INTRODUCTION
Evidence of volume loss as a primary factor associated with aging was clearly
described by Lambros1. Thus, the demand
for safe, long-lasting, and biocompatible filling materials has been
increasing2. Autologous fat grafts
have been widely used by plastic surgeons because they are abundant and easily
available3.
However, the lack of reliability and consistency in terms of its final clinical
outcome is a major concern, which may result in the need for multiple
procedures3. In fact, the literature
has not provided reliable data on how much from the injected fat remains in the
body4. This variability and the poor
results published in the late 1980s and early 1990s reinforced that several
surgeons believe that the use of fat as a filling material is not reliable5,6.
Since the late 1980s, Coleman7 has
advocated for the thorough systematization of fat grafting as a solution for
minimizing its lack of reliability. Even authors who had already published
unsatisfactory results about fat grafting began to use the methods published by
Coleman and had obtained satisfactory results, indicating that the procedure may
be successful if the transplanted fat is cautiously managed8,9.
Coleman has continually obtained expressive, consistent, and long-term results,
and in the mid-1990s, he began to consider other fat attributes, which resulted
in improved skin quality, smoothing of wrinkles, decreased pores, and improved
pigmentation9. Tonnard et al. have
reinforced this clinical impression and published studies about intradermal fat
injection using a thin needle (Sharp-Needle Intradermal Fat - SNIF) and fat
nanografting using even thinner needles10,11.
The present study aimed to analyze the results of the technique described by
Coleman and to reinforce the systematization of the method for the modification
of facial contour. Moreover, we used the methodology described in detail by Lam
et al. in the book Complementary Fat Grafting12.
OBJECTIVE
This study aimed to analyze the results of the abovementioned technique and to
present the injection volumes used in a series of cases.
METHODS
This is a retrospective clinical trial based on the medical records of all
patients who underwent surgery in this institution between October 14, 2014
(which is the time we started using the methodology of facial fat grafting) and
September 14, 2017 in Fortaleza, Ceará, Brazil. All patients undergoing face fat
grafting were included. Only one surgeon conducted the surgery in all patients.
However, patients undergoing fat grafting for reasons other than changing the
contour of the face, such as exclusive treatment of acne scars, were not
included. The study was conducted in accordance with the declaration of
Helsinki, and informed consent was obtained from all patients.
Description of the technique: fat collection
Donor area
The removal area was chosen according to convenience due to the ease of
positioning, abundance of material, and body contour of the patient.
Thus, the most frequent areas were the flank and trochanteric region.
Patients undergoing abdominoplasty had the region to be excised as a
donor area of choice.
Removal method
Patients undergoing regional blocks for simultaneous body procedures had
the donor area infiltrated with 0.9% NaCl solution and 1:200,000
adrenaline solution. Approximately 0.4% lidocaine and 0.01%
levobupivacaine were added in patients who did not receive anesthetic
block. The infiltrated volume approximately corresponds to the volume
for removal.
Fat was removed via suctioning with a 3-mm cannula with 16 1-mm holes and
sharp edges (Fagha Medical) coupled to a 10-mL Luer lock syringe (BD
Medical). The plunger was pushed by hand aiming to maintain 1 mL of
negative pressure.
The only difference between this technique and the one described by Lam
et al.12 is the non-use of
albumin solution and utilization of cannulas from another manufacturer,
with minor differences.
Preparation
The filled syringes were subjected to decanting, whereas the others were
removed. According to the guideline, the syringes that were first
subjected rapidly decanted a clear infranate, which was discarded, and
the syringe was filled again by the surgeon.
The syringes were closed and centrifuged (Surgical Monserrat®,
R = 100 mm) at 2000 rpm (448 g) for 4 min. Then, the infranate and
supranate were discarded. A gauze was placed in contact with the top of
the fat to absorb residual oil.
The remaining fat in the syringe was transferred to another syringe to
achieve a volume of 10 mL. The fat was slightly homogenized and mixed
between two syringes using a transfer device. Then, prior to the
application of fat, it was again transferred to 1-mL syringes.
Preparation of the receiving area
Patients who underwent body procedures, rhytidoplasty, and other
simultaneous face procedures were sedated. Those who underwent
rhinoplasty received general anesthesia. Furthermore, only local
anesthesia was used in some cases of isolated fat grafting.
In all cases, blockade of the infraorbital and facial zygomatic branches
of the trigeminal nerve was performed. Receiving areas were infiltrated
with 0.9% NaCl solution, adrenaline 1:200.00 and lidocaine 0.4% with the
same cannulas that will be used to inject fat. In cases of
rhytidoplasty, the solution had an adrenaline concentration of
1:400.000.
