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Lipofilling: Critical points for successful fat grafting

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Autologous fat grafting is the method of choice for soft tissue filling in aesthetic and reconstructive surgery. However, protocols differ between physicians who are still confronted with graft resorption and variable clinical outcomes. Adipose graft survival rates vary considerably depending on the method of harvest, the method of adipose tissue processing, the method of injection, and the vascularity of the recipient site. Based on various studies and the authors’ experience, this review summarizes the critical points that may influence the quality of adipose grafts, from liposuction to adipose tissue injection. Some recommendations are provided in order to optimize the overall procedure of lipofilling and to improve long-term survival of grafted tissue. KeywordsLidocaine · Liposuction · Adipose tissue processing · Centrifugation · Adipose-derived stem cells
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English version of „Lipofilling: kritische Punkte
einer erfolgreichen Fetttransplantation”
J Ästhet Chir 2014
DOI 10.1007/s12631-013-0296-2
© Springer-Verlag Berlin Heidelberg 2014
A.-C. Girard · V. Hivernaud · J. Gauthier · F. Festy · R. Roche
ADIP’sculpt , Platform CYROI, Sainte Clotilde, Reunion Island
Lipofilling: critical points 
for successful fat grafting
Introduction
Autologous fat grafting is a popular and
widely used procedure to fill soft tis-
sue for aesthetic and reconstructive pur-
poses. However, a major problem of this
technique lies in adipose cell death which
leads to graft resorption and, thus, to vari-
able clinical outcomes. From liposuction
to adipose tissue injection in the recipient
site, various factors influence the quality
of the graft. There are many parameters
and no standardized procedures; thus, the
aim of this article is to discuss the main
critical issues that may affect graft surviv-
al, through a review of the literature and
the authors’ own experience.
Adipose graft components
First, adipose grafts are not just a mat-
ter of adipocytes providing volume in
the treated area. All adipose tissue cells
must be considered to better overcome
the various critical points that may con-
tribute to fat necrosis. It is now well es-
tablished that adipose stromal cells play
a key role in adipose graft survival [3, 18,
29]. The adipose stromal vascular frac-
tion (SVF) comprises a heterogeneous
cell population containing progenitor
cells, vascular endothelial cells, hemato-
poietic cells, and the famous adipose-de-
rived stem cells (ADSCs) discovered in
the early 2000s [30]. In the context of li-
pofilling, SVF cells, including ADSCs, al-
low adipocyte differentiation, exert para-
crine effects that may contribute to tro-
phic effects in some clinical outcomes
(e.g., improvement of skin quality after
burns, improvement in wound healing),
and contribute to revascularization of the
graft.
»
Adipose cell necrosis in
autologous fat grafts leads
to graft resorption and
variable clinical outcomes
Eto et al. [6] examined adipose tissue re-
modeling thanks to SVF cells and they de-
scribed a typical scheme of a nonvascular-
ized graft with surviving cells in the pe-
riphery (the surviving area), then an area
corresponding to fat cell dying and being
renewed thanks to adipose-derived stro-
mal cells (the regenerating area), and the
most central part corresponding to ne-
crosis of both adipocytes and adipose-
derived stromal cells (the necrotic area).
Thereby, it is important to optimize all
the steps of lipofilling—from liposuction
to injection—in order to preserve all cells
within adipose tissue and to improve fat
grafting.
Many parameters can influence the
quality of the graft: duration and quali-
ty of the infiltration (effects of adrenaline
and local anesthetics like lidocaine), lipo-
suction technique and type of cannula,
fat preparation (e.g., decantation, wash-
ing, centrifugation), and fat injection [25,
27]. In order to determine how to improve
the quality of the grafts (in a simple way),
these parameters are discussed hereafter.
