Current Clinical Applications of Fat Grafting (original) (raw)

2017, Plastic & Reconstructive Surgery

he results are amazing but inconsistent." This was the sentiment surrounding free flaps in the 1980s. We discovered a naturally occurring inhibitor of coagulation that prevented anastomotic thrombosis in the laboratory 1 and conducted a double-blinded, controlled, randomized study to assess its benefit in free flaps. Disappointingly, there was no significant effect. 2 When we dissected why free flaps fail, we realized that success depended on multiple factors chain-linked in series, and that the anastomosis was not always the weakest link. 3 Free flaps became a reliable procedure when we abandoned the search for a panacea and realized that success required exacting surgical technique. This history illustrates the concept that, in a multivariable process, optimizing a single variable does not necessarily improve the outcome; the entire process must be taken into consideration. Similarly, autologous fat transfer has opened many applications in reconstructive surgery with amazing results, but many dismiss it as inconsistent. Although many individual technical factors have been singled out as being responsible for graft take, it has become clear that no single additive or processing method can serve as a panacea. 4-11 Favorable results can be consistently obtained by following established principles and techniques. Fat graft surgery should be approached with the same degree of craftsmanship as microvascular free flap surgery. 12,13 This article reviews the established principles of fat graft survival, elaborates on the surgical techniques that adhere to these principles, and provides an overview of the clinical applications. PRINCIPLES OF GRAFT SURVIVAL What Is Fat? Over 90 percent of adipose tissue volume consists of adipocytes, but nearly 50 percent of the in vivo adipose tissue total cell number consists of adipose-derived stem cells, fibroblasts, endothelial cells, and pericytes in an extracellular matrix. 14 Although fat was initially thought to be an inert substance for energy storage, recent research has elicited its regenerative capabilities. Many studies have demonstrated the regenerative potential of autologous fat transfer, presumably because of its adipose-derived stem cell content. This includes angiogenesis, 15 peripheral nerve regeneration, 16 enhancement of dermal thickness and elasticity, 17 reversal of fibrosis (secondary to radiation therapy, 18,19 scarring, 20 Disclosure: Roger K. Khouri has equity interest in LipoCosm, the manufacturer of the LipoGrafter. He is the inventor of Brava, the original External Vacuum Expander, but he no longer has any financial interest in Brava, LLC. Roger K. Khouri Jr. has no conflicts of interest to disclose.