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SPECIAL TOPIC

A Classification of Clinical Fat Grafting: Different Problems, Different Solutions


Daniel Del Vecchio, M.D., M.B.A. Rod J. Rohrich, M.D.
Boston, Mass.; and Dallas, Texas

Background: Fat grafting has reemerged from a highly variable procedure to a technique with vast reconstructive and cosmetic potential. Largely because of a more disciplined and scientific approach to fat grafting as a transplantation event, early adopters of fat transplantation have begun to approach fat grafting as a process, using sound surgical transplantation principles: recipient preparation, controlled donor harvest, time-efficient transplantation, and proper postoperative care. Despite these principles, different fat grafting techniques yield impressive clinical outcomes. Methods: The essential variables of four types of fat grafting cases were identified and compared: harvesting, methods of cell processing, methods of transplantation, and management of the recipient site. Results: Each case differed for most of the variables analyzed. The two clinical drivers that most impacted these differences were the volume demands of the recipient site and whether the recipient site was healthy tissue or pathologic tissue. After these two drivers, a matrix classification of small-volume versus large-volume and regenerative versus nonregenerative cases yields four distinct categories. Conclusions: Not all fat grafting is the same. Fat grafting, once thought to be a simple technique with variable results, is a much more complex procedure with at least four definable subtypes. By defining the essential differences in the recipient site, the key driver in fat transplantation, the proper selection of technique can be best chosen. In fat transplantation, different problems require different solutions. (Plast. Reconstr. Surg. 130: 511, 2012.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

or fat grafting to emerge as a mainstream technique, it must be safe, yield reproducible results, and be based on sound surgical principles. What began as a seemingly simple technique of suctioning fat and inserting it in into areas for cosmetic and reconstructive purposes1 has exploded into a complex menu of clinical choices. The four variables commonly considered important to the overall success of fat grafting harvesting, processing, transplanting, and management of the recipient site have evolved into a multitude of techniques, technologies, and opinions about them. As a subset of fat graft processing, we can add fat graft enhancement with a variety of additives including adipocyte-derived stem cells,2 platelet-rich plasma,3 and cell protectants.4 AlFrom Back Bay Plastic Surgery and the University of Texas Southwestern Medical Center. Received for publication December 29, 2012; accepted April 3, 2012. Copyright 2012 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31825dbf8a

though basic scientific investigations often seek to isolate one variable in a system, occasionally such studies may yield conclusions that fail to account for the holistic demands of the clinical situation. All of these factors result in a confusing picture as to which fat grafting technique is best. The purpose of the present work is to develop a matrix classification of fat grafting that seeks to analyze various clinical problems treated with different techniques. By doing so, one can begin to clarify the rationale and selection of fat grafting strategies for various clinical situations going forward.

CASE REPORTS
Case 1: Facial Volume Correction
A 24-year-old woman presented seeking treatment for facial volume wasting. Examination was notable for fat atrophy of the entire upper lip aesthetic unit, with loss of pouting and vertical

Disclosure: The authors have no financial relationships to declare that would create a conflict of interest.

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height of the upper lip, with nasolabial folds and depressions. In the office procedure room under local anesthesia, fat was harvested from her abdomen using a 12-gauge multihole cannula attached to 10-cc Luer-Lok (Becton Dickinson, Franklin Lakes, N.J.) syringes (Fig. 1). Harvested fat was processed using the Telfa-rolling technique (Fig. 2). Lipoaspirate was placed on multiple Telfa (Covidien-Kendall, Mansfield, Mass.) pads to absorb unwanted blood and crystalloid. Fat was then loaded into 3-cc and 1-cc syringes for injection. Injection was performed by means of two 16-gauge needle stab incisions, one in each oral commissure. Placement of graft into the upper lip aesthetic unit, perinasal area, and submalar area was accomplished using an 18-gauge blunt side-hole needle and placing small amounts of fat (0.05 cc) per pass. A pickle-fork cannula was also selectively used to release deep areas of the fold. A total of 8 cc of graft was placed on each side, for a total of 16 cc of grafted material (Fig. 3).

