Fat Grafting Procedures Research Articles

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis.

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis. The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis. A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed. Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed. Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

Autologous Fat Grafting with or without Processing: A Study in an Indian Clinical Context.

Background:Although fat grafting has become an attractive method of correction of soft tissue deficiencies, variability in results exists. As the understanding of mechanism of survival of graft improves, the concepts regarding fat grafting change. There are many ways to process the aspirated fat with no clear method superior.Aim:The aim of this study was to evaluate the role of processing during autologous fat transfer.Materials and Methods:The patients were serially divided into two groups, namely, A and B. Harvesting of lipoaspirate and injection of fat were same in both the groups. In group A, no processing was done. In group B, the fat was processed by sedimentation and injected. Patient satisfaction was assessed following the procedure and statistical analysis was done using the Mann–Whitney U-test.Results:Young females between 21 and 30 years formed the majority of patients who opted for fat grafting procedure. Most of the procedures were performed for defects in the face (93.3%). The most common indication of fat grafting was contour deformities, with abdomen being the most preferred donor site. The mean patients’ satisfaction following fat grafting without processing is 2.2 ± 0.68. The mean patients’ satisfaction following fat grafting with processing is 2.53 ± 0.99.Conclusion:There was not a statistically significant difference in patient outcomes following fat grafting, with or without processing, in terms of patient satisfaction. Autologous fat grafting was found to be a safe procedure with no significant complications.

The safety and efficacy of autologous fat grafting during second stage breast reconstruction

Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

Postirradiation Capsular Contracture in Implant-Based Breast Reconstruction: Management and Outcome.

Implant-based breast reconstruction is commonly avoided in the setting of radiation therapy, mainly because of risks of capsular contracture. Nevertheless, as breast reconstruction is becoming more available, more patients undergo both implant-based breast reconstruction and radiotherapy. The dilemma is how to manage capsular contracture if it does occur. The goal of this study was to examine the outcome of patients with implant-based breast reconstruction who developed postirradiation capsular contracture and were treated with capsulotomy or capsulectomy, with or without fat grafting. The authors reviewed charts of patients who developed capsular contracture following alloplastic breast reconstruction followed by radiation therapy, between 2008 and 2018. The surgical treatment methods for capsular contracture were evaluated along with their outcomes. A follow-up of at least 1 year was required. Forty-eight breasts with postirradiation capsular contracture underwent surgical implant exchange with capsular release, of which 15 had combined fat grafting and 33 did not. Overall, 35 breasts (72.9 percent) showed long-term resolution of capsular contracture; 24 underwent a single procedure and 11 required an additional fat grafting procedure. Some patients [six breasts (12.5 percent)] were offered a consecutive round of fat grafting, and some [seven breasts (14.5 percent)] were offered autologous reconstruction because of lack of improvement. Fat grafting increased the success rate by more than 30 percent when it was initially and consecutively used. Postirradiation capsular contracture may be treated successfully by secondary procedures, sustaining implant-based breast reconstruction in over 70 percent of breasts. Fat grafting may elevate resolution rates even further, to 86 percent. Larger prospective studies are required to validate these findings. Therapeutic, III.

Evaluation of a new adipose tissue processing method for breast and buttock fat grafting procedures

BackgroundThere is still some debate about the best adipose processing method for autologous fat transfer procedures. This article reports a series of 66 fat grafting procedures using a novel fat processing technique that involves washing, “micronization,” and decantation.MethodsWe retrospectively reviewed the files of all patients operated on over a 2-year period by the two investigators. They underwent breast or buttock surgery that employed the novel fat processing technique for fat transfer. Complications and patient satisfaction were recorded, and fat resorption was qualitatively assessed based on clinical examination and photographs.ResultsData were retrieved from a total of 66 procedures performed on 43 patients: 17 breast augmentations, 8 buttock augmentations, and 41 breast reconstructions. Five patients also underwent concomitant facial fat grafting. The complications were one case of transient liponecrotic cyst in the breast, one case of transient areolar sensitivity reduction, and two cases of infection. The infections were reported in patients from the breast reconstruction cohort who had a history of radiotherapy. There was no complication associated with facial fat grafting. Patient satisfaction was achieved in 82.4 to 92.5% of cases depending on the study cohort. Fat resorption was graded as minimal to moderate in 95% of all cases.ConclusionsThis retrospective study supports the safety and effectiveness of this novel fat processing method in breast and buttock surgeries. Further controlled studies are needed to compare its performance with that of other techniques.Level of evidence: Level III, therapeutic study

