Monday, December 1, 2008

Free Fat Grafting

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Grafts of small pieces of fat removed from one area of the body and placed in another area was first attempted in the late 1800s and early 1900s. These were used as padding between 2 surfaces in the body, plugs to stop bleeding, to fill out indented areas for cosmetic reasons, etc. The main difficulty was getting the fat to survive as larger blobs of fat would die before any blood vessels could grow into them. More than half of the implanted fat would disappear so early proponents of this would put more fat in place than they needed. That way they would end up with the right amount of fat after blood vessels finished growing into the fat and no more fat would die. In order to make the fat easier to work with (structurally more durable) and add some bulk to the graft a thin layer of deep skin layers were left attached to the fat grafts. These are called dermal fat grafts. Unfortunately this does not make more of the graft survive. Also those grafted tissues that do not survive tend to turn into scar tissue that may be seen and/or felt leading to a poor cosmetic result.

Over many years it was noted that graft survival was better in younger patients and when the grafts were placed in areas of higher blood flow like the face or directly into a muscle. Some doctors would treat the harvested fat with insulin or other concoctions before implanting it to improve survival but the validity of these treatments was never really proven.

The greatest advance was in the 1960s when plastic surgeons began reattaching amputated body parts and moving large pieces of tissue from one area to another by attaching blood vessels under the microscope. This was appropriately called microsurgery. The draw back to this technique was the amount of resources required in terms of personnel, training and equipment to perform the surgery. This made it prohibitively expensive for your run of the mill non-insurance covered cosmetic surgery or those procedures that required a relatively smaller amount of fat.

With the introduction of liposuction in the 1980s there was now an almost unlimited supply fat that could be harvested and grafted by merely injecting it though a needle or narrow metal tube.

Beginning in the early 1990s advances in methodology dramatically increased the survival of these fat grafts and structural fat grafting was born. This was thought to be primarily due to less damage to the fat during harvesting. It seems that survival of the fat grafts is highly dependent on the surgeon and the surgical technique he/she uses.

Currently fat grafts are frequently used either as stand alone procedures or added on to other procedures to correct defects after surgery or trauma, augment areas for cosmetic reasons (such as the lips and buttocks) and rejuvenation (to make appear younger) of the areas being treated (such as the face and hands). Certainly properly performed fat grafting to the buttocks is a safer and overall better operation than placing buttock silicone implants. Problem areas for fat grafting are around the eyes where they tend to lump and become unsightly though some surgeons claim good results in these areas. Another problem area is the breasts and injecting fat for breast augmentation instead of using breast implants, breast Lipomodeling. There having been conflicting studies published on the effects of doing so. Some say this creates mammograms suspicious for breast cancer and that leads to unnecessary breast biopsies. Others say that this is not the case. They are probably both right in that it depends on how the procedure was done. Once it is clear what methodology is the best I think this procedure will become much more popular although it will never be for everyone. The case for free fat grafting in reconstruction after breast cancer is much clearer. In the case of lumpectomy and radiation or mastectomy and radiation is has been clearly shown that free fat grafting reverses some of the radiation injury to the chest skin and makes the use of breast implants in these patients safer and more reliable.

Stem cell facelift is just a facelift with the injection of liposuctioned fat from elsewhere on the body. Proponents of this approach emphasize "stem cell" because everyone has stem cells in the fat and for marketing reasons. The regular measures employed to maximize the survival of injected fat will preserve the stem cells in that fat. I just use the term free fat grafting as more complicated terms just obscure what is actually being done.

There is recent anecdotal evidence or case descriptions of using these fat grafts to treat radiation injury to the skin after breast or head and neck cancer surgery. It reportedly makes the skin softer and more durable. There are also reports of the cutting of the fibrous bands in Dupuytren's disease of the hands and then injecting fat grafts to prevent rejoining of the bands. Lastly, some doctors have used the Brava suction bra system to stretch the breasts after breast cancer surgery and then injected fat grafts to maintain the bulk thereby regrowing breasts. These procedures will require more scientific examination before they can become mainstream.

No matter where you put grafted fat it may not take or survive and can partially or completely disappear. On the other hand it can grow with age and weight gain making an initially good result look not quite so good, especially if the fat was was taken from areas where the body concentrates fat like the hips and lower abdomen.

Fat grafting for facial rejuvenation in conjunction with a facelift

facelift with fat injection grafting

Fat grafting for hand rejuvenation - younger hands

fat injection grafting to hand

42 year old patient had 11 cc of fat injected into each hand. The after photo was taken 3 years later proving that the fat survives and maintains its shape for years.

Fat grafting for buttock augmentation instead of buttock implants

fat injection grafting to buttocks

Addendum September 10, 2012:
Prior to 2005 the results of fat grafting were highly variable. This changed with Dr. Coleman's approach of injecting small droplets of fat cells at multiple different depth levels via narrow needles or cannulas to ensure that each droplet would survive by ingrowth of blood vessels. Although this improved fat graft survival surgeons began to notice the appearance after survival depended on what part of the body received the graft. Now the distinction has been made between where the fat was being grafted to i.e. areas that had lost fat due to aging like the face (highly compliant areas with need for small amounts of fat) versus areas that had never lost fat but needed more for size increases or shaping like the breasts or buttocks (low compliance areas with a need for large amounts of fat). The theory is that injected fat moves along the path of least resistance or greater compliance. It can't wedge itself into where there is no additional room for it because there has been no fat loss from aging so in the breast and buttocks it may not stay or go where the surgeon wants it to stay or go. Injecting fat droplets via small needles into the buttocks could therefore force the fat into the hips for example. The solution is the use of large bore cannulas with exploded or mushroom tips where the tip diameter is twice that of the remainder of the cannula. This tip separates the tissue and makes room for the graft. Adding vibration along the length of the cannula expands the recipient area further.