Infiltration
Since the first autologous fat transfer by
Neuber (1893), a major advancement was
the development of liposuction in the
1970s, followed by the technique of tu-
mescent liposuction [16, 25]. Besides al-
lowing for simple local anesthesia when
general anesthesia is not needed, tumes-
cent liposuction also ensures better and
easier harvest of adipose tissue. The pre-
tunneling technique is used to distribute
the tumescent fluid in the sampling area,
which allows a suspension of adipose cells
to be made, while limiting damage [1]. It
is suggested to infiltrate an equal volume
of liquid compared to volume of fat to be
removed (e.g., 100 ml of liquid for 100 ml
of fat) [25]. It is also important to distrib-
ute the tumescent solution slowly and ho-
Fig. 1 7 The liposuc-
tion technique and the
type of cannula used
are important factors
for successful fat graft-
ing. Micro-sampling is
recommended to har-
vest small lobules of
adipose tissue and im-
prove vascularization
of the grafted tissue
1Journal fürÄsthetischeChirurgie ·2014
|
Übersichten
mogeneously in order to facilitate harvest-
ing (the fluid being a carrier of the adi-
pose tissue) and to provide better patient
comfort [1].
However, the use of tumescent local
anesthesia is another critical point for
autologous fat grafting: local anesthetics
(LAs) are known to impair adipose stem
cell proliferation, differentiation, and are
cytotoxic with long exposure and when
high doses are used [8, 14]. Lidocaine,
which has been shown to be less cytotoxic
than other LAs, is the most common LA
used for liposuction and is often mixed
with adrenaline in the tumescent fluid,
in order to limit bleeding [9]. Adrenaline
which is highly diluted (up to 1:1,000,000)
does not seem to impair adipose cell via-
bility at those low concentrations. Howev-
er, even low doses of lidocaine (<0.8 mg/
ml) can have deleterious effects on the
graft when adipose tissue processing is not
appropriate. Indeed, it has been reported
that washing and centrifuging the fat pri-
or to its injection was an effective way to
avoid this infiltrated drug effect, thus, pre-
serving the cells and ensuring better graft
efficiency [8, 10, 12].
»
Local anesthetics impair
adipose stem cell proliferation,
differentiation, and are cytotoxic
with long exposure times
or high concentrations
Thus, caution is required when using LAs.
From various studies and the authors
point of view, physicians should use low-
dose lidocaine (<0.8 mg/ml, i.e., a maxi-
mum of 20 ml lidocaine 2% in 500 ml sa-
line) and infiltration should not be pro-
longed to avoid time-dependent cytotox-
icity of the drug.
Liposuction
For liposuction, the main concern is re-
lated to the type of cannula used and the
negative pressure applied to aspirate the
fat. First, the size of the cannula is impor-
tant to consider. Despite controversies
regarding the use of a large [5] or thin
liposuction cannula (OD <3 mm) [11],
some physicians tend to use a thinner
cannula for smoother results, less bruis-
ing, and less pain for the patient. For li-
pofilling, it is also recommended to use a
cannula with small holes in order to har-
vest small lobules of fat, thus, improv-
ing revascularization of the grafted tis-
sue (. Fig. 1, [22]). Moreover, these au-
thors harvest adipose tissue with a 10 ml
syringe to exert a 2 ml negative pressure
and avoid damage.
»
Using a cannula with small
holes to harvest small lobules of
fat improves revascularization
of the grafted tissue
Regarding negative pressure, controver-
sies also remain about the impact of neg-
ative pressure on adipose graft viabili-
ty and the use of manual syringe liposuc-
tion or a vacuum device. Some studies
have shown that higher vacuum leads to
higher adipose cell death and lower graft
survival [20, 26]. For example, Mojallal
et al. [20] reported that a negative pres-
sure of −700 mmHg is harmful for SVF
cells compared to −350 mmHg pressure.
In fact, high negative pressures for lipo-
suction tend to decrease adipose tissue
survival, as shown in the authorsstudy
(.Fig. 2) where negative pressure of
50 ml led to more than a 2-fold increase of
oil (corresponding to fat necrosis), com-
pared to 10 ml negative pressure.
