**Fat Grafting**

**Chapter 10 Provisional chapter**

#### **Fat Grafting in Body Contouring Fat Grafting in Body Contouring**

Marco Romeo, Ayman Elmeligy and Khalid Elsherbeny Marco Romeo, Ayman Elmeligy and Khalid Elsherbeny Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/65486

#### **Abstract**

Fat transfer had been used since the first decades of the twentieth century for body contouring and reconstruction. Since then, a lot of controversies and ongoing research regarding indications, harvesting and transplantation technique had been a concern for plastic surgeons. More recently, the use of fat as a source of stem cells had been the major point of research joining both the aesthetic and the regenerative advantages. Body reshaping using fat graft is nowadays a common non-invasive resource in the surgeon's armamentarium popularized as body sculpturing merging the benefits of liposuction and lipofilling to improve the aesthetic of virtually all the regions of human body. In this chapter, the role of fat grafting in aesthetic body contouring will be discussed. The association of stem cells is exposed to give the reader the possibility to better understand this option of treatment. Fat harvesting/grafting techniques are explained and the authors' preferred choice is exposed. Lipofilling details are discussed per area of the body with practical tips and pitfalls for the experienced or the newbie surgeon. A final summary on complications will remind all the possible incidences that may occur in the short- and long term after surgery.

**Keywords:** lipofilling, fat grafting, aesthetic, stem cells, body contouring

### **1. Introduction**

#### **1.1. The history of fat grafting**

History of fat grafting is rather fascinating, yet quite controversial with all that it carries within its corners, from frustrations to adventurous experimentation.

The first attempt to use fat in human auto-transplantation was dated to **1889** by **Van der Meulen**, The procedure consisted of grafting an omentum and fat auto-graft between diaphragm and liver.

The first described free fat grafting attempt was recorded by Gustav Adolf Neuber, a German surgeon in 1893. Neuber used small fat grafts in order to fill facial defects in a 20-year-old man. According to Neuber, he had less success when he tried to use larger grafts, saying that 'grafts larger than an almond would not give good results'.

In 1895, Viktor Czerny (1842–1916) reported excising a lipoma and grafting it into a breast defect to establish symmetry following a unilateral partial mastectomy [1].

Gersuny in 1900 proposed paraffin injections. They became commonly used for post-syphilis saddle noses. Paraffin injections gave amazing results initially; however infections, paraffinomas, migration and pulmonary embolism were major complications of the procedure [2].

In 1912, Holländer proposed the technique of fat injection, but there was a high rate of reabsorption. He harvested adipose tissue from patients and mixed it with fat from rams. This mixture was injected as a fluid at body temperature. Patients had a painful rash afterwards for 2–3 days, but he reported a good outcome.

Lexer in 1919 also described fat grafting in his textbook, to correct sequelae of facial trauma, hemifacial microsomia, microgenia, breast asymmetry, and post-traumatic hand stiffness. He also described the use of fat to restore gliding tissue around tendons in Dupuytren disease [3].

Gillies in 1920, showed in his book, patients treated with fat grafting after facial injuries.

Peer in 1950, demonstrated that about 50% of fat cells died after transplantation and were replaced with fibrous tissue and stressed that survival of fat grafts was **dependent on early neovascular anastomoses** (new blood vessels), and stated that 50% of the adipose cells in free fat grafts survive.

Studies and research work in the past decades focused more on the pathology of obesity and the role of genetics on fat cells in obese people.

The general acceptance among researchers is that the number of adipocytes is fixed in adults.

Smith in 1971 described the fibroblast-like cells grown on tissue culture.

The adipocyte precursors studied in tissue culture was more profoundly investigated by Van in 1976, proved that fat tissue was more dynamic than historically thought it was.

It was Roncari who studied the morphology and maturation of cultured adipocytes in a culture system that he developed in 1978 [4].

Liposuction technique was invented by Fischer in 1974.

It was not until the era of liposuction in 1978 when the French physicians Illouz and Fournier further developed the procedure utilizing blunt cannulas for suction lipoplasty that made the process of fat extraction more reliably predicted.