Fig. 2. Case 1. Telfa-roll technique for removing small volumes of unwanted crystalloid and oil.

Case 2: Chronic Wound of the Lower Extremity (Courtesy of Dr. Fabio Caviggioli and Dr. Marco Klinger, Milan, Italy)
An 18-year-old woman presented with nonhealing open wounds of the left leg after being involved in a motor vehicle accident 9 months earlier. At the time of the initial injury, there was exposed peroneal nerve and extensor tendon. One wound measuring 3 5 cm had not healed after 1 year, despite a failed split-thickness skin graft (Fig. 4, above, left). Donor fat was harvested from the abdomen using a standard tumescent solution. Fat was harvested using a blunt, single-hole, 2-mm cannula attached by a Luer-Lok to a 10-cc syringe. Syringes were centrifuged at 3000 rpm for 3 minutes. After centrifugation, the oily layer was absorbed by tissue strips and the lower aqueous layer was removed. Fat was transferred from 10-cc syringes to a 1-cc Luer-Lok syringe that allowed precise control of the amount of injected fat. Graft was injected using a sharp-tipped 18-gauge needle (Fig. 4, above, right). Graft was carefully deposited at the dermal-epidermal junction at the edges of the ulcer. Fat was also grafted directly subjacent to the wound bed. Multiple radiating passages were made through the same insertion site to disperse the fat in different directions. The sharp-tipped 18-gauge hypodermic needle was used to create a tunnel in the fibrotic tissue, and grafting was performed only on axial withdrawal of the needle. The volume of tissue grafted beneath the wound was a function of the size of open wound and scar requiring treatment. As a rule, 1 cc of donor graft was injected for each 2.5-cm2 area of open wound surface. A total of 5 cc of graft was used. Care was taken to avoid overgrafting. The outcome at 3 months after one session of autologous fat grafting demonstrated complete wound closure (Fig. 4, below, left). A second grafting session of the same volume of graft was performed 6 months later to improve the depth and appearance of the scar tissue. At 12 months, there was reduction in depth and in erythema of the scars (Fig. 4, below, right).

Case 3: Primary Core Volume Breast Augmentation Using the Large-Syringe Technique
A 35-year-old woman desired larger breasts and did not want breast implants. She demonstrated relatively symmetric, welldeveloped breasts with no constrictions. She had no family history of breast cancer and did not smoke. She was screened for compliance, and a preexpansion program was developed for her using the Brava System (Brava, LLC, Miami, Fla. ), invented and devised by Khouri.5 A baseline mammogram was obtained before expansion (Fig. 8). After 3 weeks of expansion, she was brought to the operating room, where she underwent liposuction of her thighs using a standard tumescent solution (30 cc of 1% lidocaine with epinephrine, 1:100,000 per liter of normal saline). Machine aspiration at 0.67 atm was used, because less than 1 atm of negative pressure has been reported to have no effect on graft viability.6 Cannulas were 3 to 3.5 mm in diameter and had six to 12 holes as originally described by Khouri.7 Hole sizes on the cannulas were similar to that of the single-hole opening of a 14-gauge Coleman injection needle (Fig. 6). Next, 2500 cc of aspirate was harvested from the thighs and collected into an in-line collection canister (Fig. 7). After discarding unwanted crystalloid, fat was transferred to 60-cc syringes, which were capped and placed on a sterile, hand-crank centrifuge (Fig. 8). Spinning at 30 to 40 g, additional crystalloid and blood were separated from the fat in 3 minutes. The rationale for lowg-force spinning is to efficiently remove unwanted blood and crystalloid, with less potential cell trauma than is seen at 1300 g, when motorized centrifuges are used. The centrifuge held eight 60-cc syringes; 480 cc of fat was processed per 3-minute run. Fat was injected immediately into the breasts using the same syringes. Grafting was performed using a 14-gauge Coleman sidehole needle (Mentor Worldwide LLC, Santa Barbara, Calif.) by means of multiple needle insertion points along the inframammary fold. Care was taken to avoid the superomedial aspect of the

Fig. 1. Case 1. Handheld multihole Luer-Lok cannula, for attachment to a 10-cc syringe.

