Autologous Gluteal Lipograft

Transcription

1 Aesth Plast Surg (2011) 35: DOI /s y ORIGINAL ARTICLE Autologous Gluteal Lipograft Beatriz Nicareta Luiz Haroldo Pereira Aris Sterodimas Yves Gérard Illouz Received: 14 January 2010 / Accepted: 15 July 2010 / Published online: 25 September 2010 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010 Abstract In the past 25 years, several different techniques of lipoinjection have been developed. The authors performed a prospective study to evaluate the patient satisfaction and the rate of complications after an autologous gluteal lipograft among 351 patients during January 2002 and January All the patients included in the study requested gluteal augmentation and were candidates for the procedure. Overall satisfaction with body appearance after gluteal fat augmentation was rated on a scale of 1 (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent). The evaluation was made at follow-up times of 12 and 24 months. The total amount of clean adipose tissue transplanted to the buttocks varied from 100 to 900 ml. In nine cases, liponecrosis was treated by aspiration with a large-bore needle connected to a 20-ml syringe, performed as an outpatient procedure. Infection of the grafted area also occurred for four patients and was treated by incision drainage and use of antibiotics. Of the 21 patients who Presented in the 2nd Professor Illouz Association Meeting during the 11th European Societies of Plastic Reconstructive and Aesthetic Surgery Congress in Rhodes, Greece. Winner of the 1st Illouz Prize and awarded the amount of 5000 US$. B. Nicareta Department of Plastic Surgery, Policlinca Geral, 38 Av Nilo Peçanha, Rio de Janeiro , Brazil L. H. Pereira (&) A. Sterodimas Department of Plastic Surgery, LH Clinic, Rua Xavier da Silveira 45/206, Rio de Janeiro , Brazil haroldo@unisys.com.br Y. G. Illouz Department of Plastic Surgery, Saint Louis Hospital, Avenue Claude-Vellefaux, Paris, France expressed the desire of further gluteal augmentation, 16 had one more session of gluteal fat grafting. The remaining five patients did not have enough donor area and instead received gluteal silicone implants. At 12 months, 70% reported that their appearance after gluteal fat augmentation was very good to excellent, and 23% responded that their appearance was good. Only 7% of the patients thought their appearance was less than good. At 24 months, 66% reported that their appearance after gluteal fat augmentation was very good (36%) to excellent (30%), and 27% responded that their appearance was good. However, 7% of the patients continued to think that their appearance was less than good. At this writing, the average follow-up time for this group of patients has been 4.9 years. The key to successful gluteal fat grafting is familiarity with the technique, knowledge of the gluteal topography, and understanding of the patient s goals. With experience, the surgeon can predict the amount of volume needing to be grafted to produce the desired result. Although the aim of every surgeon is to produce the desired augmentation of the gluteal region by autologous fat grafting in one stage, the patient should be advised that a secondary procedure may be needed to accomplish the desired result. Keywords Autologous fat transplantation Gluteal augmentation Lipograft Liposuction Fat injection reportedly started in 1893 when German physician Franz Neuber used a small piece of upper arm fat to build up the face of a patient whose cheek had a large pit caused by a tubercular inflammation of the bone [1]. In 1926, Dr. Conrad Miller warned that the end-results in free fat transplantation depend, aside from various local and general factors, on the method and technique [2].

