfat for metabolic studies.
22
Finally, it has been clearlydemonstrated that amide local anesthetics enhancewound healing by reducing leukocyte migration, re-ducing local metabolic activation of leukocytes, andreducing release of toxic substances such as oxygenfree radicals and lysozymes known to impair woundhealing.
23,24
Lipoextraction and Survival of Fat Cells After Harvesting
Fat harvesting by liposuction does not result in in-creased fat cell damage compared to fat harvesting byexcision. This was shown in a recent study using aglycerol-3-phosphate dehydrogenase (G3PDH) enzymeassay to compare the viability of adipocytes harvestedby both methods.
25
Leakage of this lipogenic enzymeG3PDH through the plasma membrane would be a po-tential indicator of fat cell damage. Schuller-Petrovic
26
demonstrated only a few dead cells by trypan bluestaining even after defrosting (see also Figure 1). Theopinion of many surgeons that fat grafting does notwork because the fat cells do not survive transfer hasto be changed in the light of these new findings.
No correlation can be found between survival of fatharvested with syringe or machine aspiration (see Ta-ble 1). A syringe produces a relative vacuum of about
2
0.6 atm. Only if maximum negative pressure of
2
0.95 atm in machine aspiration is applied may par-tial breakage and vaporization of fatty tissue occur.
The diameter of the fat cells is mechanically distendedand is larger than in lipocytes extracted at
2
0.5 atm.
27
No correlation can be found between survival of fatharvested with a liposuction cannula or 14-gauge nee-dle (see Table 1). Isolated adipocytes remain highly vi-able after harvesting with a 3 mm liposuction cannula,as evidenced by glucose transport assays, and mayeven be used for metabolic studies in adipose pa-tients.
28
Sudan black staining, which may be used to demon-strate viable fat cells, showed an average of 14.000and 15.28 live fat cells in 1 mm
3
for cannula and sy-ringe harvesting, respectively, in a study conducted byNovaes et al.
20
Blood in Transplanted Fat
All authors agree that blood in transplanted fat accel-erates degradation of transplanted fat.
Trauma During the Cleaning Process
Fat cells do not seem to be as fragile as many surgeonsbelieve. As shown above, they survive almost any har-vesting method. The results in Table 1 do not point toany difference in outcome, whether there was centrifu-gation, vigorous washing, or no washing at all.
Exposure to Air, Contamination of the Graft
Most authors favor a closed technique. Advantagesare maintenance of sterility and avoiding exposure toair. Fat should not be allowed to dry out completely asthis would destroy adipocytes. The open technique,however, provides the surgeon with the opportunityto separate bigger fibers from the tissue and produce agraft that is easier to inject.
29
Exposure to air carriesthe risk of contamination. Although no published dataare available yet, clinical experience shows that thisrisk is no greater than with the closed technique,where infection is very rare.
30
Freezing of Adipocytes
Slow freezing of the tissue to
2
20
8
C shortly after har-vesting has no harmful effect on the adipocytes. Stud-ies show that there are a high number of viable cellseven after defrosting.
26
Figure 1 shows one dead adi-pocyte on trypan blue staining among some living fatcells and a background of fatty microdroplets. Trypanblue staining is a negative staining method used todemonstrate live cells; the staining color penetrates de-fective cell walls. This cytologic picture was taken
Figure 1. Some viable fat cells (white cytoplasm), small fat micro-droplets, and one dead adipocyte without intact cell walls (graycytoplasm) in fat from the abdominal wall, after defrosting from2208C and mechanical manipulation. (Trypan blue; magnification3400.)
1164
sommer and sattler: fat transfer: histology and literature review
Dermatol Surg 26:12:December 2000
from machine-assisted aspiration of abdominal fatwith a 3 mm blunt liposuction cannula after defrost-ing (3 years at
2
20
8
C) and manipulation through aluer-to-luer adapter and a 24-gauge needle. It clearlydemonstrates the sturdiness of aspirated adipocytes. Astoring period of up to 6 months is recommended,
30
although we sometimes store longer than this. Slowfreezing to
2
20
8
C is preferable if one wants to trans-plant viable adipocytes, whereas flash freezing may beused to destroy adipocytes, as in lipocytic dermal aug-mentation.