Besides syringe liposuction and aspi-
rator devices, other types of liposuction
have been studied (e.g., ultrasound-assist-
ed liposuction [7]), but further research is
needed to clearly verify safety of such a
technique on adipose tissue.
Fat preparation
Colemans [2] technique has been used
worldwide and has become an interna-
16%
14%
12%
10%
8%
6%
4%
2%
0%
% oil volume relative
to total adipose tissue
negative pressure of 10 ml
negative pressure of 50 ml
*
Fig. 2 8 Effect of negative pressure on adipose tissue. Adipose tissue was
harvested from a healthy patient in two different manners: with negative
pressure related to 10 ml of a 60 ml syringe, and by pulling the plunger for
a 50 ml negative pressure. Adipose tissue was then decanted before being
plated in 24-well plates for tissue culture (12 wells per condition). The % of
oil was measured after 48 h of adipose tissue culture (Student test *p<0.05)
Fig. 3 9 Summary di-
agram of the various
critical points of lipo-
filling and principal
recommendations
2
|
Journal fürÄsthetischeChirurgie ·2014
Übersichten
tional reference. This technique allows
atraumatic manipulation of adipose tis-
sue before its reinjection. However, de-
spite the major advances made by Cole-
man, the technique is still not perfect
since maintenance of the graft is not opti-
mal. Thus, over time, surgeons have tried
to refine this protocol to further optimize
cell survival and further enhance the aes-
thetic results.
While Colemans technique includes a
centrifugation step (3000 rpm for 3 min),
allowing fat to be concentrated and infil-
tration liquid to be removed, some oth-
er study results are controversial and
use decantation of adipose tissue instead
of strong centrifugation [4, 13]. Indeed,
strong centrifugation has been shown to
impair adipose cells viability, but authors
of such studies suggest that centrifugation
up to 1200 g for 3 min seems to be safe [15,
17, 28].
From the authorspoint of view, this
suggested centrifugation is still quite high
and long; thus, soft centrifugation (400 g
for 1 min), preceded by washings (at least
2), seems to be the most appropriate pro-
tocol for the re-injection of adipose tissue.
This protocol allows removal of toxic mol-
ecules coming from infiltration (e.g., lido-
caine) and that can be deleterious for the
graft [10, 12]. Centrifugation also allows
compacting of the fat with removal of in-
terstitial liquid which is one cause of graft
volume loss after injection.
»
Washing followed by
soft centrifugation removes
deleterious contaminants
and compacts the fat cells
Washing adipose tissue is also controver-
sial, but more and more studies point in
this direction as washing allows the cells
to regain their function, removes delete-
rious contaminants, and ensures the qual-
ity of the graft [4, 8, 10, 12, 21]. Anoth-
er method to purify adipose tissue con-
sists of filtration through a cotton towel
or cotton gauze [19, 23, 24] but this open
method may be harmful to tissue which
is in the open air (oxidation) and is also
more exposed to potential external con-
taminants.
Injection
Fat injection is the last critical step of the
lipofilling procedure. The protocol of in-
jection has been well refined in recent
years, leading to better results and less
trauma for the patient.
»
Improved results with
injection of tissue in different
layers using low pressure,
small quantities per passage
and limited tunneling
From various studies [22, 23, 25], an ap-
propriate method consists of
F injection with a “retrogrademethod
(e.g., removal of the cannula during
injection, in order to apply low pres-
sure on the tissue),
F injection of the tissue in different
layers to create a three-dimensional
network,
F injection of very small quantities of
tissue per passage (small amount by
small amount) and at regular inter-
vals, and
F for the face, a limited number of
passages (tunneling) should be per-
formed in order to decrease inflam-
mation, edema, and fibrosis.
All the points listed above result in bet-
ter revascularization of the grafted tissue.