2 Aesth Plast Surg (2011) 35: With the advent of liposuction in the 1980s, it became possible to aspirate and reinject fat, allowing transplantation of small volumes for soft tissue augmentation to correct contour irregularities [3]. Initially, it was performed by using microcannulas and small 5- and 10-ml syringes. In the past 25 years, several different techniques of lipoinjection have been developed to correct various problems such as those involving the buttocks (augmentation and reshaping), trochanteric depressions, breast augmentation, scar depressions, thighs and legs (calf and ankle augmentation), small wrinkles and depressions of the face (Romberg s disease), the nasolabial fold, the upper outer breast quadrant, and liposuction sequelae [4 8]. In 1989, the senior author (LHP) started introducing autologous fat to different anatomic areas such as the buttocks, the trochanteric regions, and the inner aspect of the thighs [9]. The authors performed a prospective study to evaluate patient satisfaction and the rate of complications after autologous gluteal lipografting. Patients and Methods A total of 351 consecutive women underwent surgery from January 2002 to January The women ranged in age from 19 to 72 years (mean, 31.3 years). The preoperative body mass index (BMI) of the patients ranged from 17.1 to 25.6 kg/m 2 (mean, 21.6 kg/m 2 ), obtained at the first office visit. Of the 351 patients, 73 were smokers, who were asked to refrain from smoking for 1 month before and after the surgical procedure. All the patients included in the study requested gluteal augmentation and were candidates for the procedure. No other surgical procedures were performed. The overall satisfaction with body appearance after gluteal fat augmentation was rated on a scale of 1 (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent). The patient satisfaction scale has been used already in published papers and peer reviewed [10 12]. All the patients underwent surgery by the same team of surgeons comprising Luiz Haroldo Pereira, Aris Sterodimas, and Beatriz Nicaretta. The evaluation was made at follow-up office consultations at 12 and 24 months. Surgical Technique of Fat Grafting 1. Marking of the areas to be liposuctioned and fat grafted are made while the patient is in the standing position (Fig. 1). The areas to be lipoaspirated are parallel-line marked, and the areas to be fat grafted are only hollow marked. 2. Preoperative sedation is administered in the surgical suite. Anesthesia consists of an epidural block and Fig. 1 Marking of the areas to be liposuctioned and lipoinjected intravenous sedation. The patient is placed in the prone position. Intraoperative intravenous (IV) cefazolin is administered. 3. After injection of the normal saline wetting solution containing 1:500,000 of adrenaline by a small-bore cannula and a wait of 15 min, a 60-ml syringe attached to a 4-mm blunt cannula is inserted through small incisions in the intergluteal fold as well as two incisions in the iliac crest and two additional incisions in the gluteal fold. Each incision is less than 1 cm long. 4. Fat is aspirated using the syringe method. The donor sites include flanks, thighs, and knee fat. Each individual area to be aspirated is treated separately (Fig. 2a). 5. The fatty tissue aspirated is treated in the following manner. With the syringe held vertically, open end down, the fat and fluid are separated. Isotonic saline is added to the syringe. The fat and saline are separated and the exudate discarded. The procedure is repeated until the fat becomes yellow in color and free of blood and other contaminants (Fig. 2b). 6. At completion of the liposuction procedure, access to the buttock region is gained through the same incisions in the intergluteal fold. 7. Initially, a deep plane to the gluteal muscles is created by the 4-mm cannula. Then other planes are created using the same cannula in different trajectories, always from the deeper aspect to the gluteal surface. The fat is inserted into these tunnels, beginning at the deep layer and working up into the intermediate fat compartments. The fat is injected as the cannula is withdrawn. Care should be taken to avoid injection of more fat in the superficial fat compartment. Separate incisions, if necessary, can be used to treat the whole gluteal region (Fig. 3).

3 218 Aesth Plast Surg (2011) 35: Fig. 2 a Liposuction using the syringe technique. b The treated fat ready to be inserted using 60-ml syringes Fig. 3 a d Insertion of lipograft in the gluteal area 8. Immediate postoperative dressing is performed in the area that was lipoaspirated, avoiding any pressure in the gluteal area. 9. The patient remains hospitalized for 24 h. Analgesics and antiinflammatory medications are prescribed during the following 7 postoperative days. The patient is instructed to remain in the supine body position when lying down, even when large amounts of fat are injected. Return to mild physical activities is allowed after the third postoperative week, and lying down supine is permitted after 2 weeks. A nonzippered pull-over female body vest is placed on the second postoperative day and kept in place for 1 month.

4 Aesth Plast Surg (2011) 35: Results In this study, the total amount of clean adipose tissue transplanted to the buttocks varied from 100 to 900 ml (mean, 692 ml) (Fig. 4). Nine cases of liponecrosis small in volume (2.5%) developed in the grafted gluteal area. Liponecrotic lumps were palpated at postoperative evaluation and after ultrasound confirmation. Aspiration with a large-bore needle connected to a 20-ml syringe was performed as an outpatient procedure. A correlation seemed to exist between the amount of lipograft injected and the liponecrosis complication rate. The total gluteal fat injected was 401 to 600 ml for six patients, 601 to 800 ml for two patients, and 801 to 900 ml for one patient. Infection of the grafted area also occurred for four patients (1%), which was treated by incision drainage and use of oral cephalexin for 7 days. Prompt recognition of the infection signs led to immediate treatment that did not alter the final aesthetic result. However, one case needed further fat grafting of 20 ml, which was performed as an outpatient procedure. There were no cases of cellulitis in donor and grafted areas, no deep vein thrombosis, and no pulmonary embolism. The postoperative body mass index (BMI) of the patients ranged from 17.4 to 25.2 kg/m 2 (mean of 21.5 kg/ m 2 ), obtained at the 24-month office visit. Of the 21 patients (6%) who expressed the desire for further gluteal augmentation, 16 had one more session of gluteal fat grafting. No complications were reported for the patients who underwent an additional fat-grafting session. The remaining five patients did not have enough donor area and instead received gluteal silicone implants. At 12 months, 70% of the patients reported that their appearance after gluteal fat augmentation was very good (38%) to excellent (32%), and 23% responded that their appearance was good. Only 7% of the patients thought their appearance was less than good ( fair 6% and poor 1%) (Fig. 5). At 24 months, 66% of the patients reported that their appearance after gluteal fat augmentation was very good (36%) to excellent (30%), and 27% responded that their appearance was good, whereas 7% continued to think that their appearance was less than good ( fair 6% and poor 1%) (Fig. 6). At this writing, the average follow-up time for this group of patients has been 4.9 years. Patient 1 A 24-year-old woman presented reporting that she had not enough buttocks, which made her unattractive (Fig. 7a, c). Liposuction of the back, flanks, and abdomen together with autologous gluteal lipografting was performed. The total gluteal fat transfer was 530 ml. Photos were taken 3 years after the procedure (Fig. 7b, d). The woman s Fig. 5 Schematic representation of the degree of satisfaction 12 months after autologous gluteal lipografting Fig. 4 Diagram of the total amount of clean adipose tissue transplanted to the buttocks for the 351 patients Fig. 6 Schematic representation of the degree of satisfaction 24 months after autologous gluteal lipografting

