current concepts of fat graft survival: histology of …...review of the literature and the...

© 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)



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



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

crea

se t

issu

e tr

aum

a an

d bl

ood

in a

spira

te

in t

he f

irst

plac

e

2019

98H

uman

,

N

5

40

Gen

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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



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



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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current concepts of fat graft survival: histology of …...review of the literature and the...

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