By the early eighties, liposuction became quite popular in the United States. Klein, a dermatologist, invented the tumescent technique for liposuction that allowed patients to have liposuction performed totally under local anaesthesia with less bleeding and with much smaller cannulas.

Ellenbogen started using fat pearls in the reconstruction of facial defects [5] and in 1988, Chajchir described favourable results, emphasising cautious handling of adipocytes, rinsing of the lipoaspirate to eliminate dead cells and grafting into a well-vascularised bed [6].

In the nineties, Sydney Coleman from New York described standardized techniques for fat extraction, processing and injection of fat grafting [7, 8].

#### **1.2. Fat potential and differentiation capacity**

The first described free fat grafting attempt was recorded by Gustav Adolf Neuber, a German surgeon in 1893. Neuber used small fat grafts in order to fill facial defects in a 20-year-old man. According to Neuber, he had less success when he tried to use larger grafts, saying that 'grafts

In 1895, Viktor Czerny (1842–1916) reported excising a lipoma and grafting it into a breast

Gersuny in 1900 proposed paraffin injections. They became commonly used for post-syphilis saddle noses. Paraffin injections gave amazing results initially; however infections, paraffinomas, migration and pulmonary embolism were major complications of the procedure [2].

In 1912, Holländer proposed the technique of fat injection, but there was a high rate of reabsorption. He harvested adipose tissue from patients and mixed it with fat from rams. This mixture was injected as a fluid at body temperature. Patients had a painful rash afterwards for

Lexer in 1919 also described fat grafting in his textbook, to correct sequelae of facial trauma, hemifacial microsomia, microgenia, breast asymmetry, and post-traumatic hand stiffness. He also described the use of fat to restore gliding tissue around tendons in Dupuytren disease [3].

Peer in 1950, demonstrated that about 50% of fat cells died after transplantation and were replaced with fibrous tissue and stressed that survival of fat grafts was **dependent on early neovascular anastomoses** (new blood vessels), and stated that 50% of the adipose cells in free

Studies and research work in the past decades focused more on the pathology of obesity and

The general acceptance among researchers is that the number of adipocytes is fixed in adults.

The adipocyte precursors studied in tissue culture was more profoundly investigated by Van

It was Roncari who studied the morphology and maturation of cultured adipocytes in a culture

It was not until the era of liposuction in 1978 when the French physicians Illouz and Fournier further developed the procedure utilizing blunt cannulas for suction lipoplasty that made the

By the early eighties, liposuction became quite popular in the United States. Klein, a dermatologist, invented the tumescent technique for liposuction that allowed patients to have liposuction performed totally under local anaesthesia with less bleeding and with much

in 1976, proved that fat tissue was more dynamic than historically thought it was.

Smith in 1971 described the fibroblast-like cells grown on tissue culture.

Gillies in 1920, showed in his book, patients treated with fat grafting after facial injuries.

defect to establish symmetry following a unilateral partial mastectomy [1].

larger than an almond would not give good results'.

2–3 days, but he reported a good outcome.

the role of genetics on fat cells in obese people.

system that he developed in 1978 [4].

Liposuction technique was invented by Fischer in 1974.

process of fat extraction more reliably predicted.

fat grafts survive.

168 Body Contouring and Sculpting

smaller cannulas.

In 2001, a group of researchers from the University of Pittsburgh described the implications of adipose tissue in cell-based regenerative therapies.

This was quite a revelation for the scientific community, as up until that time adult mesenchymal stem cells (MSCs) were predominantly thought of as a bone marrow product.

As it turns out, adipose tissue is a much more prolific source of MSCs than bone marrow.

By volume, mesenchymal stem cells are actually 300–500 times more abundant in adipose tissue compared to bone marrow tissue.

Comparison of multi-lineage cells from human adipose tissue and bone marrow is given in Ref. [9].

Adipocytes derived from stem cells (SC) under the right stimulation could differentiate into different lineage like endothelial cells, fat cells, epithelial cells, neuronal cells, chondrocytes, myocytes and osteocytes.