5 220 Aesth Plast Surg (2011) 35: Fig. 7 a,c Preoperative view of 24-year-old woman complaining of unattractive buttocks. b,d Postoperative view of 24-year-old woman 3 years after a 530-ml autologous gluteal lipograft. Her satisfaction 12 and 24 months postoperatively was rated as excellent satisfaction 12 and 24 months postoperatively was rated as excellent. Patient 2 A 30-year-old woman presented for liposuction and moderate buttock enhancement (Fig. 8a, c). Liposuction of the back, flanks, and abdomen as part of the composite body contouring procedure was done. Autologous gluteal lipografting was performed. The total gluteal fat transfer was 460 ml. Photos were taken 4 years after the procedure (Fig. 8b, d). The woman s satisfaction 12 and 24 months postoperatively was rated as very good. Computer tomography (CT) imaging of the gluteal area preoperatively and 24 months postoperatively is shown in Fig. 9. Arrows are incorporated in the postoperative CT scan showing the transplanted fat. Patient 3 A 39-year-old woman complained about her buttocks (Fig. 10a, c). Liposuction of the back, flanks, and abdomen together with autologous gluteal lipografting was performed. The total gluteal fat transfer was 390 ml. Photos were taken 4 years after the procedure (Fig. 10b, d). The woman s satisfaction 12 and 24 months postoperatively was rated as good. Discussion As in every surgical procedure, the success of gluteal fat grafting is dependent on many factors: the techniques and instruments used to harvest the fat tissue, the fat processing, the volumes of fat implantation, the sites to be

6 Aesth Plast Surg (2011) 35: Fig. 8 a,c Preoperative view of 30-year-old woman requesting buttock enhancement. b,d Postoperative view of 30-yearold woman 4 years after a 460- ml autologous gluteal lipograft. Her satisfaction 12 and 24 months postoperatively was rated as very good Fig. 9 a Preoperative computer tomography (CT) imaging of a 30-year-old woman s glutealarea. b Postoperative CT imaging of 30-year-old woman 24 months after an autologous gluteal lipograft. Arrows indicate the fat graft implanted, the levels of placement, and even the individual patient. Because of this variability and perhaps other factors not yet understood, the results of fat grafting with some techniques, in some patients, and in some areas can be unpredictable. A standard procedure has not been adopted by all practitioners. No agreement exists as to the best way of processing the fat to ensure maximal take and viability of the graft [13]. However, certain proven points should be taken into account when gluteal augmentation is performed. No statistical differences in adipocyte viability have been demonstrated among abdominal fat, thigh fat, flank fat, and

7 222 Aesth Plast Surg (2011) 35: Fig. 10 a,c Preoperative view of 39-year-old woman complaining about her buttocks. b,d Postoperative view of 39- year-old woman 4 years after an autologous gluteal lipograft. The total gluteal fat transfer was 390 ml. Her satisfaction 12 and 24 months postoperatively was rated as good knee fat donor sites [14, 15]. A recent paper has reported a significant difference in adipose cell concentrations obtained at the different harvest sites. In the lower abdomen, the adipose cell concentration was greater than in other areas, but no significant difference was found in relation to the inner thigh [16]. A mixture of fat obtained from the abdomen, thigh, flank, and knee areas was used for the majority of the patients in this study because the amount of required fat graft could not be obtained by choosing only a single harvest area. Recent reports have shown that mechanical centrifugation does not appear to enhance immediate fat tissue viability before implantation [15]. An important consideration for harvesting and refinement in preparation for grafting is to respect and maintain the tissue architecture of living fat. Any mechanical or chemical insult that damages the fragile tissue architecture of fat will result in eventual necrosis of the injected fat. Guerrerosantos [17] has performed numerous successful autologous fat transfers and advocates injection into the muscle as well as deep into the fat. The transplanted fat must have access to a blood supply [18]. The creation of multiple tunnels ensures an adequate blood supply for the grafted fat. Grafting of the superficial gluteal fat compartment must not exceed 20 ml per tunnel due to low vascularity and excessive compression of the area that can result in liponecrosis [9]. Intramuscular fat grafting should be done in tunnels also, and retrograde injection should be performed, to avoid intravascular fat injection. Pressure should not be applied in the grafted gluteal area [19]. Excess fat should not be injected at one spot.

