Autologous Fat Transfer
Melvin A. Shiffman (Ed.)
Autologous Fat Transfer
Art, Science, and Clinical Practice
ISBN: 978-3-642-00472-8 e-ISBN: 978-3-642-00473-5
DOI: 10.1007/978-3-642-00473-5
Springer Heidelberg Dordrecht London New York
Library of Congress Control Number: 2009926019
© Springer-Verlag Berlin Heidelberg 2010
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication
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The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply,
even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws
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Springer is part of Springer Science+Business Media (www.springer.com)
Dr. Melvin A. Shiffman
Tustin Hospital and Medical Center
Department of Surgery
14662 Newport Avenue
Tustin, CA 92680
USA

v
It is with great pleasure that I submit a foreword for this new book.
Many authors have written in detail about fat transplantation; however, experience
and education are never enough on any of the cosmetic fi elds. The fi rst text on fat
transplantation by Charles H. Willi dates back to 1926. This means that someone
before us understood the importance of autologous resources that we have.
The technique has naturally evolved and has developed in these years. It is of
utmost importance for a cosmetic surgeon to know every detail about the techniques:
anatomy, metabolism of fat, pharmacology, and eventually the treatment of complica-
tions. A simple procedure is not necessarily a procedure that has no complications.
All over the world and all over the centuries beauty has been a great spiritual force
and has affected the evolution of civilization.
Nowadays we are going toward an era in which major cosmetic surgical tech-
niques are not so requested anymore. Patients want to stay young; they do not want
to become young again!
Fat is a wonderful resource, which can be used for reconstructive purposes or for
cosmetic ones.
It is important for any surgeon paving the fi rst steps in this fi eld to study and read
and learn every time a bit more in order to have the best results with the least
problems.
I congratulate the author and my friend Mel Shiffman for his precious contributions
in everything he does.
With great affection
Rome, Italy Giorgio Fischer
Foreword
vii
Preface
This book is the most up to date text on autologous fat transfer and includes chapters
concerning the history of fat transfer and fat transfer survival, principles of fat transfer,

adipose cell anatomy and physiology, guidelines for fat transfer and interpretation of
results, subcision and fat transfer, fat transfer to a variety of areas of the body for aes-
thetic purposes and plastic reconstruction, fat autograft to muscle, complications of fat
transfer, and medical legal aspects of fat transfer. Included are chapters on fat transfer
for nonaesthetic purposes such as for recontouring postradiation defects, treatment of
migraine headaches, treatment of sulcus vocalis, transfer around temporomandibular
prosthesis, for skull base repair after craniotomy, and for congenital short palate. There
are 63 chapters by international experts with the newest techniques explained in detail.
Fat transfer is now one of the most common aesthetic procedures performed. Use
of fat avoids the complications of other fi llers, including solid and injectable, both
temporary and permanent. Fat for transfer is available on almost all patients so that
there is essentially no cost. Local anesthesia and/or tumescent local anesthesia are
most commonly used and this increases the safety of the procedure.
The effects of fat transfer are marked, resulting in a younger appearance, complet-
ing the three-dimensional correction of the face, and elevating depressions and defi -
cits. Fat transfer may also prevent excessive fi brosis in noncosmetic applications.
The techniques have improved allowing better volume retention of fat. Many pro-
cedures in fat transfer are discussed and described so that the reader will have a better
understanding of the procedure and should be able to perform fat transfer avoiding
many of the complications.
Much of the improvement in fat transfer to the liposuction technique can be attrib-
uted to the contribution of liposuction by Fischer that was fi rst reported in 1975 [1]
and the many surgeons who contributed to the advances improving fat retention and
safety. The history of fat transfer is replete with attempts to make fat transfer a viable
procedure and to improve the techniques to increase the percentage of retention.
The improvements of fat transfer have been through the contributions of surgeons
in many specialties. We should recognize these international specialists who have
spent their efforts in making fat transfer a viable procedure in aesthetic surgery.
References
1. Fischer G. Surgical treatment of cellulitis. IIIrd Congress International Acad Cosm

Surg, Rome, May 31, 1975
California, USA Melvin A. Shiffman
ix
Contents
Part I History, Principles, Fat Cell Physiology and Metabolism
1 History of Autologous Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Melvin A. Shiffman
2 History of Autologous Fat Transplant Survival . . . . . . . . . . . . . . . . . . 5
Melvin A. Shiffman
3 Principles of Autologous Fat Transplantation. . . . . . . . . . . . . . . . . . . . 11
Melvin A. Shiffman
4 The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition . . . . 19
Mitchell V. Kaminski and Rose M. Lopez de Vaughan
5 Fat Cell Biochemistry and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Melvin A. Shiffman
6 White Adipose Tissue as an Endocrine Organ . . . . . . . . . . . . . . . . . . . 37
Kihwa Kang
Part II Preoperative
7 Preoperative Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Melvin A. Shiffman
Part III Techniques for Aesthetic Procedures
8 Guidelines for Autologous Fat Transfer, Evaluation,
and Interpretation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Sorin Eremia
9 Face Rejuvenation with Rice Grain-Size Fat Implants . . . . . . . . . . . . . 53
Giorgio Fischer
10 Fat Transfer in the Asian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Samuel M. Lam
x Contents
11 Subcison with Fat Transfer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Melvin A. Shiffman
12 Autologous Fat Transplantation for Acne Scars . . . . . . . . . . . . . . . . . . 69
Bernard I. Raskin
13 The Art of Facial Lipoaugmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Edward B. Lack
14 Use of Platelet-Rich Plasma to Enhance Effectiveness
of Autologous Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Robert W. Alexander
15 Fat Transfer to the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Melvin A. Shiffman and Mitchell V. Kaminski
16 Fat Autograft Retention with Albumin . . . . . . . . . . . . . . . . . . . . . . . . . 123
Mitchell V. Kaminski and Rose M. Lopez de Vaughan
17 Aesthetic Face-lift Using Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Anthony Erian and Aqib Hafeez
18 Fat Transfer to the Glabella and Forehead . . . . . . . . . . . . . . . . . . . . . . 147
Felix-Rüdiger G. Giebler
19 Eyebrow Lift with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Giorgio Fischer
20 Treatment of Sunken Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Dae Hwan Park
21 Fat Graft Postvertical Myectomy for Crow’s
Feet Wrinkle Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Fausto Viterbo
22 Optimizing Midfacial Rejuvenation: The Midface Lift
and Autologous Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Allison T. Pontius and Edwin F. Williams III
23 Autologous Fat Transfer to the Cheeks and Chin. . . . . . . . . . . . . . . . . 179
Steven B. Hopping
24 Nasal Augmentation with Autologous Fat Transfer . . . . . . . . . . . . . . . 185
Jongki Lee

