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REVIEW
ARTICLE
http://dx.doi.org/10.14730/aaps.2014.20.1.3
Arch Aesthetic Plast Surg 2014;20(1):3-7
pISSN: 2234-0831
Recent Advancements in Autologous Fat Grafting
INTRODUCTION
It becomes obvious that fat tissue is not just storage of excess car-
bohydrate. It is a regenerative complex supporting from the skin
surface to deeper organs comprising adult stem cells as well as high
energy resource related with tissue repair and regeneration.
Fat grafting technique, which has been performed for more than
hundred years, is utilized to improve defects of facial contour, fat
atrophy as an aging process and lipodystrophy due comorbid dis-
eases. Nevertheless, the availability had been limited because of
variable survival rate in accordance with operators and side effects
such as fat necrosis. As Coleman technique was introduced in 1997,
however, consistent operative results were obtained and autolo-
gous fat grafting has been settled as a reliable natural filler [1]. Al-
though specific statistical report is deficient, autologous fat graft-
ing is one of the most commonly conducted procedures in aes-
thetic and reconstructive surgery.
Adipose stem cell (ASC), a kind of adult stem cell, was discov-
ered around 2000 and have been studied for more than ten years
by scientists and medical doctors. The outcome of scientific re-
search has been accumulated and led ASC to be the core element
of regenerative medicine [2,3]. Furthermore, ASC has been clini-
cally applied to fat grafting and a new method of ‘cell-assisted li-
potransfer’ was introduced [4,5]. Platelet-rich plasma (PRP) can
also be employed to improve survival rate of the grafted fat. PRP is
known to have synergy effect with ASC in fat graft survival [6-11].
As the improvement of surgical techniques in fat surgery, sur-
vival rate of the grafted fat increased and side effects such as fat
necrosis decreased. As a result, a new surgical trend of large vol-
Jae-Ho Jeong
Oblige Plastic Surgery Clinic, Daegu,
Korea
Autologous fat grafting has been performed for more than one hundred years and
there had been a major refinement of fat grafting by Coleman in 1997. Since then,
clinical practice using this natural filler is becoming more popular and the results are
becoming more consistent. Nowadays autologous fat grafting is utilized broadly for
both aesthetic and reconstructive purposes. With the beginning of the twenty first
century, adipose stem cell (ASC) was discovered and regenerative medicine is facing
a new era of evolution. ASC was applied to fat transfer and ‘cell-assisted lipotransfer’
technique could be developed. Eto et al. recently presented experimental results of
fat graft survival. Their efforts disclosed the important role of ASCs in fat graft, and
contributed the progress of fat transfer. Owing to the accumulation of knowledge
related with fat graft survival, discovery of ASCs and advancements in surgical tech-
niques, such as Coleman technique and cell-assisted lipotransfer, survival rate of the
grafted fat increased and side effects such as fat necrosis decreased. Consequently,
there is a new surgical trend of applying large volume fat grafting for augmentation
mammoplasty and breast reconstruction with or without silicone implant. Recently,
fat grafting is expanding it’s limit to new field of treatment of burn, scar, and wound.
This article reviews several significant advancements of fat grafting techniques in
this century, furthermore intends to widen scientific understandings and contribute
to be practiced as a feasible method.
Keywords Fat, Fat graft, Adipose stem cell, Regenerative medicine, Stem cell therapy
No potential conflict of interest relevant to
this article was reported.
Received: Feb 14, 2014 Revised: Feb 21, 2014 Accepted: Feb 21, 2014
Correspondence: Jae-Ho Jeong Oblige Plastic Surgery Clinic,
Dong-seo Bld, 2nd Fl, 77 Dongsung-ro 1 gil, Jung-gu, Daegu 700-411, Korea.
E-mail: originaljjh@naver.com
Copyright © 2014 The Korean Society for Aesthetic Plastic Surgery.
This is an Open Access article distributed under the terms of the Creative Commons At-
tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. www.e-aaps.org
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ume fat grafting for breast and buttock augmentation showed con-
sistent operative results, moreover, enabled augmentation mam-
moplasty without silicone implant [12,13]. Nowadays, fat grafting
began to be applied for burn and wound management [14,15],
moreover utilized to improve severe scar due to trauma and burn
[16,17].
There have been several important advancements in fat graft-
ing procedure during last ten years. Fat grafting is not a simple
procedure transferring fat tissue. With the discovery of ASCs, fat
grafting becomes a major tool of regenerative medicine. This arti-
cle reviews recent advancements in fat grafting techniques helping
plastic surgeons to understand and utilize fat transfer scientifically,
furthermore intends to suggest the orientation of development in
the future.