8 Aesth Plast Surg (2011) 35: For predictable results, the surgeon should refine the fat into relatively pure living tissue using sterile conditions and avoiding external contact, thus preventing contamination. Transplanting a high percentage of nonviable components such as blood and local factors reduces the potential for accurate volume estimation. In contrast to the facial region, in which graft absorption is notoriously high, the rate of volume loss in the gluteal area and lower limbs is known to be much lower [9]. The average tissue loss because of reabsorption after lipoinjection in the buttock varies between 24% and 36%, and stabilization after the procedure can take up to 1 year [5, 20]. That is the reason why the evaluation was made at a minimal follow-up time of 12 months and repeated at 24 months postoperatively. No significant difference in patient satisfaction was found when the 12- and 24-month results were compared (Figs. 5 and 6). There seems to be a relative correlation of the injected volume and patient satisfaction. The patients who rated their result as excellent at 24 months had 270 to 740 ml (mean, 575 ml) injected in their gluteal area. On the other hand, the patients who rated their result as poor or less than poor at 24 months had 130 to 290 ml (mean, 190 ml) injected in their gluteal area. There was no correlation between the cases in which complications occurred and low patient satisfaction. All the patients who had complications from the procedure rated their satisfaction as 3 (good) or 4 (very good) (mean, 3.4). The patients who rated their satisfaction as 2 (less than good) or 1 (poor) were those who did not achieve their desired gluteal augmentation. Comparison of the mean pre- and postoperative BMIs showed that the autologous gluteal lipograft is a method of repositioning the fat from the waist and hips to the buttocks. Pre- and postoperative CT scans were performed for the patients who decided to undergo this procedure and cover the extra cost for it. Of 351 patients, only 65 agreed to do so, and that is why this parameter was not included in the evaluation. Surgeons have come to realize that transplanted fat can create not only satisfying changes in contour but also longlasting results [21]. In 2000, a 7-year experience of grafting aspirated fat in the gluteal region for 233 patients was presented. In 90% of the cases, the results were considered satisfactory [22]. A recent report has shown long-lasting results of gluteal fat grafting [23]. The current study confirms the senior author s clinical observation over more than 18 years, with autologous gluteal lipograft producing high patient satisfaction and a low rate of complications. The limitations of fat transplantation are well known, particularly the long-term unpredictability of volume maintenance [24 26]. The amount of donor fat available also is an important limiting factor [27]. With experience, the surgeon can predict the amount of volume needing to be grafted to produce the desired result [9, 28, 29]. Regenerative cell-based strategies such as those encompassing the use of stem cells hold tremendous promise for augmentation of the soft tissue space. Preclinical studies and early clinical series show that adipose-derived stem cells offer the possibility of finally fulfilling the key principle of replacing like with like as an aesthetic filler without the drawbacks of current technology [30]. In cell-assisted lipotransfer (CAL), autologous adiposederived stem cells (ADSCs) are used in combination with lipoinjection. A stromal vascular fraction (SVF) containing ADSCs is freshly isolated from half of the aspirated fat and recombined with the other half. This process converts relatively ADSC-poor aspirated fat to ADSC-rich fat. The preliminary results suggest that CAL is effective and safe for soft tissue augmentation [31, 32]. Another study has confirmed that the CAL fat can survive better (35% better on the average) than non-cal fat and that the microvasculature can be detected more prominently in CAL fat, especially in the outer layers of the fat transfer [33].Well-designed studies with long-term results are needed to compare autologous fat transplantation and the stem-cell-enriched fat tissue [34]. Conclusion The key to successful fat grafting is familiarity with the technique, knowledge of the gluteal topography, and understanding of the patient s goals. Although the aim of every surgeon is to produce the desired augmentation of the gluteal region by autologous fat grafting in one stage, the patient should be advised that a secondary procedure may be needed to accomplish the desired result. Conflict of interest The authors declare that they have no conflict of interest of disclose. References 1. 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