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction.

Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making. A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures. Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05). Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons. Therapeutic, III.

Abstract 81: The Role Of Topical Tranexamic Acid (TXA) In Autologous Fat Transfer: A Single Institutional Outcomes Analysis And Considerations For Minimizing Postoperative Donor Site Ecchymosis

Purpose: Autologous fat grafting is an invaluable tool which has revolutionized breast reconstruction. However, there has been limited data on the use of pharmacologic agents to mitigate donor site ecchymosis. Antifibrinolytic medications, such as tranexamic acid (TXA) have been demonstrated to safely mitigate ecchymosis, edema, and intraoperative blood loss in plastic surgery procedures. As such, the authors investigate whether topical TXA safely reduces the degree of ecchymosis at liposuction donor sites following autologous fat grafting in the setting of breast reconstruction. Methods: A single-center, single-surgeon retrospective cohort study was performed to analyze all consecutive patients undergoing autologous fat transfer as part of second-stage breast reconstruction between 2016-2019. In all patients, the donor site was infiltrated with Klein’s tumescent solution. Once lipoaspiration was complete, patients in the intervention group received a total of 75mL of topical TXA (3g in NaCl 0.9%) into the harvest donor sites delivered via a spray applicator, whereas the patients in the historical control group did not receive TXA. The primary endpoint was degree of ecchymosis, which was graded on an ordinal assessment tool previously published by Hunstad et al. (1= no bruising” through 10= extremely bruised”). Secondary outcome measures included hematoma, seroma, and thromboembolic events. A double-blinded randomized assessment of postoperative photographs of the donor sites was performed by senior plastic surgery residents and research fellows. Comparative analysis of continuous variables and categorical variables were performed using the Mann-Whitney-Wilcoxon and Fisher’s exact tests, respectively. A value of p<0.05 was considered significant. Results: A total of 120 consecutive autologous fat grafting procedures for breast reconstruction were reviewed. Overall, 60 patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar amongst the groups. There was no difference between groups with regards to donor site locations. There was no difference in volume of tumescent injected amongst the groups. The median tumescent volume infiltrated in the TXA group was 1600mL (range: 1200-2400mL), and 1750mL (range: 800-2500mL) in the non-intervention group (p=0.86). Median volume of lipoaspirate amongst the TXA and control groups was similar: 317.5mL (range: 45-750) vs. 267.5mL (range: 55-905), p=0.44. A total of 10 blinded evaluators completed the assessment (7 senior plastic surgery residents and 3 research fellows). Average time to postoperative photograph for the TXA group was 14±13 days vs. 10.3±6.2 days for the non-intervention group (p=0.11). The median bruising score of patients who received TXA was significantly lower than the patients who did not (1.6/10 vs. 2.3/10, p=0.01). Postoperative complications, including hematoma, seroma, and thromboembolic events were similar amongst the groups. Adverse effects of TXA were not observed. Conclusion: As the role of TXA in plastic surgery increases, there remains a recognizable gap in the literature with regards to its use in autologous fat transfer procedures. Although, further prospective randomized studies are warranted, the authors demonstrate that patients who received topical TXA into the liposuction donor sites were found to have less donor site ecchymosis compared to patients who did not receive TXA.