Fat harvesting, preparation and reinjection
Rohrich et al. reported that the cell viability of grafted fat is not in-
fluenced by donor site [18]. Lidocaine and epinephrine, compo-
nents of tumescent solution, were proved not to give effects on fat
tissues [19,20]. Harvesting fat with large cannula and gentle nega-
tive pressure helps fat survival. Shiffman et al. reported that nega-
tive pressure under 700 mmHg can cause cellular loss up to 10 per-
cent [21]. Ozsoy et al. noted that using 4 mm cannula rather than
2-3 mm cannula increases survival rate of fat tissue [22].
The Coleman technique reported in 1997 recommends suction
with 10 mL syringe to reduce damage applied to fat cell in fat har-
vesting, and in preparation, removes impurities and oil through
300 rpm (800 g) of proper centrifugal filtration, so raises density
of the fat cell in same volume, and in reinjection, uses a thin can-
nula, 1 mL or 3 mL syringe, so raises possibility of revasculariza-
tion from surrounding tissue with a method doing distributed ar-
rangement of small aliquots less than 0.1 mL equally in recipient
bed. The Coleman technique extended around the globe in a short
time and fat grafting began to show improved engraftment rate
and stable result, so settleed as a new standard of transplantation
of fat [1].
Afterward, various attempts continued, and it was introduced
that a method omitting centrifugation and using washing and strain-
ing technique [23] and a method putting aspirated fat on sterile
towel so removing fluid and debris [24], but announcement about
such new attempts were not the results by controlled comparative
study so whether better results can be obtained actually with these
methods is not sure. Based on several related study results in the
meantime, various gears were commercialized to reduce damage
of fat and progress fat harvesting and preparation, so LipVage (Ge-
nesis Biosystems, Lewisville, TX), PureGraft (Cytori Therapeutics,
San Diego, CA), and Viafill (Lipose Corp, Maitland, FL) are mer-
chandised on the market [25-27].
Ozsoy reported that in fat reinjection, adipocyte viability on use
of 2.5 mm in diameter of a heavy cannula is much higher than ad-
ipocyte viability on use of 1.6 mm or 2.0 mm of cannula [22], but
Erdim reported that there is no difference of cell viability accord-
ing to needle gauge in fat reinjection experiment using 14, 16, and
20 gauge of needle [28].
While large volume fat injection for Breast and gluteal augmen-
tation was conducted, there is a problem that Coleman technique
holding 1 mL or 3 mL syringe with a hand and injecting gradually
is a time-consuming to finish hundreds mL of fat and is difficult
to operate for accuracy. A solution for this problem is a screw type
syringe (AP Medical, Seoul, Korea) with rotating syringe handle
(Fig. 1). When an assistant holds a syringe handle and turns it one
round, regular amount of o.5 mL of fat is injected. Amount of fat
transplantation per the unit area is decided in inverse proportion
to velocity of operator moves cannula. This is new method inject-
ing fat as the shape like thin and long noodle in contrast with Cole-
man technique transplanting fat as small aliquots. In this new tech-
nique, to transplant much fat efficiently in limited recipient area,
possibility of revascularization should be raised by arrangement
like several logs are laid on top of another in the other direction
(Fig. 2).
Fig. 1. Screw type syringe. (A) A disposable screw type syringe. (B) A metallic screw type syringe adapter fitted for 20 mL disposable syringe.
A B
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Fig. 2. Placement of graft fat in two different techniques are designed
to increase surface of contact with recipient vascular bed in given
situation. (A) Coleman technique and screw type syringe technique.
(B) screw type syringe technique.
A B
Adipose stem cells and fat graft update
In the middle of 1990 having 21st Century called the era of regen-
erative medicine ahead, plastic surgeons started to study adipose
tissue dumped after body contouring surgery as liposuction in
Pittsburgh University in United States. They dissociated adipose
tissue with collagenase, a histolysis enzyme, and then analyzed
stromal vascular fraction obtained by centrifugal filtration of cell
suspension. A new type of stromal cells similar to fibroblast were
identified showing multipotent differentiation potential, and these
new cells are proved to be a kind of adult stem cells through vari-
ous scientific experiments [2,3]. This adult stem cell extracted from
adipose tissue is called with various names such as adipose tissue-
derived stem cells, adipose-derived stromal cells (ADSC), adipose
tissue-derived mesenchymal stromal cells, or adipose stromal cells,
but recently, it is arranged as ADSC or ASC.