Moreover, the use of a small cannula (mi-
crocannula of 20–25 G) is recommended
for the superficial layers of the skin, pro-
viding less trauma and satisfactory results
[22].
Abstract · Zusammenfassung
J Ästhet Chir 2014
© Springer-Verlag Berlin Heidelberg 2014
A.-C. Girard ·V. Hivernaud · J. Gauthier · F. Festy · R. Roche
Lipofilling: critical points for successful fat grafting
Abstract
Autologous fat grafting is the method of
choice for soft tissue filling in aesthetic and
reconstructive surgery. However, protocols
differ between physicians who are still con-
fronted with graft resorption and variable
clinical outcomes. Adipose graft survival rates
vary considerably depending on the method
of harvest, the method of adipose tissue pro-
cessing, the method of injection, and the vas-
cularity of the recipient site. Based on various
studies and the authors’ experience, this re-
view summarizes the critical points that may
influence the quality of adipose grafts, from
liposuction to adipose tissue injection. Some
recommendations are provided in order to
optimize the overall procedure of lipofilling
and to improve long-term survival of graft-
ed tissue.
Keywords
Lidocaine · Liposuction · Adipose tissue
processing · Centrifugation · Adipose-derived
stem cells
Lipofilling: kritische Punkte einer
erfolgreichen Fetttransplantation
Zusammenfassung
Die autologe Fetttransplantation ist eine ge-
eignete Methode für die Weichgewebeunter-
spritzung in der ästhetischen und rekonstruk-
tiven Chirurgie. Allerdings richten sich die
Chirurgen, die sich weiterhin mit Transplan-
tatresorption und variablen klinischen Ergeb-
nissen konfrontiert sehen, nach verschie-
denen Protokollen. Die Transplantatüber-
lebensrate variiert je nach Entnahmetechnik,
Verfahren zur Fettgewebsaufbereitung, In-
jektionsmethode und Gefäßversorgung der
Empfängerstelle. Auf der Grundlage verschie-
dener Studien und Erfahrungen der Autoren
werden in dem vorliegenden Beitrag die kri-
tischen Punkte dargestellt, die Einfluss auf die
Qualität des Fettgewebstransplantats haben,
von der Fettabsaugung bis zur autologen Fet-
tinjektion. Es werden Empfehlungen gege-
ben, um den gesamten Prozess des Lipofill-
ings zu optimieren und das langfristige Über-
leben des transplantierten Gewebes zu ver-
bessern.
Schlüsselwörter
Lidocain · Fettabsaugung ·
Fettgewebsaufbereitung · Zentrifugation ·
Fettgewebsstammzellen
3
Journal fürÄsthetischeChirurgie ·2014
|
Conclusion
At each of the different steps of the lipo-
filling procedure, many factors may im-
pact adipose graft retention.Thus, be-
fore going further with the use of growth 
factors, platelet-rich plasma, ADSC en-
richment, bioengineering,  simple 
key points to optimize graft survival 
(. Fig. 3) should be pursued:
F Short infiltration without anesthesia 
should be practiced. If required, the 
harvested tissue should be washed 
and centrifuged at least twice. It is 
also recommended to avoid injection 
of pure anesthetics in the fat injection 
site.
F Liposuction with a low vacuum is 
recommended in order to maintain 
adipose cells viability (no more than 
0.5 atm).
F Liposuction should be performed 
with a small cannula, with small 
holes, in order to collect small fat 
lobules and, thus, to improve vascu-
larization.
F Centrifugation of the tissue is useful 
and recommended but should not ex-
ceed 400 g (i.e., 2000 rpm, depending 
on the centrifuge) for 1 min.
F Injection of very small quantity of 
tissue per passage, in multiple tissue 
planes, is required.
