Fat injection empirically started 100 year ago to correct contour deformities mainly on the face and breast. The German surgeon Eugene Hollaender (1867-1932) proposed a cocktail of human and ram fat, to avoid reabsorption. Nowadays, fat injection has evolved, and it ranks among the most popular procedures, for it provides the physician with a range of aesthetic and reconstructive clinical applications with regenerative effects on the surrounding tissues. New research from all over the world has demonstrated the role of adipose-derived stem cells, present in the adipose tissue, in the repair of damaged or missing tissues.
Key points
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The first transplantation of adipose tissue from the arm to the orbital region to correct adherent scars from osteomyelitis was performed by Gustav Neuber in 1893.
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The first report of fat injection to the face and breast in the human body to re-establish contour deformities was carried out by Eugene Holländer in 1909.
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In the 1950s, because of its tendency to reabsorb and form oily cysts, fat grafting to the face fell from favor, becoming an almost obsolete procedure.
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With the advent of liposuction, fat injection was rediscovered, but the reabsorption rate was still high.
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In the 1990s, Sydney Coleman systematized the technique for harvesting, purification, and placement of fat, so as to reduce the reabsorption rate.
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In 2001, Zuk and colleagues demonstrated that adipose tissue is the greatest source of adult mesenchymal stem cells, adipose-derived stem cells (ASCs), capable of differentiating into other types of tissues.
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Stromal vascular fraction (SVF), a source of ASCs, endothelial (progenitor) cells, T cells, B cells, mast cells, and adipose tissue macrophages was identified.
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In 2007, Gino Rigotti applied the regenerative properties of ASCs in a human patient. He successfully managed radiation tissue damages, with complete restitutio ad integrum of the affected tissues. This was one of the first examples of regenerative therapies.
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Fat Injection from Filling to Regeneration , edited by Sydney Coleman and Riccardo Mazzola, the first textbook that emphasized the regenerative potential of fat in the repair of damaged or missing tissues was published in 2009.
Introduction
The 19th century is considered the golden age of plastic surgery. A wide array of pedicled skin flaps were described and invented to restore defects, mainly of the face. One of the greatest advances in 19th century surgery was the demonstration that a piece of skin, fully separated from its original site, might survive when transplanted to another part of the body to cover a granulating raw surface. This became possible by the pioneering work of Jacques Reverdin (1842–1929). In 1869, he carried out the first successful epidermic graft on a human patient at Hôpital Necker in Paris, opening a new era in wound management. Skin grafting became soon the preferred solution for the management of chronic wounds.
Introduction
The 19th century is considered the golden age of plastic surgery. A wide array of pedicled skin flaps were described and invented to restore defects, mainly of the face. One of the greatest advances in 19th century surgery was the demonstration that a piece of skin, fully separated from its original site, might survive when transplanted to another part of the body to cover a granulating raw surface. This became possible by the pioneering work of Jacques Reverdin (1842–1929). In 1869, he carried out the first successful epidermic graft on a human patient at Hôpital Necker in Paris, opening a new era in wound management. Skin grafting became soon the preferred solution for the management of chronic wounds.
The discovery of fat transplantation: early clinical applications
Fat Transplantation: A New Discovery
Transplantation of tissues, other than skin, was soon attempted. Fat, readily available, was considered the ideal solution to fill in depressions and contour deformities. In 1893, the German surgeon Gustav Neuber (1850–1932) first harvested adipose tissue from the arm and transferred it to the orbital region to correct adherent scar sequelae from osteomyelitis. Shortly afterward, in 1895, another German, Viktor Czerny (1842–1916), transferred a lipoma to the breast to re-establish symmetry, following unilateral partial mastectomy for fibrocystic mastitis.
Fat Grafting
Its indication in the management of the facially disfigured soldiers from World War I
Until introduction of syringes for placing adipose tissue, as it is currently done, fat was always transplanted en-bloc, often with dermis (the so-called dermal fat graft). The healing potentials of fat were empirically noticed by those surgeons who were confronted with the management of the terrible disfigurements caused by World War I. Fat was inserted into the wounds either to promote the healing process or to correct uneven scars from gunshot wounds of soldiers injured in the battlefields. The German maxillofacial surgeon Erich Lexer (1867–1937) first used fat in combination with local flaps and cartilage graft to reconstruct the eye socket so as to accommodate a prosthesis in a facially disfigured soldier ( Fig. 1 ). His experience with fat grafting became soon vast. In 1919, he published a 2-volume book “ Die freien Transplantationen ” (Free Transplantations), in which all the different types free grafts available at that time were critically and histologically evaluated. More than 300 pages were devoted to fat grafting, with an incredible range of clinical applications, from the correction of contour deformities for sequelae of facial traumas, to hemifacial microsomia ( Fig. 2 ), microgenia, breast asymmetry, post-traumatic hand stiffness and Dupuytren disease to restore the gliding tissue around the tendons. The source of adipose tissue was usually the lateral thigh ( Fig. 3 ).
Another surgeon who devoted his skill to the repair of facial disfigurement was Harold Gillies (1882–1960). His book “ Plastic Surgery of the Face, ” published in 1920, showed numerous cases of soldiers from World War I with dramatic facial wounds treated by fat grafting with amazing results ( Fig. 4 ).
The Decline of Fat Transplantation
Initially, surgeons enthusiastically favored the technique of en-bloc fat grafting, alone or in combination with skin flaps, as it often represented the sole way to solve major problems in a simple way. Fat was inserted into the face in case of Romberg disease or into the breast for correct sequelae of mastectomy or to the pharynx to reduce nasal air escape in case of cleft palate surgery. However, in the 1930s, with growing experience, clinicians realized that the encouraging early results worsened over the long term because of an unpredictable reabsorption rate and a tendency to form oily cysts. The pliable fat graft gradually modified, becoming hard and fibrotic.
In the 1950s, Lyndon Peer (1898–1977) investigated the fate of autologous fat transplantation at 1 year and demonstrated that about 50% of fat cells rupture and die after transplantation, and the graft was replaced by fibrous tissue. Cells, which did not rupture, survived and constituted the amount of adipose tissue that remained. He demonstrated that, in autologous fat graft, the new blood circulation establishes at day 4, through anastomosis between blood vessels of the host and those of the graft. If this does not occur, early death of cells may develop, with oil cyst formation. Because of these considerations, fat grafting to the face fell gradually from favor, turning out to be an almost obsolete procedure.
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