Charme – Fat Graft Transfer

We are all the authors of our own bodies

And we could also say ‘we are all the authors of our own fat’. I am not being ironic; we know very well that this is an undisputed fact.

When we feast and indulge without limits and when we and are lazy and indolent, fat is deposited in fat cells wherever it pleases. In certain places, fat deposits are just right (making our bodies more attractive), but in others, there tends to be too much fat... (men can tell when they cannot button up their summer trousers after winter and women when a skirt that they have not worn for a season or two is so tight that it constricts them like a corset...).

Homo sapiens has managed to reach the Moon, and it would be unbelievable if human history were to shamefully admit that man has failed to deal with the fat on his body. At first, we were able to help ourselves with liposuction. Later, we discovered how to take fat cells from places where they are not welcome, transferring them to other places where they can have a positive purpose. This surgery is usually called fat-grafting and sometimes also lipo-transfer. Whatever the term, the concept is the same. Plastic surgeon MUDr. Josef Kulhánek, MBA has trained with Sydney R. Coleman, M.D., an international guru of highly functional fat cell transfer methods, which is why we have asked him to tell us all about fat grafting.

The bonus of this procedure is that the requisite fat tissue from the subcutaneous space is obtained from sites where the patient does not wish to have any fat and is then introduced into sites where fat is needed. Thus, the advertising slogan for fat-grafting could be the notorious “two for the price of one”. In our case, it will mean the removal and supply of fat tissue during a single operation. A major bonus from the medical point of view is that autologous tissue, i.e., the patient’s own fat, is used in the patient’s body.

The concept of fat transfer has attracted surgeons for a long time, but the first effective results only began emerging some twenty years ago, thanks to the optimal choice of procedure. As for the number of fat cells, physicians started working with dozens of millilitres of transferred purified fat, whereas today we work with hundreds of millilitres. The face is naturally a specific area, where only single millilitres of transferred fat tissue are required.

Fat transfer – it sounds logical and simple. A layman will ask “how” is fat transferred and “how” does the tissue behave at the new site, where it should live and work?

Above all, a large amount of fat must not be transferred to the given destination as a single lump. This mistake was made when the method was first used and it represented a catastrophe for fat cells. After transfer, cells survive solely from perfusion, i.e., from the flow of inter-cellular fluid; they have no other source of nourishment at that time as no blood vessels as yet lead to the mass of transferred cells. Thus, when the lump of fat was too large, no nutrients penetrated into its centre and this section of the transferred tissue died. That means that the volume of fat transferred was reduced dramatically because only those cells with access to nourishment got to survive. Today, fat is transferred in small steps, by drops, in order to make sure that the fluid can nourish as many of them as possible.

The only thing that is expected of a fat cell is that it will survive. That it will stay at the site where it has been transferred to and that it will help fill the volume that we wish to fill up. If it survives, it does not multiply and behaves like any other fat cell: when you put on fat, it will enlarge, and when you slim down, it will lose its fat content. The number of cells transferred is therefore determined by the volume that needs to be filled

How is this volume determined?

For example, breasts must always be overfilled a bit. In my experience, 30-70% of cells survive. 30% is logically a poor result, 70% a good one. It never happens that 100% of the cells survive. When an implant of a certain volume is inserted in a patient’s breast, the result is known in advance. In the case of a fat-graft transfer, the volume can only be assumed, as we do not know how many cells will be absorbed and lost. It is individual, very much dependent on the surgical technique as well as the method by which the transferred fat is processed. Survival can be assessed in several months, in half a year. Enlarged breasts can change, the volume may be reduced by up to one half. The same applies to collapsed scars that have been padded with transferred cells.

The key steps of the operation are clear: tissue removal and transfer. What is the surgical process?

As in the case of liposuction, the physician will mark the area from which fat will be removed and the area where it will be introduced. The area from which the fat will be taken is agreed upon with the patient. Thighs are suitable. The lower abdomen or abdomen is even better, as fat from these areas is of the most suitable quality for these procedures. Moreover, there are sufficient amounts of fat in these areas even in slim patients.

The cannulas used for removing this fat are different than those used in liposuction, but not too different. The application cannulas are finer and may also have a special injector that makes it possible to dose the fat in small drops – a size that can be nourished well.