31
Liporeinjection
Most authors use 14- to 25-gauge needles for reinjec-tion, depending on harvesting and processing tech-nique. There seems to be no correlation between thediameter of the needle and longevity of correction.
Histologic Fate of Reinjected Fat
There are few reports on the histologic fate of rein-jected fat in humans. Schuller-Petrovic
26
found livingfat cells, some collapsed, at 2 weeks after injection.Carpaneda
32
studied collagen alterations in adiposetissue autografts to the abdominal subcutaneous fat inpatients prior to abdominoplasty. The grafting inter-vals were 60, 30, 21, 15, 12, 8, and 5 days prior to theabdominoplasty. He found a type I collagen capsulecircumscribing the graft, besides several alterations inthe synthesis, degradation, and remodeling of type Iand type III collagen within the transplanted tissue.An increase and decrease of inflammatory response ina time sequence was shown as well as a shift in the in-flammatory process from the peripheral viable regionto the central inviable region, where small pseudocystsand nonnucleated adipocytes were present.
Coleman
31
transplanted mechanically disrupted ad-ipocytes and found rounded vacuoles 1 week after thetransplantation at the injection site and, obviously, nointact adipocytes. At 1 month, perivascular spaceswidened and contained sparse lymphocytic infiltrates,a new zone of connective tissue between the reticulardermis, and the subcutaneous fat developed.
All reports with a systematic research layout areconducted on animal models. Guerrerosantos et al.
16
found that fat transplants into subcutaneous tissuewere impossible to identify or separate from the al-ready existent fat. In his study on 120 Wistar rats,only part of the fat implanted into subcutaneous tissueseemed to survive, while fat strips implanted intramus-cularly not only survived well, but showed some aug-mentation in size in relation to the initial size of thegraft.
Blood Supply at the Recipient Site
Although some authors assume that fat cells survivebest in muscular tissue because of the high vascular-ity,
16
clinical evidence shows good survival in hemiat-rophia hemifacialis and posttraumatic scars despitedecreased vascularity in these conditions.
26
Durability of the Correction
The durability of the achieved correction remainssomewhat unpredictable despite all efforts to improvetechniques. The longest durability can be expected inatrophies after scleroderma (hemiatrophy, saber-cuttype), postsurgical or traumatic atrophy, and depressedscars.
26
For aging changes, the results are initially ex-cellent but show a higher rate of loss of volume so thattouch-up procedures may be necessary. There are well-documented cases where autologous fat transplanta-tion lasted 8 years and more.
26,33
Findings in Nondermatologic Fat Transfer
The fate of injected fat has been studied in a variety ofnondermatologic diseases. When used for perianal sub-mucosal injection to treat sphincteric incontinence,Shafik
34
found 3 of 14 patients maintained sufficient vol-ume at 18-month follow-up, 7 of 14 required one touch-up injection, and 4 of 14 required two touch-up injec-tions. Survival of fat used for frontal sinus obliterationdid not yield satisfactory results, with fat necrosis beingpresent in 5 of 8 cases 6–24 months postoperatively.
35
The average volumetric “take” following injections ofthe canine vocal fold was about 20% at 12 weeks in astudy conducted by Mikus et al.
36
Of interest, liposuc-tioned fat was significantly superior to grafts preparedby the purification method. Chairman
37
adapted thecosmetic procedure of fat transfer to a therapeuticprocedure for the foot. Treating 50 patients for resto-ration of the plantar fat pad, he found an increased fatpad in 48 patients, 1 patient required an additionaltransfer 6 months after surgery. At 5 years follow-upafter fat autotransplantation for first web space atro-phy following posttraumatic ulnar nerve palsies, 21 of25 patients had slight loss of volume, whereas 4 of 21retained the initial overcorrection.
38
There are reportsthat pacemaker pocket neuralgia secondary to inade-quate subcutaneous tissue between the pacemaker andoverlying skin may now be treated by lipoinjection.
39
Discussion
In 1988 Glogau
40
put forward the following ques-tions: What is the documented fate of the fat graft?How much survives the initial transfer? How much
Dermatol Surg 26:12:December 2000
sommer and sattler: fat transfer: histology and literature review
1165
survives long-term? In this article an attempt is madeto give an overview of the preliminary answers the sci-entific community has to give. Some questions havebeen addressed, others still await definitive solutions.
