New concepts in fat grafting

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CHAPTER 61 New concepts in fat grafting

Ewaldo Bolivar de Souza Pinto, Paulo R. Carneiro, Leonora d’Ascensão Mansur, Rodrigo Federico

History

In the 1980s, an important step was taken in body contour surgery, resulting in the liposuction procedure. It was based on the introduction of a large caliber cannula and aspiration of fat tissue, previously marked. This technique was initially abandoned, because the medical community was not convinced that the technique produced good results; also, there were concerns about the aggressiveness of the procedure, as well as potential injury to adjacent tissues. However, with the technique’s evolution, diverse instrumentation was developed, particularly regarding the types of cannula. Changes were made to caliber and tip configuration.

Nowadays, two types of liposuction are known: the dry technique, using no infiltrate, with the intention of making the fat tissue undermining easier; and the humid technique, that uses the infiltration of physiological saline or Ringer’s lactate associated with other substances, with the intention of promoting a more turgid tissue and reducing blood loss.

Histologically, the presence of two different fat layers in some body areas enabled the development of two techniques of liposuction: (1) deep liposuction, that covers the lamellar layer; and (2) superficial liposuction, that reaches both the lamellar and areolar layers, leading to skin retraction and better results on the contour of the treated areas.

Fat grafting, currently a widely used procedure, has undergone important changes along with liposuction. It is known that the first fat graft was described by Neuber in 1893; another important contribution was given by Pier in 1956, reporting that 50% of the infiltrated fat remained.

The fat grafting performed by us since 1985 has evolved, along with the methods of obtaining fat, and processing of the tissue.

Histology of the fat tissue

The fat cells are also known as adipocytes. When a certain tissue is composed almost uniquely of fat cells, organized in lobes, it is termed adipose tissue.

The fat cell lobes are separated from each other by “walls”, divisions of loose conjunctive tissue that support them. We also observe blood vessels and nerves in the interior of the fat tissue.

Inside the lobe, the fat cells are supported by the stroma, which is comprised of collagen and reticular fibers, arranged in an interspersed net shape.

Technical steps

Method for obtaining fat

Many body areas can be used to obtain fat; however, as a standard pattern for small grafts, we recommend the inner part of the knees, with a volume varying between 5 and 10 mL of fat. Where there is a need for greater amounts of fat, we then opt for areas like the abdomen, “saddlebags”, and other areas with a high percentage of fat.

We use the superficial liposuction technique to collect fat, reaching both lamellar and areolar layers. The sequential method for obtaining and preparing the fat is described below.

The first step, after asepsis, no matter what kind of anesthesia is chosen, is to infiltrate saline solution with the following proportions:

• 500 mL of Ringer’s lactate or saline solution.

• 20 mL of lidocaine 2%.

• 1 mL of adrenaline 1 : 1000.

• 3 mL of sodium bicarbonate 8.4%.

We then proceed with the liposuction, using cannulas of 3 to 6 mm caliber. The obtained fat is aspirated with a pressure around 370 mmHg, with the intention of protecting the fat cell. Studies have shown that higher pressures can damage the fat cell (Fig. 61.1).

image

Fig. 61.1 Obtaining fat.

We have evaluated the pressure variation and its effect on percentage of cell viability. We used five samples for each pressure value (between 370–590 mmHg):

1. Fat gathered with no special preparation.

2. Saline solution added to the fat and then sieved.

3. Fat that passed through the sieve (Fig. 61.2).

4. Fat retained in the sieve, injected with a 40 × 12 mm needle.

5. Fat injected with graft cannulae (Fig. 61.3).

image

Fig. 61.2 Passing fat through sieve.

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