Adipocytes also secrete more than 100 proteins (adipokines) and growth factors that regulate: angiogenesis, inflammation and apoptosis.

Growth factors include: vascular growth factor, liver growth factor, platelet and epidermic growth factors.

Fat grafting has truly opened new frontiers for plastic surgeons and other medical specialties.

Its power is only yet to be understood and it is clear that adipose tissue will be a pillar of regenerative medicine treating a huge spectrum of diseases like DM, Autism, Parkinson's disease, multiple sclerosis and others [10].

#### **1.3. The fate of fat**

The old, general concept of fat grafting was that the surgeon had to overfill the grafted area of about 40% of its volume since there will be resorption of 10–60%, some said up to 90%.

There was no proper understanding of the mechanism of survival and fate of grafted fat cells.

Today, research revealed the fate of grafted adipose tissue showing that three different zones will demarcate after 4 weeks of grafting, by name these zones are:

**1.** The outer surviving zone: the most superficial; several rows of fat cells that are clearly in direct contact with the vascularized recipient tissues of the host.


**At the outermost surviving zone**, the cells are quite close to vascularity and the adipocytes tend to survive in a process quite similar to the physiology of skin grafts, called the diffusion/ angiogenesis theory that suggests that donor adipocytes survive by oxygen diffusion at the recipient site during the initial days after grafting, with eventual micro-angiogenesis and formation of a viable blood supply.

**At the regenerating zone**, the fat cells do not succeed to survive; however the adipose-derived stem cells ( pre-adipocytes) experience ongoing adipogenesis that increased rapidly after grafting and peaked at 4 weeks and full remodelling was completed by 12 weeks.

**The necrotic zones** will eventually be absorbed, filled with fibrous tissue, or become a problematic cyst.

Grafted fat tissue undergoes degeneration within 1 week, while regeneration reaches its peak at 4 weeks. Regeneration takes place by adipose tissue-resident progenitor cells. Phagocytosis and cicatrisation occur in the regenerating and necrotic zones, predominantly by M1 and M2 macrophages respectively.

The stabilization process appears to persist for a long time after failed regeneration. The size of the necrotizing zone depends mainly on the size of the graft and the micro-environment into which it is placed. Eventually, necrotic zones will be absorbed, filled with fibrous tissue, or become a problematic cyst. Liposuction and reinjection procedures could be improved by preparing grafts with better viability and in an appropriate size, maximizing the contact surface of the grafts by ideal distribution, and placing the grafts in areas with high vascularity. Stabilization of the grafted fat may not occur until several months after complete regeneration at 3 months. This emphasizes the importance of long-term follow-up to thoroughly evaluate the clinical results of microfat grafting [11].

There are opposing theories about cell survival: The Hofer's theory versus the scaffold or matrix theory.

According to Hofer, all or most of the transplanted adult adipocytes are destined to die, acting as a non-viable scaffold, through which macrophages penetrate and through which stem cell– mediated angiogenesis and adipogenesis occur.

Cytokine induced cell-cell signalling between living and dying, and between the donor and recipient cells, is thought to play a role in this process [12, 13].

According to the scaffold matrix theory of Khouri and Rigotti, overcrowding of injected cells reaches a critical interstitial fluid pressure of 9 mmHg; therefore, in a tight recipient space fat droplets will merge into fat lakes, which is thought to interfere with capillary blood flow and hence oxygen diffusion leading to apoptosis and cell death.

In clinical setting, fat injections larger than 0.16 cm in radius will have a region of central necrosis.

## **2. Fat grafting technique**

Fat grafting is promising, but clinical outcomes are not always predictable due to the variability of degree of fat resorption, which is highly dependent on surgeon's technique.