Abstract 42: The Influence Of Fat Grafting On Breast Imaging After Post-mastectomy Reconstruction: A Matched Cohort Analysis

Purpose: Fat grafting is a common adjunct procedure in breast reconstruction. While shown to have a safe oncologic profile, it may result in the development of palpable masses on physical exam, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidences of palpable masses, imaging, and biopsies after post-mastectomy breast reconstruction. Methods: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010-2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched in a 1:1 ratio to those that did not undergo a fat grafting procedure with BMI, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. Results: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Patients that underwent fat grafting had higher incidences of palpable masses (38.0% vs. 18.3%; p=0.003) and post-reconstruction imaging (47.3% vs. 29.0%; p=0.01). However, there was no significant difference in the number of biopsies performed between patients who did and did not receive fat grafting (11.8% vs. 7.5%; p=0.32). When looking at imaging characteristics amongst the fat grafted cohort, imaging was predominately interpreted as normal (BIRADS 1, 27.9%) or benign (BIRADS 2, 48.8%), with fat necrosis being the most common finding (n=20, 45.5%). No demographic, oncologic, reconstructive, or fat grafting-specific variables were independently predictive of receiving post-reconstruction imaging in multivariate analysis when controlling for follow-up time. On Kaplan-Meier analysis, fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. Conclusions: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent post-reconstruction imaging. However, fat grafted patients do not undergo more biopsies, owing to the successful identification of fat-related changes on imaging. Thus, patients should be counseled in the preoperative period that they may be more likely to detect a palpable mass following fat grafting, and may be subject to more diagnostic imaging. Patients should be reassured, however, that fat grafting has a safe oncologic profile and does not affect overall or locoregional recurrence-free survival.

Volume Retention After Facial Fat Grafting and Relevant Factors: A Systematic Review and Meta-analysis

Autologous fat grafting is common in facial reconstructive and cosmetic surgeries; the most important drawbacks are the high absorption rate and unpredictable volume retention rate. Surgeons usually make clinical judgements based on their own experience. Therefore, this study aimed to systematically and quantitatively review the volume retention rate of facial autologous fat grafting and analyse the relevant influencing factors. A systematic literature review was performed using the Medline, EMBASE, Cochrane Library, and Web of Science databases in October 2019 for articles that reported objectively measured volume retention rates of facial fat grafting. Patient characteristics, fat graft volumetric data, and complications were collected. A meta-analysis using a random-effects model was conducted to pool the estimated fat retention rate. Relevant factors were analysed and reviewed on the basis of subgroups. We included 27 studies involving 1011 patients with facial fat grafting. The volume retention rate varied from 26 to 83%, with a mean follow-up of 3-24months. The overall pooled retention rate was 47% (95% CI 41-53%). The volume measurement method significantly influenced the reported retention rate. A trend towards better retention was found for secondary fat grafting procedures and patients with congenital deformities. Only 2.8% of all patients had complications. The exact percentage of facial fat grafts retained is currently unpredictable; the reported rate varies with different estimation methods. This review analysed studies that provided objectively measured volume retention rates, the pooled average percentage of facial fat graft retention (47%, 95% CI 41-53%), and relevant factors. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Update on Cryopreservation of Adipose Tissue.

Currently, fat transplantation occurs immediately after harvesting procedures. Because low rates of fat graft take are well reported in the literature, many patients require multiple surgical procedures for fat graft harvest. These subsequent procedures lead to increased cost, donor-site morbidity, and patient discomfort in the long term. The ability to preserve our patients' own adipose aspirate would allow us to counteract these shortcomings and ultimately improve the clinical outcome after fat grafting. Unfortunately, there is no optimal and practical adipose tissue cryopreservation protocol for use by the plastic surgeon at the present time. Because of this dilemma, the senior author (L.L.Q.P.) has investigated this concept in an effort to create a protocol that is both technically sound and clinically achievable to allow for the long-term preservation of adipose tissue. In this article, the authors aim to outline this effort, review current clinical applications that have been reported in the literature, and detail exciting future perspectives in the use of preserved lipoaspirates for repeated fat grafting procedures or in the form of cell-based therapy engineered for reconstructive endeavors for their patients.

