Fat Grafting Practices and Preferences, Are We Any Closer to a Standardized Approach? A Survey Providing Insights on Current Trends in Small and Large Fat Grafting

Abstract

INTRODUCTION: Fat grafting has revolutionized plastic surgery practices since Coleman brought it to the frontline in 1995, and it is now used in a variety of areas ranging from breast reconstruction to regenerative medicine. However, due to a lack of evidence-based studies, multicenter, prospective, and/or randomized trials, we still don’t recognize which variables influence fat grafting’s positive clinical outcomes. METHODS: Following International Society of Plastic Regenerative Surgeons (ISPRES) Board approval, a 30-item questionnaire online survey was designed for distribution to a randomized cohort of ISPRES members) from 2nd July to 16th July 2021, participation in the survey was voluntary and participants could exit the survey without submitting their responses at any time. No participant compensation was provided. The questionnaire was designed to delineate in addition to demographic information, experience, practices, and beliefs among surgeons with regard to the use of autologous fat for contour restoration. RESULTS: The survey was completed by 62 ISPRES members, with 93.5% of the participants having Plastic Surgery Board Certification Status. The mean age of the surveyed members was 53 (9.7). The majority of the members (69.4%) work predominantly in aesthetic plastic surgery. Experience with Large-volume Fat Grafting Donor Site Selection The most commonly used donor area selection criteria were based on the patient’s fat availability (59.7 percent). In addition, 35.5 percent said they preferred to go directly to the abdomen, and only three (4.8 percent) said the patients chose the donor area. Nevertheless, when asked which zones they prefer to remove fat, when possible, abdomen (88.7%) was the commonest site, followed by flanks (62.9 percent). Fat Grafting Harvesting Infiltration Solution, Harvesting Instrument and Technique The most common infiltration solutions used in high volume fat transfers are the 3: 1 ratio tumescent solution (41.9 percent), secondly the super wet solution (40.3 percent) and thirdly the wet solution {100-300 ml of liquid (with or without epinephrine) at each site to be treated} (14.5 percent). Most respondents chose multiple options for the preferred cannula size, tip, holes and method used for fat harvest. The most common instrument preferred for large-volume fat harvesting amongst the respondents are 3-4mm cannulas (69.5 percent). Respondents’ preference of type of cannula tip and holes for fat harvest in large-volume procedures were the three-hole standard cannulas. Handheld suction (59.7 percent) was the most preferred fat harvest method followed by vacuum machine suction (46.8 percent.) Fat Graft Processing Following fat harvest, 56.5 percent (n=35) respondents (without exclusivity) performed decantation of fat, 43.5 percent performed centrifugation. Routine addition of PRP (platelet-rich-plasma) and adipose stem cells have been reported by 12.9 percent and 9.7 percent respondents respectively. Furthermore, 13 respondents report employing additional processing steps to isolate, prepare and store adipose stem cells. Fat Injection For handheld injections (without exclusivity), respondents prefer 1-2mm cannula with 1cc syringe (58.1 percent), closely followed by 1-2mm cannula with 10cc syringe (56.4 percent). Assessment of Outcome Preoperative and postoperative picture evaluation (59.6 percent) and clinical assessment (20.9 percent) were the most commonly used for assessment of fat graft survival by respondents. Only 14.5 percent of participants use preoperative and postoperative 3D images to evaluate. Fat Transfer in Cosmetic Breast Augmentation and Application of Pre-expansion Devices for Breast Augmentation The most commonly preferred plane for fat injection in cosmetic breast augmentation were gland and subcutaneous tissue. Only 8.1 percent (n=5) respondents routinely use pre-expansion devices for breast augmentation before fat grafting. Experience with Small-volume Fat Grafting The majority (53.3 percent) of the responders performed none or less than 25 percent of the small volume fat grafts under general anesthesia. Although there are almost 29 percent of surgeons who apply general anesthesia in 50 percent or more of them, being that 8 percent of them perform almost all surgeries with general anesthesia. CONCLUSION: Evidence-based studies incorporating randomized controlled, prospective, multicenter trials are imperative to understand which variables influence positive fat grafting clinical outcomes. Our research shows preliminary findings analyzing the current practices and preferences of the ISPRES community. The respondents’ tendencies were similar to previous literature, with some exceptions, such as the technique for preparing fat and enrichment, as well as the disparity in responses in the use of cannulas. A cross-sectional survey study of a wider scope, involving national delegates and global representatives of plastic surgeons is anticipated.