Fat-grafting procedure is divided mainly to three main steps:

**1.** Fat Harvesting

**2.** The intermediate regenerating zone: with a thickness from 600 to 1200 μm, which shows

**3.** The inner necrotic zone: with necrotic cells, inflammatory cells, fibrosis, oil drops and rare

**At the outermost surviving zone**, the cells are quite close to vascularity and the adipocytes tend to survive in a process quite similar to the physiology of skin grafts, called the diffusion/ angiogenesis theory that suggests that donor adipocytes survive by oxygen diffusion at the recipient site during the initial days after grafting, with eventual micro-angiogenesis and

**At the regenerating zone**, the fat cells do not succeed to survive; however the adipose-derived stem cells ( pre-adipocytes) experience ongoing adipogenesis that increased rapidly after

**The necrotic zones** will eventually be absorbed, filled with fibrous tissue, or become a

Grafted fat tissue undergoes degeneration within 1 week, while regeneration reaches its peak at 4 weeks. Regeneration takes place by adipose tissue-resident progenitor cells. Phagocytosis and cicatrisation occur in the regenerating and necrotic zones, predominantly by M1 and M2

The stabilization process appears to persist for a long time after failed regeneration. The size of the necrotizing zone depends mainly on the size of the graft and the micro-environment into which it is placed. Eventually, necrotic zones will be absorbed, filled with fibrous tissue, or become a problematic cyst. Liposuction and reinjection procedures could be improved by preparing grafts with better viability and in an appropriate size, maximizing the contact surface of the grafts by ideal distribution, and placing the grafts in areas with high vascularity. Stabilization of the grafted fat may not occur until several months after complete regeneration at 3 months. This emphasizes the importance of long-term follow-up to thoroughly evaluate

There are opposing theories about cell survival: The Hofer's theory versus the scaffold or

According to Hofer, all or most of the transplanted adult adipocytes are destined to die, acting as a non-viable scaffold, through which macrophages penetrate and through which stem cell–

Cytokine induced cell-cell signalling between living and dying, and between the donor and

According to the scaffold matrix theory of Khouri and Rigotti, overcrowding of injected cells reaches a critical interstitial fluid pressure of 9 mmHg; therefore, in a tight recipient space fat droplets will merge into fat lakes, which is thought to interfere with capillary blood flow and

grafting and peaked at 4 weeks and full remodelling was completed by 12 weeks.

both surviving adipocytes along with dead.

adipocytes.

170 Body Contouring and Sculpting

problematic cyst.

matrix theory.

macrophages respectively.

the clinical results of microfat grafting [11].

mediated angiogenesis and adipogenesis occur.

recipient cells, is thought to play a role in this process [12, 13].

hence oxygen diffusion leading to apoptosis and cell death.

formation of a viable blood supply.


Most surgeons believe that fat, as autologous tissue, can be considered the ideal soft-tissue filler because it is abundant, readily available, inexpensive, compatible, and can be harvested easily. If fat grafts are manipulated correctly, structural fat grafting represents a safe, longlasting and natural-appearing method for soft-tissue augmentation in patients.

To obtain long-term survival of transplanted autologous fatty tissue, the harvested and processed fat grafts must remain viable before implantation. In 1994, Coleman first described his technique, which uses a syringe, cannula and centrifuge, for structural fat grafting [7].

He later refined and popularized his technique for fat-graft harvesting and processing with patented instruments and a centrifugation protocol, often referred to as the Coleman technique [14].

#### **2.1. Harvesting**

A number of techniques have been used for fat harvesting, these include conventional liposuction (syringe with vacuum suction), power-assisted liposuction (specialized cannula with mechanized movement), hand-held syringe liposuction (syringe with manual suction; Coleman technique) and internal ultrasound and LASER-assisted liposuction (specialized cannula that transmits ultrasound or LASER within the body syringe liposuction). A number of studies have compared conventional liposuction with suction- or power-assisted liposuction. Leong et al., upon comparing syringe liposuction to pump-assisted liposuction found no differences in cell viability, cell metabolic activity or adipogenic responses of cultured mesenchymal precursor cells processed from pump or syringe lipoaspirates [15, 16].

In contrast, Pu et al. demonstrated that syringe liposuction yields a greater number of viable adipocytes and sustains a more optimal level of cellular function within fat grafts than conventional liposuction. However, normal histologic structure was maintained in fat grafts obtained by both methods [17].