25 Lipotransfer to the Nasolabial Folds and Marionette Lines . . . . . . . . 189
Robert M. Dryden and Dustin M. Heringer
26 Autologous Fat Transplantation to the Lips . . . . . . . . . . . . . . . . . . . . . 197
Steven B. Hopping, Lina I. Naga, and Jeremy B. White
Contents xi
27 Three Dimensional Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Sid J. Mirrafati
28 Complementary Fat Grafting of the Face . . . . . . . . . . . . . . . . . . . . . . . 209
Samuel M. Lam, Mark J. Glasgold, and Robert A. Glasgold
29 Fat Transplants in Male and Female Genitals . . . . . . . . . . . . . . . . . . . 217
Enrique Hernández-Pérez, Hassan Abbas Khawaja,
José Enrique Hernández-Pérez, and Mauricio Hernández-Pérez
30 History of Breast Augmentation with Autologous Fat . . . . . . . . . . . . . 223
Melvin A. Shiffman
31 Breast Augmentation with Autologous Fat . . . . . . . . . . . . . . . . . . . . . . 229
Tetsuo Shu
32 Fat Transfer and Implant Breast Augmentation. . . . . . . . . . . . . . . . . . 237
Katsuya Takasu and Shizu Takasu
33 Fat Transfer with Platelet-Rich Plasma
for Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Robert W. Alexander
34 Cell-Assisted Lipotransfer for Breast Augmentation:
Grafting of Progenitor-Enriched Fat Tissue . . . . . . . . . . . . . . . . . . . . . 261
Kotaro Yoshimura, Katsujiro Sato, and Daisuke Matsumoto
35 Fat Transfer to the Hand for Rejuvenation. . . . . . . . . . . . . . . . . . . . . . 273
Pierre F. Fournier
36 Correction of Deep Gluteal and Trochanteric
Depressions Using a Combination of Liposculpturing
with Lipo-Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Robert F. Jackson and Todd P. Mangione

37 Buttocks and Legs Fat Transfer: Beautifi cation, Enlargement,
and Correction of Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Lina Valero de Pedroza
38 Autologous Fat Transfer for Gluteal Augmentation. . . . . . . . . . . . . . . 297
Adrien E. Aiache
39 Autologous Fat for Liposuction Defects. . . . . . . . . . . . . . . . . . . . . . . . . 301
Pierre F. Fournier
40 Periorbital Fat Transfer with Platelet Growth Factor . . . . . . . . . . . . . 303
Julio A. Ferreira and Gustavo Ferreira
41 Cryopreserved Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Bernard I. Raskin
xii Contents
Part IV Techniques for Non-Aesthetic Procedures
42 Fat Transfer for Non-Aesthetic Procedures. . . . . . . . . . . . . . . . . . . . . . 315
Melvin A. Shiffman, Enrique Hernández-Pérez,
Hassan Abbas Khawaja , José Enrique Hernández-Pérez,
and Mauricio Hernández-Pérez
43 Fat Transplantation for Mild Pectus Excavatum . . . . . . . . . . . . . . . . . 323
Luiz Haroldo Pereira and Aris Sterodimas
44 Correction of Hemifacial Atrophy with Fat Transfer. . . . . . . . . . . . . . 331
Qing Feng Li, Yun Xie, and Danning Zheng
45 Recontouring Postradiation Thigh Defect
with Autologous Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Richard H. Tholen, Ian T. Jackson, Richard Simman,
and Vincent D. DiNick
46 Management of Migraine Headaches
with Botulinum Toxin and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . 347
Devra Becker and Bahman Guyuron
47 Retropharyngeal Fat Transfer for Congenital Short Palate . . . . . . . . 357
P. H. Dejonckere

48 Autologous Fat Grafts Placed Around
Temporomandibular Joint (TMJ) Total Joint
Prostheses to Prevent Heterotopic Bone . . . . . . . . . . . . . . . . . . . . . . . . 361
Larry M. Wolford and Daniel Serra Cassano
49 Autologous Fat Grafts for Skull Base Repair
After Craniotomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Jose E. Barrera, Sam P. Most, and Griffi th R. Harsh IV
Part V Fat Processing and Survival
50 Fat Processing Techniques in Autologous Fat Transfer . . . . . . . . . . . . 391
Nancy Kim and John G. Rose Jr.
51 Injection Gun Used as a Precision Device for Fat Transfer . . . . . . . . . 397
Joseph Niamtu
52 Tissue Processing Considerations for Autologous Fat Grafting . . . . . 403
Adam J. Katz and Peter B. Arnold
53 Fat Grafting Review and Fate of the Subperiostal Fat Graft . . . . . . . 407
Defne Önel, Ufuk Emekli, M. Orhan Çizmeci,
Funda Aköz, and Bilge Bilgiç
Contents xiii
Part VI Complications
54 Complications of Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Hassan Abbas Khawaja, Melvin A. Shiffman,
Enrique Hernandez-Perez, Jose Enrique Hernandez-Perez,
and Mauricio Hernandez-Perez
55 Facial Fat Hypertrophy in Patients Who Receive
Autologous Fat Tissue Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Giovanni Guaraldi, Pier Luigi Bonucci, and Domenico De Fazio
56 Lid Deformity Secondary to Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . 433
Brian D. Cohen and Jason A. Spector
Part VII Miscellaneous
57 The Viability of Human Adipocytes After Liposuction Harvest. . . . . 439

John K. Jones
58 Autologous Fat Grafting: A Study of Residual
Intracellular Adipocyte Lidocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Robert W. Alexander
59 Autologous Fat Transfer National Consensus Survey:
Trends in Techniques and Results for Harvest,
Preparation, and Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Matthew R. Kaufman, James P. Bradley, Brian Dickinson,
Justin B. Heller, Kristy Wasson, Catherine O’Hara, Catherine Huang,
Joubin Gabbay, Kiu Ghadjar, Timothy A. Miller, and Reza Jarrahy
60 Medical Legal Aspects of Autologous Fat Transplantation . . . . . . . . . 459
Melvin A. Shiffman
61 Editor’s Commentary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Melvin A. Shiffman
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
xv
Adrien E. Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA,

Funda Aköz Department of Plastic and Reconstructive Surgery,
Osmaniye State Hospital, Osmaniye, Turkey,
Robert W. Alexander Department of Surgery, University of Texas,
Health Science Center at San Antonio, San Antonio, TX, USA
Department of Surgery, University of Washington, Seattle, WA, USA
3500 188th St. S.W. Suite 670, Lynnwood, WA 98037, USA