ASC can not only be obtained easily and plentifully from lipoa-
spirate but also be differentiated into various tissues such as adipo-
cytes, cardiomyocytes, chondrocytes, endothelial cells, myocytes,
neuron-like cells, and osteoblasts. So, it is acknowledged that utili-
ty of ASCs in regenerative medicine is very high.
If many cultured ASCs are used fully, remedial value of ASCs
can be experienced clearly, but many mandatory controls and in-
vestment of occupancy expense are necessary to apply cultured
ASC to clinics, so full-scale clinical application is not realized yet
and ASC is still in the state of clinical trial for several major dis-
ease conditions in Korea. Fortunately, even with 20-30 mL of a
small adipose tissue is dissociation, quite a number of cells can be
obtained, and effectively used in clinics without cultured process.
Especially, in ischemic condition, ASC uniformly differentiate into
neoangiogenesis, which can be helpful treating postoperative wound
problem, radiation necrosis, or ischemic flap of filler-induced skin
necrosis [29]. A new type of fat grafting called cell-assisted lipo-
transfer introduced after discovery of ASC is known as a good
method increasing survival rate of fat and reducing side effects in
comparison with existing methods [4,5] but it is a stage of imper-
fection that is not easy to apply to Asian women who devoid of
sufficient fat that is essential to this operation. When more than
enough number of cultured ASCs are mixed with fat to be trans-
planted and then cell-assisted lipotransfer is will be completed as
the method increasing survival rate of fat transplantation innova-
tively.
Another method to increase survival rate of fat grafting is the
use of platelet-rich plasma (PRP). It is known that various cyto-
kines released from platelets promote healing process and improve
fat graft survival [6-11]. However, there are a report that PRP is
ineffective in animal experiment [30], and there are criticism about
whether the results of small animal experiment still have the reli-
able value in the clinical surgical procedure on real human body.
Fate of graft fat
More than 100 years passed from first report of fat harvesting [31],
but engraftment process of fat is uncertain yet. Long-standing hy-
pothesis such as cell survivor theory and host replacement theory
about engraftment of fat was printed in textbook until recently
without clear qualification process. With increased understand-
ings on fat biology and accumulation of clinical experience, it be-
comes obvious that survival of transplanted fat is influenced by
various factors such as characteristic of patients, methods of fat
processing, and condition of recipient bed, however logical and
scientific understanding about engraftment process is still insuffi-
cient. Lately, Eto et al. published the groundbreaking result of re-
search work about engraftment of fat and I believe it is a great ad-
vancement in fat grafting [32]. According to this result, adipocyte
existing within 300 μm from the surface of transplanted adipose
tissue survives, but most adipocytes located deeper in transplant-
ed fat die within 24 hours. At this moment, some ASCs survive in
the deeper part of the transplant and play an important role to re-
generate adipose tissue in transplanted fat. Finally, it is important
to transplant fat as a small lump so increase surface area contact-
ing surrounding tissue on fat grafting. Henceforward, the process
of fat regeneration is progressed by ASC between 3 and 7 days, so
the role of ASC is important in fat grafting (Fig. 3).
Clinical application of fat grafting
According to important scientific advances such as refinement of
fat grafting, discovery of adipocyte stem cells, and understanding
an engraftment process of fat, interest about fat grafting cannot be
higher than ever before and it is expanding the limit to new fields
such as large volume fat grafting, fat transfer for burn and difficult
wounds, and also for scar treatment.
Fat grafting for breast augmentation has been already attempt-
ed since several decades ago, but complications of fat necrosis, cyst
formation, and infections have long been big issues. However, in
these latter days, breast augmentation surgery using cell-assisted
lipotransfer increases greatly [4,5], and the fat grafting procedure
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in patients with partial mastectomy or lumpectomy to improve
breast shape is already established as a stable treatment [33-35].
Lately, many patients after breast reconstruction with flap opera-
tion or breast prostheses wants fat grafting to improve breast shape
or to substitute breast prostheses for autologous fat [36]. Also, there
is new method using BRAVA, external pre-expansion device, so
enlarging skin pocket before fat grafting on breast to increase sur-
vival rate of fat [37,38].
Lately, it is reported that application of the fat tissue to burn
wound or extensive wound not only reduces therapy period but
also reduces deformity after the end of healing process [15,16].
Also, fat grafting is conducted to improve scar and scar contrac-
ture by injury or burn [17,18].
These new trials are very simple and primitive way of utilizing
regenerative potential of fat and ASCs for clinical purposes at this
age of government regulation. Near future, the ultimate form of
stem cell therapy using cultured pure ASCs can be put into use ef-
fectively and efficiently.