Fat infiltration
The cannulas have 1- or 1.1-mm light and length from 3 to 7 cm (Rhosse
Instruments®). We only used straight cannulas coupled to
1-mL syringes (BD Medical®).
The entry points of the cannula were punctured with a 40×12 cutting
needle at routine locations A, B, C, and D, as shown in Figure 1. Further punctures were made
as needed in each case. However, there was no need to close the
incisions.
Figure 1 - Injection sites.
Figure 1 - Injection sites.
Areas of application
The preparation and application methodology was in accordance with that
described by Lam et al.12. Both
the anterograde and retrograde techniques were used with the injection
of approximately 0.1 mL every 1 cm of cannula displacement. The areas of
application are presented in Figure 2.
Figure 2 - Medial lower orbital margin (MLOM), 2 - lateral lower
orbital margin (LLOM), 3 - nasojugal groove (NJG), 4 -
lateral zygomatic (lat Z), 5 - buccal, 6 - anterior
zygomatic (Ant z), 7 - upper orbital margin (UOM), 8 -
palpebral angle (PAL ANG), 9 - mandibular groove (MG), 10 -
lateral mandible (LAT MAND), 11 - pre-canine fossa (CG), 12
- marionette, 13 - chin, and 14 - temporal.
Figure 2 - Medial lower orbital margin (MLOM), 2 - lateral lower
orbital margin (LLOM), 3 - nasojugal groove (NJG), 4 -
lateral zygomatic (lat Z), 5 - buccal, 6 - anterior
zygomatic (Ant z), 7 - upper orbital margin (UOM), 8 -
palpebral angle (PAL ANG), 9 - mandibular groove (MG), 10 -
lateral mandible (LAT MAND), 11 - pre-canine fossa (CG), 12
- marionette, 13 - chin, and 14 - temporal.
A spreadsheet with the regions, application plan, and entry points as
well as the expected volume expected and that used in each area was
created (Table 1). A room
assistant strictly followed the application and took note of the areas
and volumes.
Table 1 - Volumetric distribution of facial fat grafting according to
region. Example of a standard planning framework used during
surgery. We filled the column reserved for the volume with the
mean volume applied to the patients according to each treated
region. The last two columns on the right are not part of the
standard planning. They were added along with the absolute
frequency and percentage of cases in which this region was
treated.
| Region |
Injected volume (mL) |
| Acess |
Right |
Left |
Treatment
frequency of region
|
| Planned |
Accomplished (average / SD) |
Planned |
Accomplished (average / SD) |
| Medial LOM* (supraperiosteal) |
A |
1 |
1.0/0.1 |
1 |
1.0/0.1 |
130 |
92.2% |
| Lateral LOM* (supraperiosteal) |
A |
1 |
1.0/0.1 |
1 |
1.0/0.1 |
129 |
91.5% |
| Nasojugal fossa (supraperiosteal) |
A |
1 |
1.0/0.2 |
1 |
1.0/0.2 |
126 |
89.4% |
| Lateral zygomatic (three planes) |
A |
2 |
2.1/0.5 |
2 |
2.1/0.5 |
122 |
86.5% |
| Buccal region (subcutaneous) |
A |
2 |
2.3/0.8 |
2 |
2.2/0.8 |
42 |
29.8% |
| Anterior zygomatic (three planes) |
B |
3 |
3.1/0.9 |
3 |
3.1/0.9 |
125 |
88.7% |
| UOM ** (upper orbital margin) |
B |
1 |
1.0/0.6 |
1 |
1.0/0.6 |
26 |
32.6% |
| Lateral palpebral angle
(supraperiosteal)
|
B |
0.5 |
0.7/0.7 |
0.5 |
0.7/0.7 |
29 |
27.7% |
| Mandibular groove (three planes) |
C |
3 |
2.3/0.5 |
3 |
2.3/0.5 |
66 |
46.8% |
| Lateral mandible (deep subcutaneous) |
C |
6 |
4.9/1.3 |
6 |
4.8/1.2 |
82 |
58.2% |
| Pre-canine Fossa (deep and
intermediate)
|
A |
1.5 |
1.7/0.3 |
1.5 |
1.7/0.3 |
112 |
79.4% |
| Marionette (superficial subdermal) |
D |
1.5 |
1.5/0.6 |
1.5 |
1.5/0.6 |
31 |
22.0% |
| Chin |
D |
3 |
2.9/0.6 |
3 |
2.9/0.6 |
69 |
48.9% |
| Temporal region |
B |
2 |
2.9/1.7 |
2 |
2.9/1.7 |
16 |
11.3% |
Table 1 - Volumetric distribution of facial fat grafting according to
region. Example of a standard planning framework used during
surgery. We filled the column reserved for the volume with the
mean volume applied to the patients according to each treated
region. The last two columns on the right are not part of the
standard planning. They were added along with the absolute
frequency and percentage of cases in which this region was
treated.