### **2.2. Infiltration**

For fat aspiration, the donor site is infused with tumescent solution, consisting of a local anaesthetic (LA) (lidocaine, ropivacaine, prilocaine or bupivacaine) for pain relief and epinephrine for haemostasis in Lactated Ringer's solution or normal saline. The most currently used LA for liposuction and Autologous Fat Graft (AFG) is lidocaine and that is on this molecule that literature is the most abundant. Indeed, a survey from the American Society for Aesthetic Plastic Surgery concluded that: for adipose tissue harvest, 40% of surgeons use tumescent solution containing 50 mL of 1% xylocaine + 1 mL epinephrine 1:1000 in 1 L normal saline, which corresponds to 0.5 mg/mL of lidocaine, about 30% of them use a mixture of 0.5% xylocaine with epinephrine and 22% use 1% xylocaine epinephrine mixture. The remaining 8% of American physicians use epinephrine alone or other solution [18].

Several studies [19–21] have examined the effect of the local anaesthetic or epinephrine on fat viability. Oren in a study published in the journal of drugs in dermatology in 2005 stated that neither lidocaine nor adrenaline had long-term unfavourable results on the grafted fat cells.

According to authors' experience, the use of LA should be avoided under general anaesthesia (tumescent solution with diluted epinephrine only), preferably using regional or spinal anaesthesia to avoid injection of local anaesthetics.

#### **2.3. Donor site preference**

Whether there is an optimal donor site for fat grafting or not remains to be established.

In several studies, various authors showed that fat from the lower abdomen and medial thighs consist of a higher concentration of adipose-derived stem cells compared to the fat from the upper abdomen, trochanteric region, knee and flank [22].

However, other studies reported no influence of the donor site on fat viability [23, 24].

Among adrenergic receptor subtypes that regulate lipid mobilization, the alpha-2-adrenergic receptor is involved in the inhibition of fatty acid mobilization from adipose tissue and that can explain why some areas are more resistant to fat mobilization, the so called genetic fat areas, like abdomen for the men and trochanteric areas for women.

In our experience, the genetic fat theory had a clinical correspondency, with volumes of fat less susceptible to reduction with diet and exercise. The genetic fat expresses alpha-2 receptors that are more stable with metabolism and are anti-lipolytic. So it is usually useful to ask the patient about his resistant fat areas as a guide to the donor site, usually trochanters, lower abdomen and love handles in most people.

#### **2.4. Optimal lobular size: choice of harvesting cannula**

The size of cannula is debated among physicians. Some researchers stated that larger cannulas allow harvesting of bigger fat lobules with a higher survival rate [25].

Others stated that smaller cannula sizes theoretically create less donor site trauma and allow for removal of smaller sized lobules of fat, which may improve flow characteristics and reduce trauma during reinjection. An important consideration besides cannula size is cannula hole size and number of holes. A 12-gauge cannula with 6–8 side holes 2 × 1 mm in size can extract a significant amount of fat despite its small calibre.

The summation of the surface area of the individual openings on a 12-gauge, 12-hole cannula approaches or exceeds the surface area of the opening of a classic 10 mm one-hole cannula. This results in better tissue flow with less trauma in the donor area. In addition, each hole selects for lobules of a small, uniform size, which are more likely to flow easily through the injection cannula during the grafting phase of the procedure thus, there is no need for further processing or syringe transfers. The hole sizes on the aspiration cannula approach the size of the hole on the injection cannula. This ensures 'equalization' of hole sizes for more efficient fat flow [26].

In our experience midsize cannulas (3 and 4 mm) are a good compromise between too fine instruments (2 mm) and aggressive tools (5 or 6 mm).

Using wider-diameter cannulas (2.5 mm) may however be preferred as they have been shown to potentially improve fat-graft survival and reduce fat- graft resorption compared with smalldiameter cannulas (1.6 or 2 mm).

