Success rates of fat grafting injections to face and breast are improving, physician says
Philadelphia — Although complication rates for fat grafting to the face and breast are low, researchers are continuing to work to improve variable results, says Louis P. Bucky, M.D.
Furthermore, Dr. Bucky says, "Those variable successes are what cause us many times to overdo fat grafting, particularly to the face, and to some degree to the breast." He is a Philadelphia plastic surgeon in private practice.
Small volumes for face
Many physicians have achieved excellent results with small-volume (under 100 cc) fat grafting, Dr. Bucky says. For example, to treat a young female patient with Parry-Romberg syndrome, Dr. Bucky says he injected 80 cc to her face, using a topographical mapping method, then another 43 cc 18 months later.
"Two years later, she had gained weight, and her facial fat looked fuller,” he says. “Likewise, when she lost weight eight years postoperatively, her face looked a little thinner." Overall, he says, the patient was very satisfied with her results.
Also around this time, Dr. Bucky treated an older male patient using the same approach. However, one year postsurgery, it was impossible to see any change between this patient's preoperative and postoperative photos. "This variability leads us to question what we do," and to study the variables involved in an attempt to minimize their impact, he says.
"To summarize, many of our colleagues and leaders in plastic surgery have done a good job over the last 10 years in looking at new techniques and what's happening during fat harvesting and purification, at how we store and inject the fat, and at biological characteristics of the recipient site,” Dr. Bucky says.
To build upon this knowledge, Dr. Bucky says that he and his colleagues have examined common fat-grafting challenges in the laboratory. In a series of studies, they transferred human fat into the cranial area of nude mice and analyzed the fat's viability and variability.
"When we all started fat grafting," he says, "there was a lot of talk about freezing fat" for future use so that patients would not have to undergo harvesting procedures for subsequent injections. To test this theory, Dr. Bucky and his colleagues used the nude mouse model to compare the viability of fresh and frozen fat and found that fresh specimens performed significantly better (Tuma GA, Godek CP, Hubert DM, et al. American Society of Plastic and Reconstructive Surgeons Scientific Meeting. Los Angeles. Oct. 14-18, 2000). "Therefore," he says, "freezing fat is not recommended."
As an alternative to frozen fat, "We're fortunate today to have fillers that do a great job, and in some cases, they could perhaps be the primary plan for certain areas of the face,” he adds.
In research involving human subjects, "We asked questions like, ‘Does fat from people older than 65 years transfer better than fat from people under 35?’" In this regard, he says that nine months postinjection, "We found that older patients maintained about 35 percent of their fat, and younger patients maintained about 55 percent (Kanchwala SK, Bucky LP. Facial Plast Surg. 2003;19(1):137-146)."
Dr. Bucky says that because younger patients retain more injected fat than older patients do, plastic surgeons must take care not to over-inject large volumes into younger patients' faces. When used in the breast, he says, fat grafts should smooth and fill. "But the face needs to have shape and contours. If you overdo it, you lose these,” he says.
In one such case, a 31-year-old female patient presented to Dr. Bucky two years after receiving fat grafting to the brow and face (performed by another physician) that had resulted in asymmetry. Specifically, he says, her left brow and cheek were overfilled and did not move symmetrically with the rest of her face.
"There isn't a great treatment for this problem,” he says. “I used microliposuction, using injectable cannulas for aspiration. I went percutaneously through the nasolabial fold and through an upper blepharoplasty incision to try and defat the area." Six months after this procedure, although the patient looked slightly hollow on the left side of her face, she could animate much more normally and was much happier with her results, Dr. Bucky says.
"This begs the question: Is there an appropriate amount we should be overfilling the face? Are large or small aliquots of fat better?" Dr. Bucky says. To address these questions, Dr. Bucky and his colleagues injected different amounts of fat into nude mice at different time intervals. "We found histologically and volumetrically that there was increased angiogenesis in the small aliquots, and much more fat necrosis in the larger ones."