Future of fat grafting and stem cell therapy
Future fat grafting may not be simple fat tissue grafting. It may be
more like fat cell grafting or fat tissue engineering incorporating
adipocytes, ASCs and adequate scaffold materials. Cell-assisted li-
potransfer could be upgraded by enrichment with adequate num-
ber of cultured ASCs which significantly affect the engraftment of
graft fat.
Full-scale clinical application of stem cell therapy is delayed by
legal control to ensure patients’ safety, but the effect of stem cell
therapy have been already proved through scientific verification
during the past decade. Only if enough number of cultured ASC
can be used in clinics as needed, era of regenerative medicine with
stem cell therapy can fully open for the first time.
The business of stem cell bank have already started by ambiti-
ous investors, but it is early to create a profit yet. It may not be easy
for ordinary people to spend large amount of money to preserve
their own stem cells in advance for unrealized further medical
techniques. However, to benefit from stem cell therapy that will be
developed newly and continuously in the future, cryopreservation
of own stem cells early in life will be an important medical option
before long.
CONCLUSION
Scientific knowledge about fat and fat tissue transfer are accumu-
lating rapidly. Fat is a unique regenerative complex comprising
adult stem cells as well as high energy resource related with tissue
repair and regeneration. The regenerative potential of fat tissue led
us to expand the limit of application day by day. Fat tissue is ex-
pected to be an essential component of regenerative medicine in
the twenty first century and it is essential for plastic surgeons to
understand new knowledge on fat biology to perform better and
reasonable clinical practice.
ACKNOWLEDGEMENTS
This Work was supported by a graft from the Chunma medical
research foundation, Korea 2006.
REFERENCES
1. Coleman S. Facial recontouring with lipostructure. ClinPlast Surg 1997;
24:347-67.
2. Jeong JH. Chondrogenic differentiation of human adipo-derived pre-
cursor cells. J Korean Soc Plast Reconstr Surg 2000;27:136-42.
3. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human adi-
pose tissue: implications for cell-based therapies. Tissue Eng 2001;7:211-
28.
4. Matsumoto D, Sato K, Gonda K, et al. Cell-assisted lipotransfer: sup-
portive use of human adipose-derived cells for soft tissue augmenta-
tion with lipoinjection. Tissue Eng 2006;12:3375-82.
5. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for facial
lipoatrophy: efficacy of clinical use of adipose-derived stem cells. Der-
Fig. 3. Early cell death and replacementof adipocytes. Eto H, Kato H, Suga H, Aoi N, Doi K, Kuno S, Yoshimura K. The fate of adipocytes after
nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg 2012;129:1081-92.
Surviving area
Regenerating area
Necrotic area
300 µm
100
80
60
40
20
0
Area of viable adipocytes (%)
0 1 2 3 5 7 14
Day
Early death & cell replacement
*
*
7
aaps
Archives of
Aesthetic Plastic Surgery
Jeong J-H Recent Advancements in Fat Grafting
matol Surg 2008;34:1178-85.
6. Cervelli V, Palla L, Pascali M, et al. Autologous platelet-rich plasma
mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plast
Surg 2009;33:716-21.
7. Cervelli V, Gentile P, Scioli MG, et al. Application of platelet-rich plas-
ma in plastic surgery: clinical and in vitro evaluation. Tissue Eng Part
C Methods 2009;15:625-34.
8. Nakamura S, Ishihara M, Takikawa M, et al. Platelet-rich plasma (PRP)
promotes survival of fat-grafts in rats. Ann Plast Surg 2010;65:101-6.
9. Gentile P, Orlandi A, Scioli MG, et al. A comparative translational study:
the combined use of enhanced stromal vascular fraction and platelet-
rich plasma improves fat grafting maintenance in breast reconstruc-
tion. Stem Cells Transl Med 2012;1:341-51.
10. Choi J, Minn KW, Chang H. The Efficacy and safety of platelet-rich
plasma and adipose-derived stem cells: An update. Arch Plast Surg
2012;39:585-92.
11. Sommeling CE, Heyneman A, Hoeksema H, et al. The use of platelet-
rich plasma in plastic surgery: a systematic review. J Plast Reconstr
Aesthet Surg 2013;66:301-11.
12. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for cos-
metic breast augmentation: supportive use of adipose-derived stem/
stromal cells. Aesthetic Plast Surg 2008;32:48-55.