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Fig. 3. Case 1. The patient is shown before and 6 months after fat grafting to the upper lip aesthetic unit.

Fig. 4. Case 2. (Above, left) Persistent left lower extremity wound 1 year after injury and failed split-thickness skin grafting. (Above, right) Injecting concentrated fat into the subcutaneous compartment around the base of a nonhealing wound requires small volumes; a sharp needle; and a small-caliber, higher pressure syringe. (Below, left) Chronic open wound 3 months after the first fat grafting session. (Below, right) Result 12 months after the first grafting session, 6 months after the second session.

breast, the area of decolletage or exposure in low-cut clothing. A reverse liposuction technique was used, where deliberate backand-forth motion of the needle, in conjunction with slow and steady pressure on the plunger, rendered efficient dispersion of

transplanted fat. One cubic centimeter of fat was injected per second, deploying 60 cc, or one syringe per minute. As each to-and-fro pass took an average of 1 second, 0.5 cc of graft was injected per pass on average. Fat was injected into the subcuta-

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Fig. 5. Case 3. (Left) The Brava external tissue expander worn by the patient. (Right) Three-dimensional breast imaging was performed before expansion and after 3 weeks of expansion, immediately before the fat grafting procedure. External expansion can increase breast size two- to threefold before fat transplantation.

Fig. 6. Case 3. Equalization of hole sizes in harvesting (above and center) and injecting (below) cannulas. Such a system selects for fat lobular size at the time of harvest in an attempt to minimize pressure-induced shear trauma during reinjection.
neous space of the breast and not directly into the breast tissue. A fanning pattern with was used to keep the cannula moving at all times; 550 cc was injected into each breast (Fig. 9). In 2 hours, the patient underwent harvesting, processing, and grafting. Postoperatively, the breasts were covered with Xeroform (Covidien, Mansfield, Mass.) sheets. The patient was instructed not to compress the breasts for a period of 4 months. At 6 months after grafting, the patient returned for threedimensional imaging. Quantitative determination of breast volume at 6 months revealed an increase in volume of 300 cc, or a doubling of original breast volume (Fig. 10).

Case 4: Core Volume Breast Reconstruction in Irradiated and Nonirradiated Mastectomy Sites Using Preoperative and Postoperative Expansion, Large-Syringe Technique, and Three-Dimensional Parenchymal Release
A 45-year-old woman desired breast reconstruction with autologous fat. She had a bilateral mastectomy 3 years earlier and had undergone left-sided radiation therapy. She had never had reconstructive surgery and did not desire breast reconstruction

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Fig. 7. Case 3. The in-line machine system for fat collection. From the 12-gauge, six-hole liposuction cannula, a sterile collection canister (above) is placed in line with tubing connected to the standard machine aspirator canister (top of nonsterile canister shown in red). Fat is then transferred into 60-cc syringes from this sterile canister. Note that the patient is under general anesthesia on the sterile field in the lateral decubitus position.