Comparative Analysis of Two Automated Fat-processing Systems.

Background:Plastic surgeons desire more efficient methods of processing lipoaspirate when performing fat grafting procedures. We compared, in a preclinical study, the quantity and quality of lipoaspirate processed by a novel Poloxamer Wash, Absorption, mesh filtration System (PWAS) to a frequently used Ringer’s Lactate wash, Decant, and mesh filtration System (RLDS).Methods:Lipoaspirate from 10 patients was processed with the RLDS and PWAS systems. The processed lipoaspirate from each device was centrifuged to quantify the amount of fat, free oil, and aqueous components remaining in the fat graft. A trypan blue dye exclusion test assessed cell viability. The processing time for the lipoaspirate was also measured.Results:The 10-patient average fat volume processed and available for grafting was similar using both systems. The adipose volume fraction of PWAS was greater (89% ± 3%) than RLDS (76% ± 10%, P = 0.02). The trypan blue exclusion values and processing time were similar for both systems. Oil was efficiently removed from the lipoaspirate, and both systems processed fat efficiently.Conclusion:The PWAS effectively cleans lipoaspirate with increased fat concentration.

Comparison of adipose particle size on autologous fat graft retention in a rodent model

Aim: Unpredictable retention outcomes remain a significant issue in autologous fat grafting procedures. Liposuction cannula variation leads to variability in fat particle size. Recent data suggest that the size of fat particles is closely related to graft healing outcomes; however, this remains a point of contention due to potential confounding variables such as tissue trauma with harvest. The aim of this study was to compare autologous fat grafting outcomes with variable fat particle sizes in an animal model which isolated fat particle size as the primary experimental variable. The overall goal of this work was to determine if reducing fat particle size is an effective method for enhancing graft retention in autologous fat grafting. Methods: The range of fat particle diameter harvested by four common liposuction cannulas was quantified to define relevant small and large particle target diameters. To determine if particle size impacted nutrient and oxygen permeability, small and large particles were incubated in vitro in a spinner flask with an abundance of culture media and vascular endothelial growth factor secretion was measured with enzyme-linked immunosorbent assay. Finally, small and large fat grafts were prepared from subcutaneous mouse fat pads and grafted in syngeneic Balb/CJ mice. Weight and volume retention were evaluated at 1, 4, 8, and 12 weeks. Histological analysis with Masson’s trichrome and perilipin immunofluorescent staining was performed. Real-time quantitative polymerase chain reaction was performed for adipogenic, inflammatory and apoptotic genes. Results: The range of fat particle diameters harvested with four commonly used cannulas was 2-7 mm. In vitro studies showed that 5-7-mm particles had significantly increased VEGF secretion normalized to weight, indicating increased tissue hypoxia in these particles compared to 2-4-mm particles. Surprisingly, in vivo comparison in two unique studies showed 2-4-mm and 5-7-mm fat particles had comparable graft retention (P = 0.5329). Masson’s trichrome staining revealed increased extracellular matrix and fibrosis in the 5-7-mm particle group (P = 0.0115). Adipocyte survival with perilipin demonstrated comparable viability. Gene expression showed large particles experienced increased inflammation and apoptosis at one week after grafting, but overall there were no significant differences between groups. Conclusion: The ideal fat particle size should be large enough to contain adequate mesenchyme while not so thick as to preclude imbibition. This study suggests that, despite changes in hypoxia and VEGF levels, differing fat particles (2-4-mm and 5-7-mm) can achieve similar graft retention.

A Comparison of Fat Graft Processing Techniques: Outcomes in 1,158 Procedures in Prosthetic Breast Reconstructions.