This study's findings suggest that fat grafting has a limited diffusion mechanism, Dr. Bucky says. Therefore, he does not recommend over-injecting the face with large fat volumes.
Similarly, he says that it's important to limit hypoxia. "While that's not critical in the face, it has changed the way I do fat grafting when I'm performing a facelift," he says. Now, he harvests and grafts fat at the beginning of the procedure or does these steps at the end, rather than harvesting fat upfront and storing it for up to two-and-a-half hours before injection.
As for complications of facial fat grafting, Dr. Bucky says, the periorbital area — particularly the lower lid — is probably the most prone. In this area, he says, typical complications can include a shelf-like appearance and isolated lumps.
"This problem should not be treated with steroid injection,” he says. “If you see it early, you can massage it or try needle aspiration. But typically, a very small direct excision is the best way to treat an isolated lump.
“The best way to avoid one is to inject retro- or suborbicularis, preperiosteally,” he adds. “You can do it directly, but just stay underneath the orbicularis. Unlike the variability of the hyaluronic acids, which provide a little more flexibility, fat still is particulate. So you need to inject more deeply and have adequate soft tissue coverage to avoid trouble."
Dr. Bucky says that in his practice, the best patients for facial fat grafting are those who are already planning lower-lid or facial rejuvenation procedures and want to blend the cheek-lid junction. "Typically, we use small volumes — 0.3 to 1.5 cc, a small cannula and feathered injections, not isolated deposits," he says.
Fat grafting works well as monotherapy, Dr. Bucky says, but he typically uses dermal fillers instead for this purpose.
Regarding fat grafting to the breast, "It was very easy when we were doing small-volume fix-up to reconstruct small-volume defects," Dr. Bucky says. However, lipoaugmentation of the breast is a very different process. "It can achieve tremendous results, but it needs a lot of thought to (address) the reliability issue."
The face is better vascularized than the breast, he says, "But it also has the limitation of having more motion." He says, however, the breast is generally harder to treat. Patients who require breast reconstruction often have fibrosis in the area. Additionally, "We have larger volume requirements, and we're trying to expand a mechanically limited envelope and asking fat to do things it can't,” he says.
Nevertheless, large-volume reconstructions are easier than large-volume augmentations because revisions are part of the reconstructive process, Dr. Bucky says.
"Small-volume reconstructive surgery has a built-in backup plan. We have an opportunity to do fat grafting when we take the expander out and put an implant in," and another revision opportunity at the time of nipple reconstruction. Typically, he says, these procedures are covered by insurance.
"Where we will really shine in small-volume fat grafting is in improving the soft-tissue envelope of our everyday results," he adds.
In large-volume fat grafting to the breast, "There are many more demands on reliability." To meet these demands, Dr. Bucky says that pre-expansion, performed before fat grafting, is gaining popularity.
Research has shown that such pre-expansion achieves mechanical decompression, thereby increasing vascularity and upregulating growth factors and making the procedure much more reliable (Khouri R, Del Vecchio D. Clin Plast Surg. 2009;36(2):269-280, viii). "Preoperative overexpansion is far better than trying overcorrection," Dr. Bucky says.
A study co-authored by Dr. Bucky showed that preoperative expansion for three weeks before fat grafting allowed patients to maintain on average 60 percent of the grafted volume two years postoperatively (Del Vecchio DA, Bucky LP. Plast Reconstr Surg. 2011;127(6):2441-2450). "There were no revisions in this group," he says, adding that the fact that the grafting procedure could be done in two hours resulted in less hypoxia.
“Large-volume fat grafting has great promise to dramatically improve what we are doing both in reconstructive surgery and cosmetic surgery, with and without implants,” Dr. Bucky says. “But we need pre-expansion, and we must provide an efficient, reliable process in order to get these results."
Disclosures: Dr. Bucky is a consultant for Allergan and LifeCell. He presented the information in this article at the 2011 American Society of Plastic Surgeons Scientific Meeting in Denver.