with muscle flaps or implants. Physical examination demonstrated bilateral mastectomy sites, with the right, nonirradiated side having more pliable skin than the left, which demonstrated relative immobility to the chest wall and a depressed scar. A four- to five-stage bilateral breast reconstruction was planned and was discussed with the patient. She was initially screened for compliance and a program of preexpansion was developed for her (Fig. 11). After 3 weeks of daily expansion, she was brought to the operating room, where she underwent fat harvesting similar to the technique described in case 3. Then, 1200 cc of aspirate was harvested from her abdomen and processed in a manner similar to that in case 3. Because serial sessions were planned, only fat intended to be grafted was harvested. Once the fat was processed in 60-cc syringes using low-g-force centrifugation as in case 3, the fat was injected into the expanded mastectomy sites using a 14-gauge Coleman side-hole needle (Mentor) by means of multiple insertion points along the planned inframammary fold. Care was taken to avoid needle sticks in the superomedial aspect of the breast. On the right, nonirradiated chest, a reverse liposuction technique was used, transplanting 390 cc of graft material into the right side. On the left, irradiated chest, a much slower, deliberate technique was used, with a 14-gauge pickle-fork cannula. Care was taken to advance the injection cannula slowly within the thickened and scarred tissue, and to inject graft material only on axial withdrawal of the cannula. Care was taken not to overgraft the irradiated chest subcutaneous tissue. Percutaneous release of internal scar tissue tethering the skin to the chest wall was performed to allow more fat to be injected and to improve mound shape, as described by Rigotti et al.8 Only 180 cc of processed fat was transplanted into the left breast, or approximately 50 percent of the volume transplanted into the right side (Fig. 12). Postoperatively, bismuth-impregnated sheets covered the mounds for 48 hours, followed by external expansion for an additional 3 weeks. The process of preexpansion and fat

Fig. 8. Case 3. (Above, left) Aspirate separates out at 1 g and unwanted crystalloid is tapped off. (Above, right) Fat is loaded into 60-cc syringes. (Center) View of low-g-force centrifugation showing additional crystalloid separating out from fat. (Below, left) Syringes that are filled with what appears like pure fat drawn up at 1 g, before spinning, actually separate out 20 to 30 percent additional crystalloid (below, right) using low-g-force centrifugation. Omitting this step reduces long-term volume maintenance, or percentage yield, by 20 to 30 percent before the procedure is even finished.

grafting was repeated two additional times, spaced 4 months apart. With each subsequent session, expansion volumes and grafting volumes increased. The nonirradiated right breast expanded and augmented consistently larger than the left breast each time. After three stages, the patient was pleased with her reconstruction and did not desire additional grafting (Fig. 13).

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Plastic and Reconstructive Surgery September 2012 COMPARISON OF TECHNIQUES


Table 1 summarizes the essential strategic differences in harvesting, processing, transplanting, and recipient-site management in each of the cases. In the smaller volume cases of facial atrophy and chronic wound fat grafting, adequate amounts of fat were harvested using a hand-held syringe. Although less time efficient, the small volumes of fat required in these cases did not impact time inefficiency. In addition to the smaller volumes required, the smaller cannula sizes and smaller cannula hole sizes resulted in a smaller lobular size of graft material. Small lobules of graft are desirable in more volume-sensitive areas such as the face and at the periphery of nonhealing wounds. Methods of separating unwanted blood and crystalloid also varied. In lower volume cases of fat grafting to faces and wounds, separation of fat using Telfa rolling and high-speed centrifugation of 10-cc syringes in a motorized centrifuge did not

Fig. 9. Case 3. Reverse liposuction technique for time-efficient transplantation of large volumes of graft. At an injection rate of 1 cc/second, one 60-cc syringe can be transplanted per minute. For 550 to 600 cc of graft injected, this takes approximately 10 minutes.

Fig. 10. Case 3. (Left) Preoperative views of the breast with quantitative volume measurements (right breast, 240 cc; left breast, 313 cc). (Right) Postoperative views of the breast at 6 months with quantitative volume measurements (right breast, 546 cc; left breast, 606 cc). The volume increase was 306 cc on the right and 293 cc on the left.

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Fig. 11. Case 4. (Left) Preoperative external expansion of the recipient site works differently in irradiated tissue (left breast) compared with nonirradiated tissue (right breast). (Center) The Brava external tissue expander was worn by the patient 3 weeks before the fat grafting procedure. (Right) After expansion, note that the nonirradiated side is already convex, the mastectomy scar being lifted, whereas the irradiated side demonstrates edematous skin and a depressed mastectomy scar, clefting the mound in half.