There are two approaches to soft tissue augmenta-tion: use of permanent or resorbable fillers. Wheneverpermanent fillers such as polytetrafluoroethylene (PTFE)or polymethylmethacrylate (PMMA) are used, the possi-bility or impossibility of extraction of unwanted materialhas to be kept in mind. Whereas single implants such asPTFE can be removed, silicon oil, Artecoll, and Derm-alive are distributed diffusely into the subcutaneoustissue. The difficulty or impossibility of removing mil-lions of 30 mm implants such as PMMA-spheres in theevent of an undesired immune response to the materialshould be discussed with the patient.41 No human faceis “permanent.” As skin atrophy progresses in the ag-ing individual, permanent implants are more likely tobe detected through the thinned skin. We refer to thisphenomenon as the “snow-melting effect”: after thesnow has largely disappeared in the spring, the snowsurface now follows every stone surface instead of ly-ing perfectly straight (Reinmüller R, pers. comm.).
By far the most popular substance currently usedfor soft tissue augmentation is injectable bovine col-lagen.42,43 The duration of the correction from inject-able collagen depends on the underlying cause and lo-cation of the implant and varies between 6 and 24months.44,45 Autologous fat has to be regarded as anonpermanent implant. Compared to other nonper-manent filler substances, the longevity is equal but notas easily predictable. Under unfavorable conditionsmost of the graft can be lost after 4 weeks, while inother cases the correction lasted up to 7 years, withhistologic evidence of living adipocytes (Figure 2).
While it has been shown that fat augmentation, onaverage, has more staying power than injectable col-lagen,18 some authors consider loss of volume over aperiod of 3 years disappointing.46 Is the glass half fullor half empty? Is an average maintenance of correc-tion of 6 months good or unsatisfactory? We have todetermine our goals in augmentation therapy.
Authors writing on fat transfer share the view thatfatty tissue has a delicate structure that is easily dam-aged by mechanical insults. Neither our own experi-ences nor the evidence from the literature seems tosupport this view. Even if aspirated fat that was storedfor 3 years at 2208C is manipulated multiple timesthrough luer-to-luer adapter, many living cells can befound by trypan blue staining (Figure 1). The majorityof mechanically aspirated fat cells are viable, as wasshown by biochemical assay studies.25 It may be con-fusing if surgeons argue about adipocyte viability afterlipoextraction when at the same time they flash freezethe transplant in liquid nitrogen.47 The principle of
flash freezing is used in cryotherapy for skin cancerand works by destroying cells through the formationof ice crystals, dehydration, and toxic electrolyte con-centrations.48 When storing spermatozoa for furtheruse, the freezing is a complex process that involvesmultiple temperature steps in order to protect the liv-ing cells.
Do we want to transplant living fat cells or fat mi-crodroplets? It is evident that reinjected cell debrissuch as fat droplets will be resorbed by the host tissuein a relatively short time, whereas living cells will per-sist longer or even permanently (Figure 2).
There is some disagreement as to the role of fibro-sis. While some authors think that fibroblasts can onlycause contraction,49 it is certainly true that they canprovide augmentation as well; a good example is be-nign fibrous histiocytoma. On the other hand, somebelieve that the fibrous host reaction may be all thatoccurs in some patients.50 Passot in 1920 stated that itdoes not matter what ultimately happens to the trans-planted fat as long as it fulfills its goal of filling aspace (51, cited by 52).
Conclusion
Longevity of correction after fat transfer depends onthe tissue, mobility, and the vascularity of the ana-tomic recipient site. Fat cells are relatively sturdy anddo survive syringe and medium-power vacuum pumpaspiration equally well. The use of lipoaspiration can-nulas is as effective as a 14-gauge needle for lipoex-traction. Concerning technique, it seems to be impor-tant that only small amounts of fat are transferred andemphasis is placed on careful distribution into the re-cipient tissues.
Figure 2. Viable mature adipocytes as in a lipoma. Excision of apermanent unwanted overcorrection. (Picture courtesy of Drs.Blugerman and Schavelzon, Buenos Aires). Seven years after trans-plantation of aspirated adipose tissue to the dorsum of the hand.(Hematoxylin and eosin; magnification 3400.)
1166 sommer and sattler: fat transfer: histology and literature review Dermatol Surg 26:12:December 2000
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