Peter B. Arnold University of Virginia, P.O. Box 800376, Charlottesville,
VA 22908-0376,
Jose E. Barrera Department of Otolaryngology, Division of Facial Plastic and
Reconstructive Surgery, Wilford Hall Medical Center, 59 MDW/SGOSO,
2200 Bergquist Drive, Ste 1, Lackland AFB, TX 78236-9908, USA


Devra Becker 29017 Cedar Road, Cleveland (Lyndhurst), OH 44124, USA,
devra:becker@uhospitals:org
Bilge Bilgiç Department of Pathology, Istanbul University, Fevzi Pasa cad.
Sarachane Parki Yani Fatih, Istanbul, Turkey,
Pier Luigi Bonucci Strada del Diamante 86, 41100 Modena, Italy

James P. Bradley Division of Plastic and Reconstructive Surgery, 200 UCLA
Medical Plaza, Suite 465, Los Angeles, CA 90095, USA,
Daniel Serra Cassano Rua Vicente Satriana, 316 apt 52, Jardim Sao Jorge,
Araraquara, Sao Paulo, Brazil 14807-9878,
Brian D. Cohen Combined Divisions of Plastic Surgery, New York-Presbyterian,
The University Hospital of Columbia and Cornell, 525 East 68th Street, P.O. Box 115,
New York, NY 10065, USA,
M. Orhan Çizmeci Department of Pathology, Istanbul University, Fevzi Pasa cad.
Sarachane Parki Yani Fatih, Istanbul, Turkey,
Domenico De Fazio Strada del Diamante 86, 41100 Modena, Italy,

Contributors
P. H. Dejonckere The Institute of Phoniatrics, ENT Department, Division of
Surgery, University Medical Centre, P.O. Box 85 500, 3508 Utrecht, The
Netherlands,

Brian Dickinson 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Vincent D. DiNick 135 S.Prospect, Ypsilante, MI 48198, USA,

Robert M. Dryden Arizona Centre of Plastic Surgery, Tucson, AZ 85712, USA,
rmdryden@fl ash.net
Ufuk Emekli Department of Pathology, Istanbul University, Fevzi Pasa cad.

Sarachane Parki Yani Fatih, Istanbul, Turkey, @
Sorin Eremia Cosmetic Surgery Unit, Division of Dermatology, UCLA,
Brockton Cosmetic Surgery Center, 4440 Brockton, Suite 200, Riverside,
CA 92501, USA,
Anthony Erian Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK,

Gustavo Ferreira Velez Sorsfi eld 220, 1640 Martinez, Buenos Aires, Argentina,
drferreira@fi bertel.com.ar
Julio A. Ferreira Santiago Del Estero 102 (1640), Buenos Aires, Argentina,
drferreira@fi bertel.com.ar
Giorgio Fischer Via della Camiluccia, 643, 00135 Rome, Italy,
giorgiofi scher@fl ashnet.it
Pierre F. Fournier 55 Boulevard de Strasbourg, 75 010 Paris, France,

Joubin Gabbay 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Kiu Ghadjar 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA,

Felix-Rüdiger G. Giebler Vincemus-Klinik, Brückenstrasse 1a,
25840 Friedrichstadt/Eider, Germany,
Mark J. Glasgold Robert Wood Johnson Medical School,
University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA
31 River Road, Highland Park, NJ 08904, USA,
Robert A. Glasgold Robert Wood Johnson Medical School,
University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA,

Giovanni Guaraldi Department of Medicine and Medicine Specialities,
Infectious Diseases Clinic, University of Modena and Reggio Emilia School
of Medicine, Via del Pozzo 71, 41100 Modena, Italy,
Bahman Guyuron Department of Plastic Surgery, Case Western Reserve University,

Cleveland, OH 44124, USA,
xvi Contributors
Contributors xvii
Griffi th R. Harsh IV Department of Neurosurgery, Stanford University,
School of Medicine, Stanford, CA, USA
875 Blake Wilbur Drive CC2222, Stanford, CA 94305, USA,
Justin B. Heller 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Dustin M. Heringer Arizona Centre of Plastic Surgery, Tucson, AZ 85712, USA,

Enrique Hernandez-Pérez 7801 NW 37th St., Club VIP, Suite 369, Miami,
FL 33166-6503, USA,
José Enrique Hernández-Pérez Center for Dermatology and Cosmetic Surgery,
Pje. Dr. Roberto Orellana Valdé #137, Col. Médica, San Salvador CP 0-804,
El Salvador,
Mauricio Hernández-Pérez Center for Dermatology and Cosmetic Surgery,
Pje. Dr. Roberto Orellana Valdé #137, Col. Médica, San Salvador CP 0-804,
El Salvador,
Steven B. Hopping George Washington University, Washington, DC, USA
The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington,
DC 20037, USA,
Catherine Huang 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Ian T. Jackson Gretchen Hofman, Craniofacial Institute, 16001 West Nine Mile Road,
Third Floor Fisher Center, Southfi eld, MI 48075, USA,
Robert F. Jackson 330 North Wabash Avenue, Suite 450, Marion IN 46952, USA,

Reza Jarrahy Division of Plastic Surgery, 200 UCLA Medical Plaza, Suite 465,
Los Angeles, CA 90095, USA,
John K. Jones 6818 Austin Center Blvd, Suite 204, Austin, TX 78731-3100, USA,


Mitchell V. Kaminski Finch University of Health Sciences, Chicago Medical
School, 230 Center Drive, Vernon Hill, Chicago, IL 60061-1584, USA,

Kihwa Kang Department of Genetics and Complex Diseases,
Harvard School of Public Health, 665 Huntington Avenue, Bldg2,
Rm 129, Boston, MA 02115, USA,
Adam J. Katz Department of Plastic and Maxillofacial Surgery, University of
Virginia, P.O. Box 800376, Charlottesville, VA 22908-0376, USA,
Matthew R. Kaufman Drexel College of Medicine, Shrewsbury, NJ, USA
Plastic Surgery Center, 535 Sycamore Avenue, Apt. 732, Shrewsbury,
NJ 07702-4224, USA,
Hassan Abbas Khawaja Cosmetic Surgery and Skin Center, 53A, Block B II,
Gulberg III, 53660 Lahore, Pakistan,
Nancy Kim Oculoplastics Service, Department of Ophthalmology,
University of Wisconsin Hospitals and Clinics, 600 Highland Avenue,
F3-332, Madison, WI 53703, USA,
Edward B. Lack 2350 Ravine Way, Ste 400, Glenview, IL 60025, USA,