13. Willemsen JC, Lindenblatt N, Stevens HP. Results and long-term pa-
tient satisfaction after gluteal augmentation with platelet-rich plasma-
enriched autologous fat. Eur J Plast Surg 2013;36:777-82.
14. Sultan SM, Barr JS, Butala P, et al. Fat grafting accelerates revasculari-
sation and decreases fibrosis following thermal injury. J Plast Reconstr
Aesthet Surg 2012;65:219-27.
15. Ranganathan K, Wong VC, Krebsbach PH, et al. Fat grafting for ther-
mal injury: current state and future directions. J Burn Care Res 2013;
34:219-26.
16. Viard R, Bouguila J, Voulliaume D, et al. Fat grafting in facial burns
sequelae. Ann Chir Plast Esthet 2012;57:217-29.
17. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar
treatment. J Craniofac Surg 2013;24:1610-5.
18. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer
viability: a quantitative analysis of the role of centrifugation and har-
vest site. PlastReconstr Surg 2004;113:391-5; discussion 396-7.
19. Moore JH Jr, Kolaczynski JW, Morales LM, et al. Viability of fat ob-
tained by syringe suction lipectomy: effects of local anesthesia with li-
docaine. Aesthetic Plast Surg 1995;19:335-9.
20. Shoshani O, Berger J, Fodor L, et al. The effect of lidocaine and adren-
aline on the viability of injected adipose tissue--an experimental study
in nude mice. J Drugs Dermatol 2005;4:311-6.
21. Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of harvest
and transfer methods on adipocyte viability and review of the literature.
Dermatol Surg 2001;27:819-26.
22. Ozsoy Z, Kul Z, Bilir A. The role of cannula diameter in improved adi-
pocyte viability: a quantitative analysis. Aesthet Surg J 2006;26:287-9.
23. Kuran I, Tumerdem B. A new simple method used to prepare fat for
injection. Aesthetic Plast Surg 2005;29:18-22.
24. Ramon Y, Shoshani O, Peled IJ, et al. Enhancing the take of injected
adipose tissue by a simple method for concentrating fat cells. Plast Re-
constr Surg 2005;115:197-201.
25. Brown SA, Levi B, Lequeux C, et al. Basic science review on adipose
tissue for clinicians. Plast Reconstr Surg 2010;126:1936-46.
26. Li H, Zimmerlin L, Marra KG, et al. Adipogenic potential of adipose
stem cell subpopulations. Plast Reconstr Surg 2011;128:663-72.
27. Chazenbalk G, Bertolotto C, Heneidi S, et al. Novel pathway of adipo-
genesis through cross-talk between adipose tissue macrophages, adi-
pose stem cells and adipocytes: evidence of cell plasticity. PLoS One
2011;6:e17834.
28. Erdim M, Tezel E, Numanoglu A, et al. The effects of the size of lipo-
suction cannula on adipocyte survival and the optimum temperature
for fat graft storage: an experimental study. J Plast Reconstr Aesthet
Surg 2009;62:1210-4.
29. Jeong JH. Adipose Stem Cells and Skin Repair. Curr Stem Cell Res
Ther 2010;5:137-40.
30. Por YC, Yeow VK, Louri N, et al. Platelet-rich plasma has no effect on
increasing free fat graft survival in the nude mouse. J Plast Reconstr
Aesthet Surg 2009;62:1030-4.
31. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Gesell-
sch Chir 1893;22:66.
32. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascular-
ized fat grafting: evidence of early death and replacement of adipo-
cytes. Plast Reconstr Surg 2012;129:1081-92.
33. Delay E, Garson S, Tousson G, et al. Fat injection to the breast: tech-
nique, results, and indications based on 880 procedures over 10 years.
Aesthet Surg J 2009;29:360-76.
34. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour
deformities in the reconstructed breast. Plast Reconstr Surg 2005;116:
1300-5.
35. Kanchwala SK, Glatt BS, Conant EF, et al. Autologous fat grafting to
the reconstructed breast: the management of acquired contour defor-
mities. Plast Reconstr Surg 2009;124:409-18.
36. Sinna R, Delay E, Garson S, et al. Breast fat grafting (lipomodelling)
after extended latissimusdorsi flap breast reconstruction: a preliminary
report of 200 consecutive cases. J Plast Reconstr Aesthet Surg 2010;63:
1769-77.
37. Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion
and autologous fat transplantation: a clinical radiographic study. Plast
Reconstr Surg 2011;127:2441-50.
38. Khouri R, Del Vecchio D. Breast reconstruction and augmentation us-
ing pre-expansion and autologous fat transplantation. Clin Plast Surg
2009;36:269-80, viii.