Background:As fat grafting in breast reconstruction evolves, questions of technique and outcomes persist. We compared 2 common fat processing techniques—decantation (DEC) versus closed wash and filtration (CWF)—with regard to outcomes and efficacy.Methods:Chart review of a single surgeon experience with breast fat grafting was performed. Data extracted included demographics, technique, complications, graft volume, and revision rates. Secondarily, the timeline of complication profiles was analyzed. Lastly, subgroup analysis of radiated versus nonradiated breast outcomes was performed.Results:One thousand one hundred fifty-eight fat grafting procedures were performed on 775 breasts (654 DEC, 504 CWF). Time-to-event analysis for all complications showed no difference between groups. Independent risk factors for fat necrosis included DEC technique, body mass index >30 kg/m2, and fat injection >75 mL. The majority of cases of fat necrosis, cyst/nodule formation, ultrasounds, and biopsies occurred more than 6 months after grafting. Average graft volume was lower in DEC compared with CWF breasts (50.6 versus 105.0 mL, P < 0.01), and more DEC breasts required repeat fat grafting procedures (39.9% versus 29.6%, P < 0.01). Radiated breasts received larger fat graft volume (89.9 versus 72.4 mL, P < 0.01) and required more fat graft procedures (average 1.62 versus 1.47, P < 0.01).Conclusions:This study represents the largest series of breast reconstruction fat grafting to date. DEC harvest technique may be a risk factor for fat necrosis, which results in less fat injection and greater need for repeat procedures. Similarly, radiated breasts require larger graft volume and more repeat procedures.

Autologous Fat Grafting for the Treatment of Mild to Moderate Velopharyngeal Insufficiency.

To assess speech results following the treatment of mild to moderate velopharyngeal insufficiency (VPI) post cleft palate surgery with autologous fat grafting to the velopharynx. A retrospective study was conducted on 9 consecutive patients who underwent velopharyngeal fat grafting for the treatment of VPI at the Red Cross War Memorial Children's hospital from 2010 to 2014. All the patients previously had primary palatoplasty performed and subsequently developed VPI. Patients were assessed pre- and postoperatively by an experienced speech and language therapist looking at perceptual speech and by 2 senior cleft surgeons interpreting lateral view videofluoroscopies. Eleven fat grafting procedures were performed on 9 patients and an average of 5.64 mL (range 1-7 mL) of autologous fat was transferred to the velopharynx. The average age at the time of operation was 6.5 years (range 3-14 years) with a follow-up period of 18 months (range 7-34 months). Most of the patients (7 out of 9) showed improved speech after fat grafting. One of the 7 patients had multiple procedures. The 2 who did not show speech improvement only had a single procedure. There were no complications related to the fat grafting procedure. This small study suggests that fat grafting either as a single procedure or as multiple procedures is an effective, safe, minimally invasive surgical alternative, and/or adjunct for the treatment of mild to moderate VPI in patients following cleft palate surgery and to the knowledge, is the first reported study from Africa.

The use of autologous fat grafts in breast surgery: A literature review.

Autologous fat injection was first described roughly a century ago and has been used in surgery ever since. In addition to its use in many surgical fields, it is also frequently used for both aesthetic and reconstructive purposes in breast surgery. Since the application of fat grafting in breast surgery has steadily increased, studies investigating its reliability have simultaneously become increasingly common. Previous studies have reported that the use of fat grafting in breast surgery is reliable, but some pending questions remain about its routine use. In order to use fat grafts successfully in breast surgery, it is necessary to be familiar with the structure and content of adipose tissue, the efficacy of adipose stem cell-enriched fat grafts, the oncological safety of fat grafts, and the problems that may occur in the radiological follow-up of patients who undergo fat grafting procedures. In this literature review, we aim to discuss the use of fat grafts in breast surgery by investigating these common problems.

Forehead Fat Grafting: Asian Facial Contouring and Augmentation.