Samuel M. Lam Willow Bend Wellness Center, Lam Facial Plastic Surgery Center
and Hair Restoration Institute, 6101 Chapel Hill Boulevard, Suite 101, Plano,
TX 75093, USA,
Jongki Lee In & In Apt. 101-Dong 903-Ho, 834 Jijok-Dong Yooseong-Gu
Daejeon-City, Korea 305-330,
Qing Feng Li Department of Plastic and Reconstructive Surgery,
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine,
639 Zhizhaoju Road, Shanghai, PR China, 200011, liqfl
Rose M. Lopez de Vaughan Successful Longevity Clinic, 381 W. Northwest
Highway, Palatine, IL 60067, USA,
Todd P. Mangione Pasco Surgical Associates, 37840 Medical Arts Court,

Zephyrhills, FL 33541-4325, USA,
Daisuke Matsumoto Department of Plastic Surgery, University of Tokyo School
of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan,

Timothy A. Miller 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Sid J. Mirrafati 3140 Redhill Avenue, Costa Mesa, CA 92626, USA,

Sam P. Most Departments of Otolaryngology and Surgery (Plastic Surgery),
Division of Facial Plastic and Reconstructive Surgery, Stanford University,
School of Medicine, 801 Welch Rd, Stanford, CA 94305, USA,

Lina I. Naga The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205,
Washington, DC 20037, USA,
Joseph Niamtu 11319 Polo Pl., Midlothian, VA 23113-1434, USA,

Catherine O’Hara 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,
USA,
Defne Önel Plastic and Reconstructive Surgery Department, Medical Park Hospital,
Fevzi Pasa cad. Sarachane Parkı Yani Fatih, Istanbul, Turkey,

Dae Hwan Park Department of Plastic and Reconstructive Surgery,
College of Medicine, Catholic University of Daegu, 3056-6 Daemyung 4-dong Namgu,
Daegu, 705-718, Korea,
Luiz Haroldo Pereira Luiz Haroldo Clinic, Rua Xavier da Silveira 45/206,
22061-010, Rio de Janeiro, Brazil,
xviii Contributors
Contributors xix
Allison T. Pontius The Williams’ Center for Plastic Surgery,
1072 Troy Schenectady Road, Latham, NY 12110, USA,


Bernard I. Raskin Department of Medicine, Division of Dermatology,
Geffen School of Medicine at UCLA, Los Angeles, CA, USA,

John G. Rose Jr. Davis Duehr Dean and The Aesthetic Surgery Center,
Dean Health Systems, 1025 Regent Street, Madison, WI 53715, USA,

Katsujiro Sato Cellport Clinic Yokohama, Yokohama Excellent III Building 2F,
3-35, Minami-nakadori, Naka-ku, Yokohama, Japan,
Melvin A. Shiffman Department of Surgery, Tustin Hospital and Medical Center,
17501 Chatham Drive, Tustin, CA 92780-2302, USA,
Tetsuo Shu Daikanyama Clinic, 4F, 1-10-2 Ebisu-Minami, Shibuya-ku, Tokyo,
Japan 150-0022
Richard Simman 2130 Leiter Road, Suite 205, Miamisburg, OH 45342, USA,

Jason A. Spector Division of Plastic Surgery, Weill Medical College of Cornell
University, 525 East 68th Street, Payson 709, New York, NY 10065, USA,

Aris Sterodimas Department of Plastic Surgery, Ivo Pitanguy Institute,
Pontifi cal Catholic University of Rio de Janeiro, Rua Dona Mariana 65,
22280-020, Rio de Janeiro, Brazil,
Katsuya Takasu Takasu Clinic, 2-14-27 Akasaka, Kokusai-Shin-Akasaka Building,
Higashi-kan 2F, Minato-ku, Tokyo 107-0052, Japan,
Richard H. Tholen Minneapolis Plastic Surgery, Ltd., 4825 Olsen Memorial
Highway, Suite 200, Minneapolis, MN 55422, USA,
Lina Valero de Pedroza Carrera 16 No 82-95-Cons: 301, Bogotá DC, Colombia,

Fausto Viterbo Rua Domingos Minicucci Filho, 587, Botucatu – SP 18607-255,
Brazil,
Kristy Wasson 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,

USA,
Jeremy B. White Division of Otolaryngology Head and Neck Surgery,
George Washington University Washington, DC, USA
2440 Virginia Avenue, Apt. D710, Washington, DC 20037, USA,
Edwin F. Williams III Division of Otolaryngology-Head and Neck Surgery,
Department of Surgery, Albany Medical Center, Albany, NY 12208, USA
The Williams’ Center for Plastic Surgery, 1072 Troy Schenectady Road, Latham,
NY 12110, USA,
Larry M. Wolford 3409 Worth Street, Suite 400, Dallas, TX 75246, USA,

Yun Xie Department of Plastic and Reconstructive Surgery,
Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai,
PR China, 200011,
Kotaro Yoshimura Department of Plastic Surgery, University of Tokyo School of
Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan,

Danning Zheng Department of Plastic and Reconstructive Surgery,
Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai,
PR China, 200011, adizdn@@gmail.com
xx Contributors
Part
History, Principles, Fat Cell Physiology
and Metabolism
I
M. A. Shiffman (Ed.), Autologous Fat Transfer 3
DOI: 10.1007/978-3-642-00473-5_1, © Springer-Verlag Berlin Heidelberg 2010
1.1 Introduction
The history of autologous fat augmentation gives an
insight into the development of fat transfer for both cos-
metic and non-cosmetic problems. Transplantation of

pieces of fat and occasionally diced pieces of fat advanced
to the removal of small segments of fat by liposuction
after the development of the technique by Fischer and
Fischer, reported in 1975.
1.2 History
Neuber (1) reported the use of small pieces of fat from
the upper arm to reconstruct a depressed area of the
face resulting from tuberculosis osteitis. He concluded
that small pieces of fat, of bean or almond size, appeared
to have a good chance of survival. Czerny (2) used a
large lipoma to fill a defect in the breast following
resection of a benign mass. The transplanted breast,
however, appeared darker in color and smaller in vol-
ume than the opposite breast. Verderame (4) observed
that fat transplants solved the problem of shrinkage at
the transplant site. Lexer (3) reported personal experi-
ence with fat transplants and found that larger pieces
of fat gave better results. Bruning (5) used fat grafts
to fill a post-rhinoplasty deformity by placing fat in
a syringe and injecting the tissue through a needle.
Tuffier (6) inserted fat into the extrapleural space to
treat pulmonary conditions. Biopsy of the fat 4 months
post transplant showed that most of the fat was resorbed
and replaced by fibrous tissue.
Straatsma and Peer (7) used free fat grafts to repair
postauricular fistulas and depressions or fistulas result-
ing from frontal sinus operations. Cotton (8) used a
technique of broad undercutting and insertion of finely
cut fat that was molded to fill defects.
Peer (9) noted that grafts the size of a walnut appear