There are several methods for eliminating the oil components and water contained in the removed fat, together with the liposuction fluid. One of them is Coleman’s fat purification method using a centrifuge.

Fat centrifugation at a certain centrifugal force for a certain period of time ensures the requisite purification of fat cells. The central part of the sediment, which contains the highest number of undamaged fat cells and a large amount of mesenchymal stem cells (MSC), is used for the transfer. These are multipotent cells capable of renewing mesenchymal and hematopoietic tissue and transforming into a broad range of blood cell types. Stem cells are more readily available and more plentiful in fat tissue than in bone marrow. Fat tissue is applied straight away, without any delay. The centrifuged mass is prone to suffer from lack of nutrition and should not come into contact with air oxygen so that it is not degraded. When handling fat tissue which is relatively resistant, cells must not be damaged and their cell membrane must not rupture, as this would kill the cells. We have to make sure that we do not overfill the site of application with cells, as this would put them under great pressure.

We have talked about applying small drops to different places. When we first started doing these transfers, we strove to puncture various layers from various directions, making sure that the punctures crossed each other many times. Gradually, as we acquired experience – and I do not mean only us, but worldwide – the number of punctures was reduced and today the maximum is eight to ten punctures. Sometimes even fewer will suffice.

When does this method really make sense and when does a fat graft transfer have the greatest effect?

This method can be used to enlarge those parts of the body where augmentation or synthetic implants are indicated. It can be used in aesthetic surgery for breast enlargement and for correcting breast asymmetry. It can also be used to refine the contour of breasts after augmentation when the implant edges might be visible in slim women. The edges are covered with a small layer of fat. Small amounts can be used to enhance lips, cheekbones, or external genitals. In this case, fat grafts from the buttocks are used. In reconstructive surgery, fat grafts are used to fill in defects, collapsed scars, atrophic areas, etc.

One bonus is the overall rejuvenation of the tissue at the site where the fat is introduced, which is why this method is used on the face, applying small amounts of fat. Fat cells and the stem cells that are found in between them will help blood vessels to grow through the site, providing a new blood supply. Thus, the site is better supplied with blood, nourishment of the atrophic subcutaneous tissue is improved and the complexion brightens visibly.

The risks of the method?

The risk of cyst formation and calcification cannot be fully eliminated, but such undesired complications can be prevented by dosing the fat in small drops applied in several layers and lines. The risk was far greater in the past, when the entire dose of fat was literally “crammed” into a single spot with a syringe. A poorly nourished lump of fat formed. This then necrotised in the centre forming a fatty cyst that calcified.

The patient’s age plays an important role. With increasing age, the chance of cell multiplication and survival decreases. But there is no age limit after which the method could not be used. Other diseases from which the patient suffers are, naturally, a problem. Diabetes is the most marked example. I do not recommend that people with diabetes undergo this surgery solely for cosmetic reasons. Perhaps, and again only in extreme cases, diabetic defects could be solved by fat transfer. It is also not suitable to perform breast enlargements in women who suffer from diabetes. The same applies to other metabolic disorders.

After surgery, it depends on how the patient treats the area involved, because the site of the transferred fat graft should not be under increased pressure. Unlike in liposuction, wearing tight underwear is not recommended. By applying pressure, oxygen supply from lymphatic and inter-cellular fluid to the fat graft cells is cut off.

Is it necessary for a patient to stay at the clinic under medical supervision for a few days after the operation?

Fat tissue transfer is usually – with a few exceptions – performed under general anaesthesia, which is why the patient needs to spend the night at our clinic. Checkups are planned similarly as in the case of a standard liposuction – one week after surgery and then at intervals of several weeks.

If you decide to be a truly active “author of your own body” and undergo this attractive surgery, compare all the pros and cons, not only in front of a mirror in the dim light of your living room, but, above all, at the clinic with our experienced plastic surgeons. Needless fears will be dispelled and no important detail will be missed. And if you do decide to give your fat cells a chance and appoint them into the role of your make-up artist, it will definitely be the right decision. And a right decision is always the happy option. So why not treat yourself to such happiness and be the author of your happiness and well-being?