Corresponding address
A.-C. Girard
ADIP’sculpt , Platform CYROI
2 rue Maxime Rivière, 97490 Sainte Clotilde,
Reunion Island
France
ac.girard@adipsculpt.com
Acknowledgments. We are grateful to the plastic
surgeons P. Delarue and O. HulardO, who took part in
our studies and allowed the collection of subcutane-
ous adipose tissue samples, to the group Clinifutur,
and to the French Ministry of National Education and
Research for the financial support. This work was also
financially supported by Adipsculpt.
Compliance with ethical
guidelines
Conflict of interest. A.C. Girard, V. Hivernaud, J.
Gauthier, F. Festy, and R. Roche state that there are no
conflicts of interest.
All studies on humans described in the present manu-
script were carried out with approval of the responsi-
ble ethics committee and in accordance with nation-
al law and the Helsenki Declaration of 1975 (in its cur-
rent, revised form). Informed consent was obtained
from all patients included in studies.
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Journal fürÄsthetischeChirurgie ·2014
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Supplementary resource (1)

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The book covers all aspects of autologous fat transfer including the history of fat transfer, the history of autologous fat survival, a variety of aesthetic and plastic procedures of the face and body, noncosmetic applications of fat transfer, preoperative care, complications, and medical-legal aspects. The contributors are international experts in the field of autologous fat transfer. The Table of Contents shows the variety of subjects.The book is intended for residents and fellows, practicing and highly experienced cosmetic surgeons, and surgeons in the fields of plastic surgery, general surgery, otolaryngology, ophthalmology, oral-maxillofacial surgery, neurosurgery, orthopedic surgery, and other surgical subspecialties.
Article
Background: Variability in harvest and processing technique may impact the success of fat grafting. This study compared properties of fat grafts produced by differing methods and assessed volume retention of the grafted tissue in a nude mouse model. Methods: In phase I, fat was harvested by either suction-assisted lipoaspiration or ultrasound-assisted lipoaspiration and then filtered using two different pore sizes. Graft material was analyzed for average parcel size; relative oil, fat, and aqueous fractions; and stromal vascular fraction yield. Filtrands and filtrates were injected into athymic nude mice. In phase II, lipoaspirate harvested by suction-assisted lipoaspiration only was processed by centrifugation, cotton gauze rolling, or filtration, and then studied in a similar manner. Results: Fat harvested by ultrasound- and suction-assisted lipoaspiration had comparable stromal vascular fraction counts and graft retention in vivo. Ultrasound-assisted lipoaspiration released only slightly more oil than suction-assisted lipoaspiration; filtering with either 500- or 800-µm pore size effectively removed fluid and oil. Centrifugation, cotton-gauze rolling, and filtration also effectively removed fluid and oil. In vivo graft retention and stromal vascular fraction yield was highest with the cotton gauze method. Histologic analysis of all explants showed intact adipose tissue. Conclusions: Ultrasound- and suction-assisted lipoaspiration yielded similar retention of fat grafts in a xenograft model. Processing with cotton gauze rolling may be best suited for grafting cosmetically sensitive areas of the body in which optimal retention is critical and lower total graft volumes are needed. Filtration and centrifugation both effectively removed fluid fractions and resulted in comparable graft retention, and are more feasible when larger volumes are required.
Article
Background: Adipose tissue grafting is a promising method in the field of surgical filling. We studied the effect of centrifugation on fat grafts, and we propose an optimised protocol for the improvement of adipose tissue viability. Methods: Adipose tissue was subjected to different centrifugations, and the volumes of interstitial liquid and oil released were measured to choose the optimal condition. Tissue from this condition was then compared to tissue obtained from two traditional techniques: strong centrifugation (commonly 3 min at 3000 rpm/900 g), and decantation, by injecting into immunodeficient mice. The cytokine interleukin-6 (IL-6) and chemokine monocyte chemotactic protein-1 (MCP-1) were assayed 24 h post-injection, and after 1 month of grafting the state of the lipografts was evaluated through macroscopic and histological analysis, with oil gap area measurement. Results: Strong centrifugation (900 g, 1800 g) is deleterious for adipose tissue because it leads to until threefold more adipocyte death compared to low centrifugation (100 g, 400 g). In addition, mice injected with strong centrifuged and non-centrifuged adipose tissue have higher rates of blood IL-6 and MCP-1, compared to those grafted with soft centrifuged fat. Moreover, extensive lipid vacuoles were detectable on histological sections of the non-centrifuged lipografts, whereas lipografts from soft centrifugation contain a higher amount of connective tissue containing collagen fibres. Conclusion: It is necessary to wash and centrifuge adipose tissue before reinjection in order to remove infiltration liquid and associated toxic molecules, which in the long term are deleterious for the graft. However, strong centrifugation is not recommended since it leads very quickly to greater adipocyte death. Thus, soft centrifugation (400 g/1 min), preceded by washings, seems to be the most appropriate protocol for the reinjection of adipose tissue.