to lose less bulk after transplanting than do smaller
multiple grafts. He also found that free fat grafts lose
about 45% of their weight and volume 1 year or more
following the transplantation because of the failure of
some fat cells to survive the trauma of grafting as well as
the new environment. Fat grafts are affected by trauma,
exposure, infection, and excessive pressure from dress-
ings (10). Peer (11) stated that microscopically, grafts
appear like normal adipose tissue 8 months after trans-
plantation.
Liposuction was conceived by Fischer and Fischer
in 1974 (12) and put into practice in 1975 (13).
Fischer (14) first reported removal of fat by means of
5 mm incisions using a “rotating, alternating instrument
electrically and air powered.” This allowed aspiration of
fat through a cannula. Through a separate incision, saline
solution was injected to dilute the fat. In 1977 (15), they
reviewed 245 cases of liposuction with the “planotome”
for treatment of cellulite in the lateral trochanteric areas.
There was a 4.9% incidence of seromas despite wound
suction catheters and compression dressings. Pseudocyst
formation, which required removal of the capsule through
a wider incision and the use of the planotome, occurred
in 2% of cases.
The advent of liposuction spurred a move toward
using the liposuctioned fat for reinjecting areas of the
body for filling defects or augmentation. Bircoll (16)
History of Autologous Fat Transfer
1
Melvin A. Shiffman

1
M. A. Shiffman
Department of Surgery, Tustin Hospital and Medical Center,
17501 Chatham Drive, Tustin, CA, 92780-2302, USA
e-mail:
1
Reprinted with permission of Lippincott Williams & Wilkins.
4 M. A. Shiffman
first reported the use of autologous fat from liposuc-
tion for contouring and filling defects. Illouz (17)
claimed that in 1983, he began to inject aspirated fat.
Johnson (18) stated that in 1983, he began to use auto-
logous fat injection for contouring defects of the but-
tocks, anterior tibial area, lateral thighs, coccyx area,
breasts, and face. Bircoll (19) presented the method of
injecting fat that had been removed by liposuction.
Krulig (20) asserted that he began to use fat grafts by
means of a needle and syringe. He called the procedure
“lipoinjection.” He began to use a disposable fat trap
to facilitate the collection process and to ensure the
fat’s sterility. Newman (21) stated that he began rein-
jecting fat in 1985. The idea of utilizing the aspirated
fat, which was otherwise wasted, was an attractive idea
and other surgeons began to make use of the aspirate to
augment defects and other abnormalities.
The American Society of Plastic and Reconstructive
Surgery (ASPRS) Ad-Hoc Committee on New Proce-
dures produced a report on 30 September 1987, regard-
ing autologous fat transplantation (22). The conclusions
were:

1. Autologous fat injection has a historical and scien-
tific basis.
2. It is still an experimental procedure.
3. Fat injection has achieved varied results, and long-
term, controlled clinical studies are needed before
firm conclusions can be made regarding its validity.
4. Fat transplant for breast augmentation can inhibit
early detection of breast carcinoma and is hazard-
ous to public health.
Coleman and Saboeiro (23) reported success in fat
transfer to the breast and concluded that it should be
considered as an alternative to breast augmentation and
reconstruction procedures. Two of 17 patients had breast
cancer diagnosed by mammography, one 12 months and
the other 92 months after fat transfer to the breast.
Now fat transfer to the breast area is being used out-
side the breast itself, into the pectoralis major muscle
and behind and in front of the muscle. The fat is also
being used to augment tissues around the breast fol-
lowing treatment for breast cancer.
Although most of the fat transfer procedures are for
augmentation of tissues, there has been a surge of the
use of fat for non-cosmetic procedures.
References
1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche
Gesellsch Chir 1893;22:66.
2. Czerny V. Plastischer ersatz der brustdruse durch ein lipoma.
Chi Kong Verhandl 1895;2:126.
3. Lexer E. Freie fettransplantation. Deutsch Med Wochenschr
1910;36:640.

4. Verderame P. Ueber fettransplantation bei adharenten kno-
chennarben am orbitalrand. Klin Monatsbl fur Augenh 1909;
47:433–442.
5. Bruning P. Cited by Broeckaert, TJ, Steinhaus, J. Contribution
e l’etude des greffes adipueses. Bull Acad Roy Med Belgique
1914;28:440.
6. Tuffier T. Abces gangreneux du pouman ouvert dans les
bronches: Hemoptysies repetee operation par decollement
pleuro-parietal; guerison. Bull et Mem Soc de Chir de Paris
1911;37:134.
7. Straatsma CR, Peer LA. Repair of postauricular fistula by
means of a free fat graft. Arch Otolaryngol 1932;15:620–621.
8. Cotton FJ. Contribution to technique of fat grafts. N Engl
JMed 1934;211:1051–1053.
9. Peer LA. The neglected free fat graft. Plast Reconstr Surg
1956;18(4):233–250.
10. Peer LA. Loss of weight and volume in human fat grafts.
Plast Reconstr Surg 1950;5:217–230.
11. Peer LA. Transplantation of Tissues, Transplantation of Fat.
Baltimore, Williams & Wilkins, 1959.
12. Fischer G. The evolution of liposculpture. Am J Cosm Surg
1997;14(3):231–239.
13. Fischer G. Surgical treatment of cellulitis. Third Congress of
the International Academy of Cosmetic Surgery, Rome, 31
May 1975.
14. Fischer G. First surgical treatment for modeling body’s cel-
lulite with three 5 mm incisions. Bull Int Acad Cosm Surg
1976;2:35–37.
15. Fischer A, Fischer G. Revised technique for cellulitis fat
reduction in riding breeches deformity. Bull Int Acad Cosm