Fig. 12. Case 4. (Left) Reverse liposuction technique used to transplant 390 cc of fat into the supple, nonirradiated, right-side chest tissue in the first-stage breast reconstruction in a bilateral mastectomy patient. Note the previously irradiated, left-side breast mound in the upper part of the photograph has already been transplanted with 180 cc of graft yet appears much flatter. A much more deliberate injection method, injecting only on retrograde axial withdrawal, is used in heavily scarred tissues such as irradiated mastectomy skin flaps. (Right) After fat is transplanted into the irradiated left breast area, the depressed scar persists and is lifted by percutaneous three-dimensional mesh release. Using a 16-gauge needle, bands are released in three dimensions by means of multiple percutaneous approaches. Adjacent fat then fills in the released areas and acts as a spacer to maintain the desired shape changes.

greatly impact overall procedural time because the low volume of graft required did not impact the time inefficiency of the separation technique. In contrast, larger volume cases of breast augmentation and breast reconstruction required a more time-efficient fat-processing strategy using lowspeed centrifugation of large syringes, albeit less effective than high-speed centrifugation of large numbers of 10-cc syringes in a motorized unit. Injection techniques also varied widely across recipient sites. In case 1, fat was used as simple

filler to increase volume in specific facial fat compartments. Because facial fat compartments are pliable, have identifiable vessels that run along their boundaries, are well delineated, and are occupied by recipient site fat,9 a relatively timeefficient injection technique can be used. In contrast, in the chronic nonhealing leg wound (case 2), a sharp needle was used to introduce graft into heavily indurated and chronically inflamed recipient tissue. Hypodermic needles were used to sharply dissect a channel into fi-

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Fig. 13. Case 4. (Above) Baseline photographs of a patient after bilateral mastectomy with radiation treatment on the left side, before preexpansion. (Below) Six months after three sessions of preexpansion and fat grafting. Note the smaller breast mound on the left, irradiated side. Such asymmetry could be corrected with additional grafting on the left side.

brotic scar, into which a core of fat was deposited on axial withdrawal. This strategy of fat deployment, on both technical and flow-rate bases, is markedly different from more aggressive techniques seen in nondiseased subcutaneous tissue such as the reverse liposuction technique (case 3), where blunt cannula dissection was used and fat was injected in a to-and-fro manner on both insertion and withdrawal. In indurated but expanded irradiated tissue (case 4), a crossover between sharp hypodermic needles and blunt needles (the pickle fork) was used. Recipient-site external preexpansion was used in both of the larger volume fat transplantation cases. In these situations, the existing soft-tissue capacity of the recipient site was insufficient to host enough transplanted fat for the desired clinical volu-

metric endpoint. Finally, additional expansion after grafting was not used in simple augmentation (case 3) but was used in reconstruction (case 4). When fat grafting is used for breast reconstruction following mastectomy, either in irradiated or nonirradiated tissue, a final desired core volume enhancement cannot be attained in a single procedure and requires serial grafting of three to five stages.10 Therefore, in breast reconstruction with serial fat grafting, each postoperative phase is also the preoperative phase of the subsequent session, justifying the rationale for expansion in the postoperative period. After this logic, the final fat grafting session in a reconstruction patient is like a primary one-stage augmentation with fat and does not routinely require postoperative expansion.