Article
Background Adipose stem cells have gained great interest in plastic and reconstructive surgery with their ability to improve engraftment after fat transfer for soft tissue filling. It is therefore essential to know the effect of the drugs commonly used during the lipoaspiration procedure, such as lidocaine and adrenaline. Indeed, these drugs are infiltrated at the fat donor site for local anesthesia and for reduction of bleeding. This study analyzed the effects of these drugs on the viability of adipose-derived stem cells and on their inflammatory status. Methods Adipose-derived stem cells from lipoaspirates were grown in culture before being treated with different clinical doses of lidocaine at different times of exposure (1–24 h), and with adrenaline (1 μg/mL). Cytotoxicity was measured by lactate dehydrogenase assay and by flow cytometry with annexin V/propidium iodide staining. In parallel, the secretion of the proinflammatory cytokines tumor necrosis factor-alpha (TNFα), interleukin-6 (IL-6), and monocyte chemotactic protein-1 (MCP-1) was tested by enzyme-linked immunoassay. Results Lidocaine affected cell viability after 24 h, even when the cells were exposed for only 1 or 2 h. Apoptosis was not involved in lidocaine cytotoxicity. Regarding inflammation, no TNFα was produced, and lidocaine decreased the levels of IL-6 and MCP-1 in a dose-dependent manner. In contrast, adrenaline did not influence cell viability or cytokine secretions. Conclusions Adipose tissue should be handled appropriately to remove lidocaine and adrenaline, with such procedures as washing and centrifugation. This study provides new insights into the use of lidocaine and adrenaline for fat transfer or stem cell isolation from lipoaspirates. Level of Evidence II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer. com/ 00266.
Article
Background: Autologous fat graft, by virtue of its volumetric qualities and its action on skin trophicity, can be considered as a gold standard implant. Current techniques do not allow very superficial or subdermal injections of adipose tissue. The authors report technical modifications that enable fat transfer through a 25-gauge cannula. The viability of grafted fat was assessed after subcutaneous injection on a murine model. Methods: Micro-fat grafting consists of harvesting fat tissue using a multiperforated cannula with holes of 1 mm. Fat tissue is refined as described by SR Coleman and transferred through a micro-cannula. Initially, human fat was first harvested using two different procedures: Coleman's technique and the modified harvesting technique. Preliminary comparative histologic analyses were performed. Sixteen nude mice received human fat tissue: one side was filled with 0.7 cc through a 17-G cannula using Coleman's technique, and the opposite side was grafted using smaller cannulae (20G, 23G and 25G) following the modified harvesting technique. Mice were euthanised at 12 weeks and skin biopsies were performed. Results: Experimental fat grafts on mice were observed and analysed: macroscopically, the fat tissue of each side showed the same healthy aspect. Haematoxylin-eosin-saffron staining revealed intact adipocytes and anti-CD31 antibody immunohistochemical staining highlighted an abundant neo-vessel network. Conclusion: Fat graft obtained by the modified technique maintains a normal histologic structure. Fat injection with micro-cannulae extends the application of lipostructure to the superficial layers of the skin.