Surg 1977;2(4):40–43.
16. Bircoll M. Autologous fat transplantation. The Asian
Congress of Plastic Surgery, February 1982.
17. Illouz YG. The fat cell “graft”: A new technique to fill
depressions. PlastReconstrSurg 1986;78(1):122–123.
18. Johnson GW. Body contouring by macroinjection of autolo-
gous fat. Am J Cosm Surg 1987;4(2):103–109.
19. Bircoll MJ. New frontiers in suction lipectomy. Second Asian
Congress of Plastic Surgery, Pattiyua, Thailand, February 1984.
20. Krulig E. Lipo-injection. Am J Cosm Surg 1987;4(2):123–129.
21. Newman J, Levin J. Facial lipo-transplant surgery. Am J
Cosm Surg 1987;4(2):131–140.
22. American Society of Plastic and Reconstructive Surgery
Committee on New Procedures. Report in autologous fat
transplantation September 30,1987. Plast Surg Nurs 1987;
Winter:140–141.
23. Coleman SR, Saboeiro AP. Fat grafting to the breast revis-
ited: Safety and efficacy. Plast Reconstr Surg 2007;119(3):
775–785.
M. A. Shiffman (Ed.), Autologous Fat Transfer 5
DOI: 10.1007/978-3-642-00473-5_2, © Springer-Verlag Berlin Heidelberg 2010
2.1 Introduction
The survival of free fat used as an autograft is operator
dependent and requires delicate handling of the graft
tissue, careful washing of the fat to minimize extrane-
ous blood cells, and installation into a site with ade-
quate vascularity.
There is evidence that fat cells will survive and that
filling of defects is not from the residual collagen fol-
lowing cell destruction. There is some loss of fat after

transplant, and most surgeons tend to overfill the recip-
ient site.
2.2 Historical Review
Verderame (1) reported that autogenous fat grafts in ocu-
lar surgery became reduced in size and advised the use
of a larger transplant than that seemed necessary to fill
the defect. Lexer (2) claimed that manipulation and tear-
ing of the graft at the time of transfer would cause a great
degree of graft shrinkage. Kanavel (3) felt that graft sur-
vival was improved by not using suture to secure the
graft, careful hemostasis, and aseptic technique. He
transplanted sheets of fat varying from 0.25 to 1 in. in
thickness to prevent adhesions and contractures and
lessen deformity of tendons, nerves, blood vessels, and
joints. He felt that fat can be transplanted into any
ordinary field with the assurance that it will not act as a
foreign body. Clinically it appears to live, become a part
of the structure in which it is placed, and persists for
many months and probably years. Davis (4) concluded
that omentum, transplanted freely beneath the skin in a
mass, 1 in. in diameter, maintains the greater part of its
bulk. Lexer (5) reported excellent clinical results with
very large fat grafts but stated that up to 66% of the fat
autografts were absorbed and significant overcorrection
should be used. He stated that multiple small grafts
would turn to scar, while larger grafts would remain fatty
tissue. Mann (6) performed free transplant of omentum
fat and stated that it remained seemingly viable for as
long as 1 year and retained a small percentage of its fat.
Neuhof (7) examined available experimental and

clinical evidence and concluded that:
1. Transplanted autologous fat undergoes practically
some changes as transplanted bone.
2. The transplant dies and is replaced either by fibrous
tissue or by newly formed fat.
3. Newly formed fat occurs through the activity of a
large wandering histocyte-like cell, which takes on
fat and becomes a fat cell.
Guerney (8) noted that autogenous fat grafts should be
transplanted in larger bulk than required since only
25–50% of the graft survives 1 year after transplanta-
tion. He studied transplanted, 1.7 mm
3
(average size),
fat grafts over a period of 12 months in rats and con-
cluded that:
1. Liberation of fat by contiguous cells probably gives
rise to fatty cysts.
2. Phagocytosis of liberated fat was assisted by poly-
morphonuclear leucocytes.
3. The percentage of normal fat in any surviving graft
gradually increased throughout the year.
History of Autologous Fat Transplant
Survival
1
Melvin A. Shiffman
2
M. A. Shiffman
Department of Surgery, Tustin Hospital and Medical Center,
17501 Chatham Drive, Tustin, CA 92780-2302, USA

e-mail:
1
Reprinted with permission of Lippincott Williams & Wilkins.
6 M. A. Shiffman
4. A certain portion of the transplanted tissue gained
an adequate blood supply early and continued to
survive, while the remainder of the graft degener-
ated and was gradually eliminated from the site of
the implant without evidence of gross scar.
5. Crushed grafts eventually disappeared attesting to the
devastating effect of trauma on the vitality of a graft.
6. Single pieces of fat remain viable for at least 1 year,
while grafts of a similar size cut into smaller pieces
may last as long as 6 months, but the majority dis-
appear by the third month.
7. Absolute hemostasis is essential since even a slight
hemorrhage jeopardizes the viability of the graft.
8. Although slight infection results in only a small
loss of tissue, gross infection leads to a loss of the
whole graft.
9. Phagocyte cells do not use their fat to form new fat
cells during the first year after transplantation.
Hilse (9) showed histologically that free fat transplants
regenerate fatty tissue without any exception. He
referred to the histocyte filled with fat as a “lipoblast.”
Green (10) used fat and fat-fascia autografts in the
treatment of osseous defects secondary to osteomyeli-
tis. He presumed that transplanted fat would become
connective tissue and then bone, closing the defect.
Wertheimer and Shapiro (11) studied fat physiology

and determined that fat develops from primitive adi-
pose cells the structure of which is like that of the
fibroblasts of connective tissue.
Peer (12) implanted autogenous fat (single piece
compared to a piece cut into 20 segments) into the rec-
tus muscle. Grafts were removed at intervals from 3 to
14 months. Grossly all grafts were surrounded by a
connective-tissue capsule and, upon sectioning, the
bulk of the graft contained fatty tissue. Single grafts
(the size of a walnut) lost 45% of their weight while
multigrafts lost 79% of their weight. He concluded that
the fat grafts appeared like normal fat tissue 1 year or
more after transplantation.
Bames (13) noted that circulation in grafts is estab-
lished in about 4 days after transplantation by anastomo-
sis between the host and graft blood vessels. Traumatized
fat grafts lose much more weight and volume than gen-
tly handled transplants (50% loss after 1 year). Normal
appearing adipose cells were present in all the trans-
plants. Dermal-fat grafts provide a readily available
transplantation material for establishing normal contour
in small breasts instead of foreign implants.
Hansberger (14) proposed that histocytes phagocy-
tose the lipid and do not replace graft fat. After the
graft of mature autotransplanted fat goes through ini-
tial ischemia, fat cells either necrose or dedifferentiate
into immature cells. Under suitable conditions, the
immature fat cells revert to mature adipocytes.
Schorcher (15) reported using autogenous free fat
transplantation to treat hypomastia. He noted that the