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Table 1. Details of Harvesting, Processing, Transplanting, and Recipient-Site Management
Variable Harvesting Vacuum source Vacuum amount Cannula Cannula holes Cannula hole size Processing Technique g force on graft Processing time Injecting Cannula Technique Volume Flow rate Recipient site Pathology Pretreatment Postgraft manipulation Case 1 10-cc syringe Unknown 12-gauge 6 1 1 mm Telfa NA 5 min/60 cc 18-gauge blunt Retrograde 16 cc 1 cc/min Facial, volume None None Case 2 10-cc syringe Unknown 3-mm 3 1 1 mm Machine centrifuge 1300 g 3 min/80 cc 18-gauge sharp Retrograde 5 cc 0.5 cc/min Wound, regenerative Dressings Minimal release of nasolabial bands Case 3 In-line machine 50 cm Hg 3-mm 912 2 3 mm Hand centrifuge 40 g 3 min/480 cc 14-gauge blunt Reverse liposuction 1100 cc (550 each) 60 cc/min Breasts, volume External expansion Minimal three-dimensional parenchymal release Case 4 In-line machine 50 cm Hg 3-mm 912 2 3 mm Hand centrifuge 40 g 3 min/480 cc 16-gauge blunt/pickle fork Both 570 cc (190 left) 30 cc/min Breasts, regenerative External expansion Major three-dimensional release, postoperative expansion

DISCUSSION
Giorgio Fischers initial idea of removing unwanted fat by means of an abortion cannula was discovered by Illouz,12 who introduced the concept of liposuction to Europe and the Americas and fat grafting by lipoaspirate reinjection first became possible. Fat grafting for reconstruction and/or cosmetic purposes was initially described in the late 1980s,13 but it was not until the 1990s when Coleman outlined a standardized reproducible process of fat harvesting, centrifugation, and injecting into the face that structural fat grafting14 could be reliably replicated and a reproducible technique became more clear. Like early grafting in the face, fat grafting to the buttocks and breasts was also initially described in the late 1980s,15,16 but larger volume applications, especially to the breast, were met with more criticism, and were placed on standby for the next 20 years because of published concerns regarding patient safety and lack of efficacy.17 If skin grafting took centuries to evolve as a viable procedure, one should consider the progress that has been made over the past three decades with fat. The clinical development of skin grafts followed an empirical progression, dependent on graft physiology, available technology, and the clinical requirements and the capacity of the recipient site. The search for ideal skin graft thickness leads us to the concept of ideal lobular size in fat transplantation (Figs. 14 and 15). Graft size on the order of single cells in suspension lack stromal elementsfibroblasts, connective tissue, and
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blood vessels. Although individual cells may have the potential to survive better by diffusion, they ultimately may not serve as ideal targets for angiogenesis. On the other extreme, grafts that are too large may suffer central necrosis because of a lack of both adequate diffusion and adequate angiogenesis. Whatever the ideal lobular size is for fat transplantation, there also exists an ideal lobular size requirement based on the specific practical and aesthetic demands of the recipient site. For example, if 2-mm fat lobules were eventually demonstrated to be ideal for graft survival, it might still not be practical to use such large lobules in the eyelids. Conversely, if 500- m graft size turns out to be optimal, it may not make practical sense to use such small graft sizes in megavolume applications. Extracorporal Anoxia Time and Selection of Processing Technique Time-efficiency (optimization) versus effectiveness of technique (maximization) is a critical workflow concept in fat transplantation. Selection of technique comes into play because cells subjected to frank anoxia suffer an increasing likelihood of apoptosis and cell death, as extracorporal anoxia time increases. The negative effects of extracorporal anoxia time potentially outweigh the benefit of the chosen technique, if the chosen technique takes too long to perform. This principle may partly explain the rationale for the differences seen in some of the fat graft processing choices used above.

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Fig. 14. Fat transplantation and different lobular size. Fat harvested with a 3-mm, 12-hole cannula, after separation at 1 g, does not demonstrate a simple bilayer of fat and crystalloid, but separates out to at least five layers based on density and size. The white layer at the bottom may represent individual cells. Ideal graft size as it relates to graft survival is currently unknown.

Fig. 15. Optimal lobular size in fat grafting. Although there may be a theoretical singular ideal lobular size for fat graft survival, there may be different lobular size requirements based on the recipient site that can all fall into an acceptable survival range.

