Technical Refinements in Large Volume Fat Transfer to the Face and Breast
As autogenous fat grafting becomes increasingly popular the need to analyze harvest, processing, delivery and storage methods becomes critical to the success of the technique. Technical refinements in the surgical processing and placement of autogenous fat transfer to both the face and breast have been developed to maximize the benefits of large volume restoration using fat.
Methods/Technique:
Under a retrospective IRB approved study, 90 consecutive patients undergoing autogenous fat transfer were evaluated since December 2009. Of these, 35 (ages 19-75) underwent conventional autogenous fat transfer using a new, FDA approved, fat processing technology with a bilaminar filter that cleans the fat, while preserving viable adipocytes as well as their associated cells. Of the 35 patients, 30 had AFT to the face and 5 had AFT to the breast. For the face, the operative sequence was simple and efficient, placing tumescent solution first, marking the proposed facial incisions and injecting the face with local anesthetic. Lipoharvest of fat was then performed and the fat was placed into a filtration bag and washed with ringers lactate. Following mini-or sub-SMAS facelift, the fat is then injected through strategically placed, 18 gauge needle punctures using a Byron cannula and 10 ml infiltration device, which delivers microdroplets and threads to the site of implantation. For the breast, an 18 gauze needle is used for peri-areolar puncture and subcutaneous deliver of fat through a Byron cannula and infiltration device. A small incision (2 mm) or needle puncture is made in the inframmary crease and fat transfer is performed with a 3 mm cannula in the subglandular and muscular planes. Cooper's ligaments are subcised on a as needed basis with either an 18 gauge needle or special sickle device.
Results/Complications:
Total volume of fat transfer to the face ranged from 20 ml to 200 ml and for the breast from 150 to 370 ml at a single surgical session. Three of 35 patients had a complication. One patient had a transient neuropraxia of the levator major to the upper lip and 2 patients had residual excess fat graft in the nasojugal fold. One patient responded with mesotherapy and one required surgical excision. Initially, fat transfer to the malar region was done from a puncture in the midportion of the nasolabial fold. A needle puncture lateral to the cheek is now utilized. The temporal region is approached from inside the hairline and the lateral brow can be addressed through this needle hole as well. Fat is placed to the temporalis muscle, the lateral brow and also to the temporal extension of the buccal fat pad through this needle hole. To restore mid-facial volume, intraoral injection of the buccal fat pad is performed. This is done through a needle puncture in the upper buccal sulcus well away from Stentsen’s duct. For the lips, nasolabial folds and marionette basins, needle punctures evolved into specific sites. For the breast, fat is delivered to the muscle, subglandular tissue and subcutaneous tissue planes with a Byron cannula and 10 ml syringe using a finger controlled wheel to permit threading of microdroplets of fat. A 3 mm cannula attached to the same syringe is used for injection to the subglandular and muscular planes.
Conclusion: Technical refinements in large volume fat transfer to the face and breast have enabled rapid sterile processing of up to 250 ml of fat in 15 minutes without the need for a centrifuge. Using a 10 ml syringe attached to a specialized device that permits gentle finger pressure on a wheel-like delivery mechanism, permits rapid and precise placement of threads of fat microdroplets. An 18 gauge needle is used for the incisionless, incisions. Transoral placement of fat grafts in the buccal fat pad enable injection following facelift into a vascularized bed. For fat transfer to the breast, predictable incisions, proper graft placement in subcutaneous and subglandular planes and selective use of Cooper ligament subcision have become standard practice.