connective elements remained intact with fat shrink-
age to 25% of the original size by 6–9 months. He
believed that if the graft was in several pieces, it would
receive better nourishment from the recipient site.
Van and Roncari (16, 17) demonstrated conversion
of adipocyte precursors into adult adipocytes, both in
vitro and in vivo, in rats. Saunders et al. (18) studied
fat autograft survival and observed initial adipose tis-
sue breakdown followed by revascularization. There is
early breakdown of fat cells with formation of cyst like
lipid deposits and infiltration by host histocytes.
Illouz (19) opined that the human body is an excel-
lent culture medium and that the fat cells apparently sur-
vive by intercellular lipolysis and osmosis until they are
revascularized. The area to be augmented should be over
corrected by 30% because approximately 30% necrosis
of fat cells results when using the wet technique.
Illouz (20) reported that fat transplantation in one
patient biopsied 9 and 16 months later, showed normal
fat cells.
Asken (21) found that 90% of fat extracted by liposuc-
tion appears viable, assuming it is not traumatized either
by handling or by high suction pressure. Damage incurred
by the adipocytes is inversely related to the diameter of
the instrument used for harvesting and injection.
Campbell et al. (22) noted, both morphologically and
biochemically, that adipocyte integrity and metabolism
remain intact when subjected to liposuction. Johnson
(23) examined liposuctioned fat and noted that 90% or
more of the fat cells remained viable. He found that there

was 75–85% of original fat present 3 months after trans-
plantation. Agris (24) claimed that trauma and desicca-
tion injured transplanted fat cells. Bircoll (25) stated that
the ASPRS report (26) of 30% survival and Peer’s report
(27) of 50% survival of autologous fat transplantation
were based on the older technique of bulk fat transfer.
Biopsies show 80% survival of fat after 1 year and an
additional bulk of 10–20% of fibrous tissue. Fat trans-
plants must be placed into the fatty subcutaneous tissue.
Billings and May (28) analyzed the histology of
free fat grafts and noted the following:
2 History of Autologous Fat Transplant Survival 7
Markman (29) has suggested that the number of fat
cells may increase, through differentiation of existing
preadipocytes, when fat cells reach a “critical size.”
Illouz (30) reported that fibroblast-like precursor
cells are able to multiply and give rise to fibroblasts or
cells that resemble fibroblasts. When these cells are
stimulated to absorb fat vacuoles with insulin or dex-
amethasone, they do not because adipocytes. He noted
that adipocytes are very fragile and have a short life
span outside the body. The cells live longer if mixed
with normal saline and kept at a moderate temperature.
They do not tolerate excessive manipulation, refrigera-
tion, or major trauma such as grinding.
Hudson et al. (31) demonstrated a greater cell size
and lipogenic activity (using measurement of activity
of lipogenic enzyme adipose tissue lipoprotein lipase
[ATLPL]) in the gluteal – femoral area compared to
the abdomen. Facial fat was found to have small cells

with almost no ATLPL activity. This may have impli-
cations for donor site suitability.
Nguyen et al. (32) compared suctioned fat, aspi-
rated fat, and excised fat 9 months after implantation.
Suctioned fat was obtained by using 1 atm negative
pressure and on microscopy, only 10% of the fat cells
were found with intact cell membrane. In all the grafts,
fat was replaced with fibrosis, and only a small number
of surviving adipocytes were still present.
Kononas et al. (33) compared the loss of fat fol-
lowing transplant between surgically excised fat cut
into small pieces and suctioned fat which was centri-
fuged. Weight loss was 59% for excised fat and 67%
for suctioned fat. Ersek (34) used a wire whisk to agi-
tate harvested fat and then strained it. He reported
disappointing results even with repeated injection
and concluded that little, if any, autologous fat sur-
vives in its new site.
Courtiss et al. (35) reported marginal success in fat
grafting of two patients with postliposuction depres-
sions. Asaadi (36) reported 5-year successful retention
of fat transplanted to a right trochanteric post-traumatic
depressed scar.
Samdal et al. (37) measured blood flow and the
amount of surviving fat following needle abrasion of
the recipient site in rats. Abrasion was performed by a
criss-cross pattern with 20 strokes using an 18 gauge
needle in the subcutaneous tissue prior to transplant and
compared this to controls without abrasion. They found
that the mean weight of the fat transplant had shrunk to

44.6% of the original weight in the abraded group and
33.5% in the control group. The mean blood flow in fat
was 0.165 mL/min/g in normal fat, 0.120 mL/min/g in
the controls, and 0.187 mL/min/g in the abraded group.
Microscopic examination of the transplanted fat varied
from oil cysts, connective tissue, and inflammatory cells
in some specimens and completely normal fatty tissue
in others. Fat survival varied from 0–90%. They con-
cluded that fat transplant survival was unpredictable.
Eppley et al. (38) reported that the addition of basic
fibroblast growth factor delivered by dextran beads to
fat grafts results in a larger weight maintenance of fat
at 1 year than controls.
Time (days) Histology
First 4 days Cellular infiltrate: polymorphonuclear cells, plasma cells, lymphocytes, eosinophils
With vessels of graft: red blood cells were clumped together, white blood cells were in the process of
diapedesis (passage of blood cells through intact vessel walls)
No degeneration of graft endothelial cells and fibroblasts of the stroma
Fourth day Engorgement and dilatation of smaller stromal vessels with abundant red blood cells and diapedetic white
blood cells (anastomoses between smaller graft vessels and host red blood supply). Increased number of
eosinophils in cellular infiltrate. Foreign-body type giant cells often seen
10 days Areas of necrotic adipose tissue. Regenerative proliferation of original fat cells mostly at periphery of lobules
– includes proliferating adipose cells of the graft and host round “histocyte-like” cells that took up lipid
and enlarged 14–21 days.
Further adipose cell breakdown.
Increasing number of large host histocytes that appear to be picking up lipid with formation of droplets
within their cytoplasm
30–60 days Increasing numbers of large histocytes which peak at 2 months. Coalescing of fat globules in the cytoplasm.
Group A
Fat alone

Group B Fat with dextran beads
Group C Fat with dextran beads soaked with
cytochrome C (nonmitogenic control
solution)
Group D Fat with dextran beads soaked with basic
fibroblast growth factor
8 M. A. Shiffman
Histologically, he noted extensive interlacing collagen
formation between the adiposites that provide support
for the known effects of basic fibroblast growth factor on
mesenchymal cell lines. There was an increased unifor-
mity in adipocyte size seen in 1 year grafts compared to
1 month grafts which may indicate a possible matura-
tion of these more “immature” cells. Whether this repre-
sents repair of damaged adipocytes, preadipocyte
differentiation, conversion of infiltrating macrophages
or fibroblasts, or entrapped lipid material is speculative.
Carpaneda and Ribeiro (39) examined fat 2 months
after transplantation and noted viable tissue only in the
peripheral zone of 3.5 mm diameter cylindrical grafts.
There was 60% loss of grafted tissue which occurred
closer to the center. They reported, in 1994 (40), that
graft viability depends on the thickness and geometric
shape and is inversely proportional to the graft diame-
ter if the diameter is greater than 3 mm. The maximum
percentage of viability is 40% when the graft is no
greater than 3.0 mm thick.
Niechajev and Sevchuk (41) reported 50% fat sur-
vival over 3.5 years after single fat transplantation with
50% overcorrection. They found that fat obtained under