Opposing Theories of Volume Maintenance after Fat Grafting Similar to the physiology of skin grafts, the socalled diffusion/angiogenesis theory of fat grafting suggests that donor adipocytes survive by oxygen diffusion in the recipient site during the initial days after grafting, with eventual microangiogenesis and the formation of a viable blood supply to the grafted stroma. Overcrowding or excessive interstitial pressure in the recipient site is thought to interfere with diffusion, which leads to cellular death, apoptosis, and loss of graft volume. An alternative theory of graft physiology is based on the recent experimental work of Hofer et al., who demonstrated adipocyte proliferation and angiogenesis in a perforated hollow tube filled with Matrigel (BD Biosciences), a nonviable poly(D,L-lacticco-glycolic acid) sponge matrix that was implanted into the groins of rats.18 In the so-called scaffold or matrix theory, historically rooted in Peers host replacement theory,19 all or most of the transplanted adult adipocytes are destined to die, and act as a nonviable scaffold, through which macrophages penetrate and through which stem cellmediated angiogenesis and adipogenesis occurs. Cytokine induced cell-cell signaling between living and dying, and between donor and recipient cells, is thought to play a role in this process.20 A third consideration, a tandem theory, lies somewhere between the two opposing theories: that an element of adult adipocyte survival occurs by diffusion angiogenesis and those cells that do not survive form a biological scaffold for macro-

phage and induction of angiogenesis and stem cellmediated adipogenesis. In small-volume fat grafting, diffusion may play a more significant role; in large-volume grafting, more cells may not survive and the scaffold effect may play a relatively greater role. Further clinical and basic science work will clarify the various weights of these two theories and how they might vary in different recipient sites. The Recipient Site and Grafting Strategy The transfer of technologies and techniques helps drive innovation in plastic surgery. However, one may fail to recognize the subtle changes that may be necessary to adopt the technology or technique for a new clinical application. The 10-mmdiameter, single-hole liposuction cannulas of the 1980s turned out to be impractical for cosmetic liposuction. As obvious as that seems today, it may be equally impractical to apply the championed small-volume techniques of facial structural fat grafting to the large-volume demands of breast or buttock augmentation. Recipient-site preparation in the form of preexpansion is unnecessary and impractical in the face but may be critically important in megavolume fat grafting. In general, when the capacity of the recipient site is exceeded by the volume of fat graft required to achieve the desired cosmetic or reconstructive result, preexpansion in the breast is currently used. Not all fat grafting strategies need to be the same (Fig. 16). Fat grafting, once considered a singular procedure, has emerged as a multivariate technique with different recipient-site demands for different applications. The 220- to 600-cc vol-

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Fig. 16. A matrix classification of fat grafting. The correct strategy for fat grafting must take into consideration the relative volume requirements and the regenerative demands of the recipient site.

umes of graft used in megavolume fat transplantation21 required for effective breast and buttock augmentation must be distinguished from the smaller volume fat grafting needed to improve facial contour defects or to heal ulcers and smooth scars. As such, the technical strategies of large- versus small-volume fat grafting must be considered differently. The newly emerging regenerative aspect of fat grafting22 adds a second dimension to the matrix. Not simply filler, some grafting strategies seek to improve tissue abnormality in the recipient site, as in cases of irradiated mastectomy sites or in the case of open chronic wounds. What was once thought of as a simple procedure can therefore be expanded into four strategies focusing on the needs and capacity of the recipient site (i.e., the volume required at the recipient site and the regenerative demands at the recipient site).

Daniel Del Vecchio, M.D., M.B.A. Back Bay Plastic Surgery 38 Newbury Street Boston, Mass. 02116 dandelvecchio@aol.com

ACKNOWLEDGMENTS

The authors acknowledge Dr. Fabio Caviggioli and Professor Marco Klinger, of Instituto Clinico Humanitas, Milan, Italy, for their assistance with this article.
PATIENT CONSENT

Patients provided written consent for use of their images.