RESULTS
A total of 151 face fat grafting procedures were performed between October 14,
2014 and September 14, 2017, of which 148 aimed to modify the face contour. We
did not include two cases involving treatment of acne scars and one case of
correction of Bichat ball atrophy. Approximately, 8.8% (n=13) and 91.2% (n=135)
of the patients were men and women, respectively. The age of the patients ranged
from 22 to 82 years (mean: 45.45 years, standard deviation [SD]: 12.33). A total
of 87 (59.2%) patients underwent body surgery, and 63 (42.9%) had face surgery.
The number of patients are shown in Table 2.
Table 2 - Frequency of associated facial procedures.
| Rhinoplasty |
23 |
36.5% |
| Rhytidoplasty |
18 |
28.6% |
| Forehead lift |
14 |
22.2% |
| Upper blepharoplasty |
11 |
17.5% |
| Mentoplasty |
5 |
7.9% |
| Buccal fat extraction |
4 |
6.3% |
| Lower blepharoplasty |
1 |
1.6% |
| Otoplasty |
1 |
1.6% |
Table 2 - Frequency of associated facial procedures.
All patients were followed-up at least until the seventh postoperative day. Four
(2.7%) patients were lost to follow-up after 7 days due to unknown reasons. The
mean follow-up time was 289.29 days (minimum: 7 days, maximum: 1254 days, and
SD: 275.1).
Three (2%) patients underwent a second fat grafting procedure because they wanted
a more visible result. The mean interval between the first and second procedure
was 16 mos (SD: 5.8). One of these three patients had already undergone face fat
grafting before the start of this study.
No complications correlated to the method were observed, considering that the
presence of ecchymosis and edema within the first 15 days is not a complication
but normal side effects of the procedure. Previously non-existent asymmetries
were not observed.
Accurate information about the injected volumes in 7 (4.7%) of 148 patients was
not obtained. Thus, the injected volume statistics were calculated considering a
total of 141 patients. Table 2 shows the
distribution of volumes in their respective regions with the mean injected
volume and frequency with which this area was treated. The mean injected volume
was 32 mL (range: 4-68 mL, SD: 14).
DISCUSSION
Considering that volume loss is a primary factor associated with aging1, we have adopted systematic volumization
in our clinical practice in recent years. This demands the assessment of safe,
long-lasting, and biocompatible materials, as stated by several authors in the
literature2.
Several types of synthetic filling materials, with emphasis on hyaluronic acid,
are available13. However, none of the
materials are perfect. Thus, although some publications have been discouraging
this procedure in the past5,6, we have
observed that such a procedure has been used again for autologous fat grafting
for soft tissue reconstruction within the last 20 years, and for a wide variety
of indications, such as facial rejuvenation3.
However, even with the increased use of fat grafting, high-quality clinical
studies of any of the technical stages of the procedure, such as the selection
of the ideal donor area, fat collection, processing, and injection technique,
are extremely limited14. Moreover,
previous studies have rarely shown the injected volumes in each area, which
makes learning difficult for beginners in the area.
Thus, we chose to follow a feasible and reproducible methodology and create a
basic planning model that is safe for beginners and most patients. We applied
similar volumes in the same region in different patients, even though the need
for filling varied among individuals. That is, due to the treatment of more or
fewer areas, the differences in the total injected volume (minimum of 4 mL and
maximum of 68 mL) were higher than those in the injected volume in the same
region in different individuals.
This study aimed to identify safety measures and procedures applicable to most
cases. To date, it is necessary to explain that the procedure may not be
sufficient and that the procedure, in all or any of its stages, can be
repeated.
Surgeons are usually doubtful of the reliability, durability, and safety of
facial fat grafting. Thus, we analyzed a series of cases considering these
points.
There are several definitions for the term reliability. Cronbach defined it in
four ways: “Definition 1 - coefficient of stability: Reliability is the degree
to which the result of a test remains with unalterable differences individually
in any treatment”15. In an actual
setting, we believe that reliability is achieving predictable results. That is,
there are no cases in which individuals had more or less grip of the graft,
particularly in the differences between the sides of the face, causing
asymmetries.
In this regard, since previously non-existent asymmetries have not been observed,
no significant variability was noted in each case. Tools that objectively
determine the variability of the grip in different cases are not available.
However, in all patients, the treated area improved, and there were no reports
of excessive treatment. However, cases of insufficient treatment have been
reported.
Therefore, the procedure, as previously described, satisfied the expected degree
of reliability. However, further studies must be conducted to objectively
validate its reliability.