Addendum October 10, 2012:
Lesley Kelly of Glasgow, Scotland, fell into a bathtub filled with hot water that scorched most of the right side of her body at the age of 2. She had third-degree burns that stretched over 60 percent of her body and lost full range of motion around many of her joints. She underwent numerous surgeries through the years to remove scar tissue, but the scar tissue continued to grow back and the appearance of her scars did not improve.

In 2011, 40 years after the initial burn, surgeons removed scar tissue from the elbow, used liposuction to remove fat from the waist, separated stem cells from the fat injected those cells into her elbow. The whole surgery took 2 hours and within months she regained 40 degrees of motion at the elbow. 40 degrees that were lost 40 years earlier.
Stem Cell Treatment of Burn Scar Across the Elbow 40 Years After the Burn

This stem cell therapy, approved in the U.K. to treat soft tissue wounds, is now gaining traction in the U.S. where there are an estimated 50,000 to 70,000 burn cases each year. Cytori Therapeutics, Inc., the biotechnology company that created the therapy, has been awarded a $4.7 million U.S. government contract to further develop the stem-cell treatment for thermal or radioactive burns. For the first two years, the research will evaluate the therapy in animals before it can be tested clinically in humans.

Addendum July 2, 2013:
Of 456 plastic surgeons responding to an ASPS Member Surgeons survey only 70 of the surgeons reported ever performing fat grafting to the breast. Of these 70 the majority (88%) use fat grafting as part of their breast reconstruction often doing fat grafting along with implants or flap procedures.

Addendum January 22, 2018:
Researchers in Holland conducted a double blinded placebo contolled study of 32 women undergoing nasolabial fold free fat grafting with platelet-rich plasma (PRP) vs. a placebo of only saline salt water. PRP is harvested by obtaining a sample of the patient's blood and spinning the blood in a centrifuge to isolate the platelets (a blood component involved in blood coagulation). At 1 year follow up they found that though adding PRP significantly improved recovery time after lipofilling/fat grafting, it did not improve cosmetic outcomes or patient satisfaction. A 2017 review of the medical literature retrieved 11 clinical studies on humans and 7 on animals studying the effects of PRP on fat graft survival. A statistically significant increase of the survival rate of fat grafts was found in 9 of these 18 comparative studies. Therefore it is not clear that PRP adds anything to the procedure besides marketing or costs.

Dr. Stone's Twitter
Buttock Implants - Augmentation
Facial Rejuvenation with Fat Grafts
Stem Cell Facelifts

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  1. If someone were to want to get fat injections on their breasts as an alternative to silicone implants what are the biggest risks, and how can they go about getting the procedure done. Also would it be more expensive to use your own fat?

  2. A 1987 American Society of Plastic and Reconstructive Surgeons position paper predicted that fat grafting would compromise breast cancer detection and should therefore be prohibited. Subsequently malpractice insurance companies placed riders in their policies excluding coverage of free fat grafting to the breasts. Consequently almost all surgeons in the United States were risk averse to doing this procedure. As is increasingly the case the push against commonly accepted practices occurred first outside the United States.

    The main issues are that the injected fat may not completely survive, grafted fat survival is highly dependent on surgical technique and the part that does not survive can calcify or form cysts that contain fat as an oil. Calcifications visible on a mammogram may be considered suspicious for cancer by a radiologist and that in turn leads to unnecessary and costly breast biopsies. Cysts can present themselves as lumps which can be worrisome for the patient. Cysts as large as 2 inches in diameter have been reported after fat grafting to the breast. Collections of dead fat in cysts can easily become infected especially if there is any break in surgical technique/sterility. If infected these cysts have to be cut open and drained of their contents. Antibiotics alone will most likely not be sufficient.

    It is clear that to minimize the chance of these complications occuring these procedures should be performed by well-trained and skilled surgeons, small not more than a millmeter or two pieces of fat should be layered into many different levels within the breast and sterile surgical conditions should be employed in certified/accredited operating rooms. The grafting of fat in large lumps in discrete areas instead of tiny pieces in multiple layers is frequently disastrous. Some surgeons advocate not grafting more than 200cc or so at a time and preoperative as well as after surgery mammograms to monitor for calcifications that could be false markers for cancer. If you consider the extra costs of more operating time to place small amounts of fat in multiple layers, mammograms to follow for calcifications and the limited amounts of fat that can be injected per operative session leading to more than one operation this approach may end up being much more expensive than the usual breast implant augmentation.

  3. Had a accident that left my face looking very aged. Are thier any Dr who use stem cells now to help with scars and damaged skin? In the U.S or even another country? I've tryed fat transfer, it helpex but its been a year and it seems to all be going away and I'm to thin for them to take any more fat.

  4. The results for plain fat grafting with scars, even burn scars, have been impressive. Manipulating the fat to increase or extract the stem cells is considered experimental by the FDA and requires investigational review board oversight etc. so it cannot be done by just going to any doctor's office. It sounds more like you have facial fat atrophy associated with aging. If that is the case you should look into sculptra, voluma, perlane etc.


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