REFERENCES
1. Illouz YG. The fat cell graft: A new technique to fill depressions. Plast Reconstr Surg. 1986;78:122123. 2. Lu F, Mizuno H, Uysal CA, Cai X, Ogawa R, Hyakusoku H. Improved viability of random pattern skin flaps through the use of adipocyte-derived stem cells. Plast Reconstr Surg. 2008;121: 5058. 3. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile P. Autologous platelet-rich plasma mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plast Surg. 2009;33:716721. 4. Murphy A, McCormack M, Bichara D, Nguyen J, Randolph M, Austen W. Poloxamer 188 significantly decreases muscle necrosis in a murine hindlimb model of ischemia reperfusion injury. Paper presented at: 25th Annual Meeting of the Northeastern Society of Plastic Surgeons; October 25, 2008; Philadelphia, Pa. 5. Khouri R. Follow up on the BRAVA non-surgical breast expansion. Paper presented at: American Society for Aesthetic Plastic Surgery Annual Meeting; May 17, 2008; San Diego, Calif.

CONCLUSIONS
Thirty years after the inception of lipoaspirate injection, autologous fat transplantation has evolved from an underrated, oversimplified procedure to at least four different strategies that take into account harvesting technique, lobular size, processing of the graft, injection technique, and the specific requirements of the recipient site. As the true physiology of unmanipulated and stem cell enriched fat grafts becomes better delineated, our choices for technical solutions will better fit the clinical problems we face.

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6. Shiffman M, Mirrafati S. Fat transfer techniques: The effect of harvest and transfer methods on adipocyte viability and review of the literature. Dermatol Surg. 2001;27:819826. 7. Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autologous fat transplantation. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2011:13741400. 8. Rigotti G, Marchi A, Khouri R. Minimally invasive autologous mastectomy incisionless reconstruction; external expansion fat grafting and percutaneous scar release: A multicenter experience. Paper presented at: 88th Annual Meeting and Symposium of the American Association of Plastic Surgeons; March 2125, 2009; Rancho Mirage, Calif. 9. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2009;123:695700. 10. Khouri R, Del Vecchio D. Breast augmentation and reconstruction using pre-expansion and fat grafting. Clin Plast Surg. 2009;36:269280. 11. Fischer G. Surgical treatment of cellulitis. Paper presented at: Third Congress of the International Academy of Cosmetic Surgery; May 31, 1975; Rome, Italy. 12. Illouz YG. Body contouring by lipolysis: A five year experience with over 3000 cases. Plast Reconstr Surg. 1983;72:591597. 13. Teimourian B. Repair of soft-tissue contour deficit by means of semiliquid fat graft. Plast Reconstr Surg. 1986;78:123124. 14. Coleman SR. Structural fat grafting. Plast Reconstr Surg. 2005; 115:17771778. 15. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue augmentation. Plast Reconstr Surg. 1989;84:921934. 16. Bircoll M. Autologous fat transplantation. Plast Reconstr Surg. 1987;79:492493. 17. Fredericks S. Fat grafting injection for soft tissue augmentation (Discussion). Plast Reconstr Surg. 1989;84:935. 18. Hofer SO, Knight KM, Cooper-White JJ, et al. Increasing the volume of vascularized tissue formation in engineered constructs: An experimental study in rats. Plast Reconstr Surg. 2003;111:11861192; discussion 11931194. 19. Billings E Jr, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg. 1989;83:368381. 20. Suga H, Eto H, Aoi N, et al. Adipose tissue remodeling under ischemia: Death of adipocytes and activation of stem/progenitor cells. Plast Reconstr Surg. 2010;126:19111923. 21. Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous fat transplantation: A clinical radiological study. Plast Reconstr Surg. 2011;127:24412450. 22. Caviggioli F, Malone L, Forcellini D, Klinger F, Klinger M. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg. 2011;128:349352.

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