**3. Discussion**

Both men and women have attended consultations for fat transfer and more particularly for the FAMI procedure (Facial Autologous Muscular Injection) which was developed to avoid the two major disadvantages of the conventional lipofilling, the unpredictability and the longevity.

When longevity is considered, every step of the technique becomes important, from the local anaesthesia and the anatomy of the fat deposit to injection of facial targets.

The choice of the candidates for lipo transfer is important and they must be chosen among the two first groups of the four described by Ricardo Baroudi.

*Group I – Fat deposits with firm skin. Patients are usually young, in their twenties with no flabbiness and no exaggerated volume.*

*Group II – Fat deposits with moderate to flabby skin. The fat deposit is not excessive and the skin is no longer firm. If a large amount of fat is removed the significant flaccidity may produce undulations, waves, grooves and dimples. The patients of group II are generally between 20 and 35 years of age (Figure 4).*

## **Figure 4.**

*Fat deposits with firm skin or with moderate to flabby skin are good candidates for fat harvesting in lipo transfer.*

We have to be very careful in choosing patients in the last 2 groups, to which I recommend the surgical approach (**Figure 5**).

*Group III – Fat deposits with marked skin flaccidity. The liposuction is generally associated to traditional surgery to tighten the skin.*

*Group IV – Skin flaccidity without fat deposit. In these particular cases we can find only the fat deep in gluteal area or in the flanks.*

The anatomy and histology of the adipose tissues were well described in his book by J.A. Klein [8].


*Liposuction for Fat Transfer: The "Island Technique" DOI: http://dx.doi.org/10.5772/intechopen.96869*


Lidocaine, the first amino amide–type local anaesthetic, was first synthesised under the name 'xylocaine' by Swedish chemist Nils Löfgren in 1943 [9]. The local anaesthesia (LA) with lidocaine presents a rapid onset and an intermediate duration of action. Although lidocaine is the oldest aminoamide, this drug is widely used all over the world in the context of autologous fat transfer.

The effects of local anaesthesia with lidocaine on the viability of fat obtained by syringe suction lipectomy was studied in1995 by John H. Moore Jr. and Jerzy W. Kolaczynski [10]. They examined if adipose tissue viability is compromised by using syringe suction lipectomy and by infiltration of the tissue with lidocaine. They found that Lidocaine potently inhibited glucose transport and lipolysis in adipocytes and their growth in culture. That effect, however, persisted only as long as lidocaine was present; after washing, the cells were able to fully regain their function and growth regardless of whether the exposure was as short as 30 minutes or as long as 10 days. These preliminary results indicated that adipose tissue obtained by syringe lipectomy consists of fully viable and functional adipocytes, but local anaesthetics may halt their metabolism and growth.

Tao Wu and Jay Smith, published in 2018 an article on the Cytotoxicity of Local Anaesthetics in Mesenchymal Stem Cells [11] and found that local anaesthetics may have negative impact on Mesenchymal Stem Cells dosing because of cytotoxicity or other biological effects. They reviewed 11 studies that involve *in vitro* experimentation with MSCs using aminoamide-type anaesthetics including lidocaine, ropivacaine, mepivacaine, bupivacaine, articaine, and prilocaine and concluded lidocaine seems to have the most significant effects on stem cell viability. They conclude that local anaesthetic agents have time- and concentration-dependent detrimental effects on Mesenchymal stem cells (MSCs). They noticed that *in vivo* studies will be required to understand the interactions of these agents with MSCs, because *in vitro*

#### **Figure 6.**

*A, B and C shows the best areas for fat removal. Abdominal region, lateral parts of the waist, and brachial fat pad.*

studies cannot replicate the pharmacokinetics of anaesthetics *in vivo* or the recovery of (MSCs) in a more physiological environment.

The most recent study came from Felix Grambow and Rico Rutkowski (2020) [12]. They made a clinical research on a series of cases to conclude that lidocaine has no negative impact on the distribution, cell number, and viability of Adipose derived stem cells (ASCs) and preadipocytes. After centrifugation, only the middle fatty portion of processed lipoaspirate (PLA) in the syringe will contain Adipose derived stem cells (ASCs), which are crucial for successful lipotransfer. Adipose stem cells, which are restricted to adipogenic evolvement, were found to be significantly more common inside the Processed liposuction (PLA) than inside the Processed liposuction aspirate fluid (LAF).