maximum negative pressure (−0.95 atm) results in par-
tial breakage and vaporization of the fatty tissue. About
two-thirds of the fat withstood the trauma of aspiration.
Low pressure (−0.5 atm) resulted in smaller cell size
(29% smaller than with aspiration at −0.95 atm) and
they assumed that high pressure causes mechanical dis-
tention of the adipocytes which increases the risk of and
sometimes causes cell breakage.
Courtiss (42) stated that fat grafting remains contro-
versial and poorly understood and that “some surgeons
have some impressive results, but most of us have many
disappointing results.” Fagrell et al. (43) examined fat
6 months after implantation in the ears of rabbits. The
fat implanted was obtained by:
1. Fat cylinder retrieved with 4.5 mm internal diameter
syringe pushed into the fat and pulling the piston back.
2. Excised fat, 1 mg in weight.
3. Aspirated fat using 2 mm (14 gauge) cannula and
syringe.
The tissue was examined by light microscopy and
computer-assisted image analysis. There was no dif-
ference between the weight of the 6 month excised
specimen (no weight loss) between the fat cylinder and
excised fat, but there was a 59% loss of weight of the
aspirated fat. The conclusion was that fat aspiration is
traumatic and breaks up the cells. However, there was
histologic evidence of viable fat cells in all
transplants.
Jones and Lyles (44) harvested fat with a 60 mL
syringe, 3.0 mm pyramid cannula, and locked the plunger

at 35 mL. The harvested fat was washed three times with
normal saline and gently agitated. Cell cultures were pre-
pared and maintained for 1 day to 2 months. Microscopy
disclosed maintenance of mature adipose cells without
dedifferentiation into a precursor phenotype. There was
very little evidence of cellular damage or debris.
Using photographs over a 6 year period of time,
Coleman (45) demonstrated long-term survival of lipo-
suctioned fat transplanted into the nasolabial fold. He
stated that fat can migrate as the pressure of excess tis-
sue forces the transplanted fat to shift and that fat can
die from inadequate nutrition and oxygen from compe-
tition with other transplanted parcels of fatty tissue.
Placement of fat into multiple tunnels allows closer
location to nutrition. He concluded that fat survival is
technique dependent and the primary reason for failure
of long-term correction of the nasolabial fold is initial
inadequate correction.
Sattler and Sommer (46) found that autologous fat,
dried over sterile swabs and frozen at −20°C (lower
temperatures down to −70°C are preferable) up to 2
years and then thawed at room temperature, contains
only fat cells and no fibrous debris.
Ullmann et al. (47) added Cariel, a modified
serum-free cell culture medium (MCDB 153), to
aspirated human fat prior to reinjection into mice.
Cariel contains essential and nonessential amino
acids, vitamins, inorganic salts, trace elements, buf-
fers, thyroxin, growth hormone, insulin, and sodium
selenite. There was 46% of the weight of the fat

remaining after 15 weeks in the group with Cariel
compared to 29% in the control without Cariel. They
concluded that the addition of nutrients enriched with
anabolic hormones enabled the survival and take of
more adipose cell in the graft. United States Patent
(Lindenbaum) Composition and methods for enhanc-
ing wound healing. Patent No. 5461030. Date of
patient: 24 October 1995.
Group Weight retention after
12 months (%)
A 48.8
B 79.6
C 75.2
D 93.8
2 History of Autologous Fat Transplant Survival 9
References
1. Verderame P. Ueber fettransplantation bei adharenten kno-
chennarben am orbitalran. Klin Montsbl f Augenh 1909;
7:433.
2. Lexer E. Ueber freie fettransplantation. Klin Therap Wehnschr
1911;18:53.
3. Kanavel AR. The transplantation of free flaps of fat. Surg
Gynecol Obstet 1916;23:163–176.
4. Davis CB. Free transplantation of the omentum, subcutane-
ously and within the abdomen. J Am Med Assoc 1917;68:
705–706.
5. Lexer E. Fatty tissue transplantation. In: Die Transplantation,
Part I. Stuttgart, Ferdinand Enke, 1919, pp. 265–302.
6. Mann FC. The transplantation of fat in the peritoneal cavity.
Surg Clin N Am 1921;1:1465–1471.

7. Neuhof H. The Transplantation of Tissues. New York,
D. Appleton, 1923, p. 74.
8. Guerney CE. Experimental study of the behavior of free fat
transplants. Surgery 1938;3:679–692.
9. Hilse A. Histologische ergebuisse der experimentellen freien
fettgewebstronsplantation. Beitr 2 Path Anal U Z Allg Path
1928;79:592–624.
10. Green JR. Repairing bone defects in cranium and tibia.
South Med J 1947;40:289.
11. Wertheimer E, Shapiro B. The physiology of adipose tissue.
Physiol Rev 1948;28:451.
12. Peer LA. Loss of weight and volume in human fat grafts: With
postulation of a “cell survival theory.” Plast Reconstr Surg
1950;5:217–230.
13. Bames HO. Augmentation mammoplasty by lipotransplant.
Plast Reconstr Surg 1953;11(5):404–412.
14. Hansberger FX. Quantitative studies on the development of
autotransplants of immature adipose tissue of rats. Anat Rec
1995;122:507.
15. Schorcher F. Fettgewebsver pflanzung bei zu kneiner brust.
Munchen Med Wochenschr. 1957;99(14):489.
16. Van RL, Roncari DA. Complete differentiation of adipocyte
precursors: A culture system for studying the cellular nature
of adipose tissue. Cell Tiss Res 1978;195(2):317–329.
17. Van RL, Roncari DA. Complete differentiation in vivo of
implanted cultured adipocyte precursors from adult rats.
Cell Tiss Res 1982;225(3):557–566.
18. Saunders MC, Keller JT, Dunsker SB, Mayfield FH. Survival
of autologous fat grafts in humans and mice. Connect Tiss
Res 1981;8(2):85–95.

19. Illouz YG: New applications of liposuction. In Illouz YG
(ed), Liposuction: The Franco-American Experience. Beverly
Hills, CA, Medical Aesthetics, 1985, pp. 365–414.
20. Illouz YG. The fat cell “graft”: A new technique to fill depres-
sions. Plast Reconstr Surg 1986;78(1):122–123.
21. Asken S. Autologous fat transplantation: Micro and macro
techniques. Am J Cosm Surg 1987;4:111–121.
22. Campbell GL, Laudenslager N, Newman J. The effect of
mechanical stress on adipocyte morphology and metabolism.
Am J Cosm Surg 1987;4:89–94.
23. Johnson GW. Body contouring by macroinjection of autog-
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