Expectations in terms of short- and long-term evolution with regard to durability
must be explained in detail.
Appearance significantly changed within the first week when a patient begins to
feel uncomfortable appearing in public. After 1 week, most patients were highly
satisfied with themselves. However, they asked whether they were still extremely
swollen. After 30 days, the result was still slightly voluminous, but it was
already close to the result after 90 days.
We considered the result obtained after 90 days as the final result because
minimal changes were observed after this period, although the study that was the
basis for our method has stated that edema should resolve around the sixth
postoperative month. The same author has observed some increase in volume in
several patients after 1 year12.
We agree with this statement as we also noticed an increase in the result without
loss of volume until the current follow-up (maximum of 1254 days), as shown in
Figures 3 and 4, in which the zygomatic increase persists. However, we
could not objectively quantify this. Thus, such results should be validated in
future studies.
Figure 3 - A: Preoperative frontal images; B:
After 7 days; C: After 14 days; D: After
90 days; E: After 3 years and 1 month of postoperative
evolution.
Figure 3 - A: Preoperative frontal images; B:
After 7 days; C: After 14 days; D: After
90 days; E: After 3 years and 1 month of postoperative
evolution.
Figure 4 - A: Oblique-view images: before surgery;
B: After 90 days; C: After 3 years and
1 month. Note that the volume increased after a few years.
Figure 4 - A: Oblique-view images: before surgery;
B: After 90 days; C: After 3 years and
1 month. Note that the volume increased after a few years.
However, when we identified the durability of the method, it does not answer the
question on how much remains from what was injected. To date, a measurement
methodology capable of answering this question is not available. Therefore, we
prefer to direct our learning in understanding the volume required to correct
each deformity.
For example, we observed that a volume of 2-3 mL is sufficient to correct the
lower orbital margin region and that the lateral mandible does not undergo major
transformations with a volume less than 4 mL.
With regard to graft survival, theories about the survival mechanism of injected
fat, which is not consistent in the literature, are worth discussing.
In 1923, Neuhof and Hirshfield have observed that fat grafts at 2-3 months were
dominated by degenerative phenomena. Moreover, some degree of regeneration
during the second month was observed, and by the end of 5 months, regeneration
was complete and a new metaplastic fat assumed the appearance of adipose tissues
permeated by connective tissues. Then, they have concluded that the injected fat
died completely and was replaced by fibrous tissues or neoformed metaplastic
adipose tissues. Thus, this introduced the host cell replacement theory, or
reposition theory9.
Thirty years later, Peer16 has concluded
that approximately 50% of adipose tissues survived, giving rise to the theory of
cell survival.
According to Coleman9, both theories , in
addition to the role of undifferentiated cells, may be correct, and this has
been considerably explored to date.
Several studies on the longevity of grafts have been conducted. However, research
about their complications is limited. Lam et al.12 have reported about possible complications, such as
protuberances, bulging, persistent zygomatic edema, overcorrection,
under-correction, and retraction at the injection site. Among these
complications, only under-correction was observed. Therefore, our procedure was
considered safe.
A recent study has shown that age affects the viability of adipocytes in specific
anatomical regions in different ways and that the lower abdomen is preferred
than the flank in patients under 45 years of age. Meanwhile, the flank is
preferred to the lower abdomen in patients over 45 years of age. In this study,
no difference was observed in the viability of the inner surface of the thigh in
the two age groups14. Therefore, in the
future, we may consider the age of the patient when choosing the donor area.
However, to date, practicality and availability are still considered more
relevant attributes.
CONCLUSION
Fat grafting is a safe, predictable, and effective procedure, and it can be used
in facial rejuvenation in certain cases.
COLLABORATIONS
|
EATF
|
Data analysis and/or interpretation; statistical analysis; final
approval of the manuscript; data collection; conceptualization;
conception and design of the study; resource management; project
management; research; methodology; performance of surgeries and/or
experiments; writing and preparation of the original manuscript
(writing; review; editing; supervision; and visualization).
|
|
DBS
|
Statistical analysis; data collection; and writing and preparation of
the original manuscript.
|
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1. Clínica Eduardo Furlani, Cirurgia Plástica,
Fortaleza, CE, Brazil.
2. Universidade Federal do Ceará, Medicina,
Fortaleza, CE, Brazil.
Corresponding author: Eduardo Antonio Torres Furlani, Rua Barbosa
de Freitas, nº 1990 - Aldeota - Fortaleza, CE, Brazil, Zip Code 60170-021.
E-mail: eduardo@eduardofurlani.com.br
Article received: May 23, 2018.
Article accepted: October 4, 2018.
Conflicts of interest: none.