Aesthetic facial contouring procedures, particularly forehead augmentation, continue to increase in popularity in the Asian population. However, there are very few reports in the literature specifically examining the long-term outcomes of forehead fat grafting. In the present study, the authors aimed to objectively evaluate the efficacy of autologous forehead fat grafting through evaluation of facial proportions and patient-reported outcomes. Patients who underwent autologous fat grafting for forehead contouring procedures between July of 2011 and June of 2017 were recruited for participation in the study. Patient demographic and clinical variables were collected preoperatively and postoperatively. Facial proportion analysis was collected and compared from preoperative and postoperative photographs. Satisfaction with outcome was assessed by the patient, the surgeon, and a layperson postoperatively. A related-samples Wilcoxon signed rank test was used for statistical analysis. Postoperative outcomes were evaluated in a total of 24 patients who underwent forehead autologous fat-grafting procedures. The average postoperative follow-up was 8.1 months. There were no intraoperative or postoperative complications. More than 50 percent of the postoperative results were evaluated as "satisfactory" by all three groups (i.e., patient, surgeon, and layperson) in terms of aesthetic contouring. Average forehead projection increased 0.24 U (ratio of horizontal distance from midforehead plane to cornea plane/cornea diameter) after one round of fat grafting (p = 0.01). Seven patients (29.2 percent) required more than a single round of fat grafting to achieve optimal results. Autologous fat grafting remains a viable option for forehead contouring and augmentation. The findings of this study demonstrate that the operation is effective and offers stable satisfactory results after long-term follow-up. Therapeutic, IV.

Comparison of the Pedicled Latissimus Dorsi Flap With Immediate Fat Transfer Versus Abdominal-based Free Flaps for Breast Reconstruction

PURPOSE: Abdominally based free flaps and the latissimus dorsi and immediate fat transfer (LIFT) procedure are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique while the LIFT combines a common set of techniques familiar with all plastic surgeons. Comparison of the 2 methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making. METHODS: A retrospective review was performed to analyze outcomes of both patients who underwent the LIFT procedure and patients who underwent abdominal-based flaps between March 2017 and July 2018 by the senior surgeon. Data were analyzed per breast. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat grafting procedures. Continuous variables between the 2 groups were compared using the 2-sample t test. Categorical variables were compared using Pearson’s chi-square and Fischer’s exact tests as appropriate. RESULTS: Sixty-five breasts were identified as having undergone abdominal-based flap procedures, and 31 breasts underwent the LIFT procedure. Average follow-up time was 8 months (± 4.6 months) for the abdominal-based flap patients and 7.9 months (± 4.2 months) for the LIFT patients (P > 0.05). Demographics were not statistically different between the 2 flap cohorts (P > 0.05). This includes age, body mass index (abdominal-based flaps, 29.9 ± 4.76; LIFT, 28.2 ± 6.2 kg/m2), diabetes mellitus, hypertension, connective tissue disease, and current tobacco use. Additionally, the use of neoadjuvant chemotherapy and adjuvant radiation was not statistically different between the 2 groups (P > 0.05). The LIFT procedure cohort had a shorter length of operation time (375 ± 136 minutes) as compared to the abdominal-based flap cohort (514 ± 136 minutes) (P < 0.001). Similarly, the LIFT cohort had a shorter length of hospital stay (1.65 ± 0.85) than the abdominal-based flap cohort (3.83 ± 1.65) (P < 0.001). However, the average abdominal-based flap procedure had a shorter time until drain removal (13.3 ± 4.3 days) as compared to the LIFT (24.0 ± 11.2 days). The number of overall, major (requiring operation), and minor complications including infection/cellulitis, seroma, dehiscence, hematoma, and flap issues and/or failure were also not statistically different (abdominal-based flaps: major 20.0%, minor 27.7%; LIFT: major 12.9%, minor 19.35%). Similarly, the need for reoperations for revisions (abdominal-based flaps 0.80 ± 0.71 versus LIFT 0.87 ± 0.71) and fat grafting (abdominal-based flaps 41.54% versus LIFT 58.8%) was not statistically different. CONCLUSIONS: Both the LIFT versus abdominally based free flaps have similar outcomes and complication rates. However, the LIFT may be preferred in patients that require shorter operation times due to comorbid medical conditions or with severe obesity which may result in abdominal donor site problems. Furthermore, the LIFT may be the fully autologous breast reconstruction choice for nonmicrosurgeons.

Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study.

The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients. A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry. There were significant (all P < 0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons. Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

Molecular Mechanisms of Adipose Tissue Survival during Severe Hypoxia: Implications for Autologous Fat Graft Performance.

Background:Variable retention outcomes remain a significant issue in autologous fat grafting procedures. Among seemingly similar patients, using identical harvesting procedures, variability in graft retention is noted. Recent data suggest that the inherent characteristics of donor adipose tissue dictate graft healing outcomes. The goal of this study was to elucidate intrinsic qualities of human adipose tissue that confer resistance to ischemic stress to therapeutically target such mechanisms and improve overall results of fat grafts.Methods:Whole fat from 5 female patients was cultured in vitro under severe (1% O2) and mild (8% O2) hypoxic conditions. Microarray analysis of 44 hypoxia-related genes was performed. Perilipin was used to visualize viable adipocytes. Macrophage phenotypes were identified using PCR.Results:Analysis of adipocyte survival with perilipin suggested improved viability for tissue obtained from high BMI donors. Microarray data revealed a significant positive correlation for induced expression of ANGPTL4, a survival gene, and subject BMI (P = 0.0313) during hypoxic conditions whereas HIF1α and HIF2α genes were negatively correlated with donor BMI (P = 0.0003 and 0.0303). Interestingly, induced differentiation of proinflammatory M1 macrophages was negatively correlated with BMI under hypoxia (P = 0.0177).Conclusions:The innate resilience of adipocytes to hypoxia and relative macrophage activation play a crucial role in fat graft retention. This study suggests that adipose tissue from high BMI donors demonstrates greater resistance to hypoxia-induced apoptosis associated with an increased expression of ANGPTL4. Therefore, therapeutic interventions that target this factor may improve clinical adipose graft survival.

Anatomical Fat Grafting for Reconstruction of Frontotemporal Contour Deformities After Neurosurgical and Craniofacial Surgical Interventions: A Symmetry Outcome Study

Fat grafting has been described as an option to repair frontotemporal contour deformities (volumetric deficiency of bone and/or soft tissues) after neurosurgical/craniofacial surgical interventions. However, technical surgical descriptions have varied, with reports describing the bolus fat injection or the classical multilayer injection, but with no detailed descriptions concerning how and where the fat should be grafted. The purpose of this study was to assess the frontotemporal symmetry outcomes after a single fat-grafting procedure for postoperative frontotemporal contour deformity reconstructions using the anatomical fat-grafting approach. A prospective analysis was conducted of consecutive patients (n= 106) who underwent anatomical fat grafting (Coleman's structural fat grafting technique using anatomical facial subunit and fat compartment principles) to reconstruct frontotemporal contour deformities after neurosurgical/craniofacial surgical interventions. A subjective assessment by a panel of external surgical professionals and laypersons was obtained to grade the frontotemporal symmetry. Objective ultrasound symmetry assessment was blindly performed preoperatively and at 3- and 12-month follow-up. There were significant (all P < 0.05) postoperative subjective and objective frontotemporal symmetry enhancements (preoperative < postoperative) after anatomical fat grafting, with no differences (all P > 0.05) between the 3- and 12-month postoperative comparisons. Thirty-seven percent of patients required an additional fat grafting session for residual asymmetry after 12 months of follow-up. Patients with frontotemporal contour deformities presented improved subjective and objective frontotemporal symmetry after an anatomical fat grafting session.