The size of the needles does not appear to affect cell viability, at least when using 14-, 16-, and 20-gauge needles (Erdim et al) [27]. However, for any given needle size, it appears that fat viability is influenced by the shear stress, which is a function of the flow rate. Thus, fat injected at a slow rate (low shear stress) results in better fat-graft retention than fat injected at a fast rate (high shear stress) [25]

In the author's practice, nowadays with evolving of microfat and nanofat techniques, harvesting allows injection with ease using 0.7 and 0.9 mm diameter injection cannulas and needles as common practice without much worry about friction and sheer stress especially in areas of the face and hands where tiny injectors are needed.

#### **2.5. Negative pressure**

**2.2. Infiltration**

172 Body Contouring and Sculpting

grafted fat cells.

**2.3. Donor site preference**

For fat aspiration, the donor site is infused with tumescent solution, consisting of a local anaesthetic (LA) (lidocaine, ropivacaine, prilocaine or bupivacaine) for pain relief and epinephrine for haemostasis in Lactated Ringer's solution or normal saline. The most currently used LA for liposuction and Autologous Fat Graft (AFG) is lidocaine and that is on this molecule that literature is the most abundant. Indeed, a survey from the American Society for Aesthetic Plastic Surgery concluded that: for adipose tissue harvest, 40% of surgeons use tumescent solution containing 50 mL of 1% xylocaine + 1 mL epinephrine 1:1000 in 1 L normal saline, which corresponds to 0.5 mg/mL of lidocaine, about 30% of them use a mixture of 0.5% xylocaine with epinephrine and 22% use 1% xylocaine epinephrine mixture. The remaining

Several studies [19–21] have examined the effect of the local anaesthetic or epinephrine on fat viability. Oren in a study published in the journal of drugs in dermatology in 2005 stated that neither lidocaine nor adrenaline had long-term unfavourable results on the

According to authors' experience, the use of LA should be avoided under general anaesthesia (tumescent solution with diluted epinephrine only), preferably using regional or spinal

Whether there is an optimal donor site for fat grafting or not remains to be established.

However, other studies reported no influence of the donor site on fat viability [23, 24].

In several studies, various authors showed that fat from the lower abdomen and medial thighs consist of a higher concentration of adipose-derived stem cells compared to the fat from the

Among adrenergic receptor subtypes that regulate lipid mobilization, the alpha-2-adrenergic receptor is involved in the inhibition of fatty acid mobilization from adipose tissue and that can explain why some areas are more resistant to fat mobilization, the so called genetic fat

In our experience, the genetic fat theory had a clinical correspondency, with volumes of fat less susceptible to reduction with diet and exercise. The genetic fat expresses alpha-2 receptors that are more stable with metabolism and are anti-lipolytic. So it is usually useful to ask the patient about his resistant fat areas as a guide to the donor site, usually trochanters, low-

The size of cannula is debated among physicians. Some researchers stated that larger cannulas

8% of American physicians use epinephrine alone or other solution [18].

anaesthesia to avoid injection of local anaesthetics.

upper abdomen, trochanteric region, knee and flank [22].

er abdomen and love handles in most people.

**2.4. Optimal lobular size: choice of harvesting cannula**

areas, like abdomen for the men and trochanteric areas for women.

allow harvesting of bigger fat lobules with a higher survival rate [25].

The literature regarding the isolated effects of negative pressure suggests that adipocytes can be suctioned below 700 mmHg without undue trauma according to Shiffman [28].

Claims of syringe suctioning as being safer than machine suctioning should be carefully considered. While a standard liposuction machine can generate up to one atmosphere (760 mmHg) of negative pressure, a 60-cc syringe connected to an in-line manometer can also generate nearly one atmosphere of negative pressure. It is likely that absolute pressure and not the source of this pressure is the key variable in adipocyte trauma and its effect of adipocyte viability [26].

The author's experience agrees with the aforementioned literature about keeping a low suction pressure at the level of 700 mmHg to maintain the viability of fat cells.

#### **2.6. Processing**

The harvested fat is processed in order to eliminate tumescent fluid, blood, cell fragments and oil (from disrupted adipocytes) [29].

Processing aims to retain viable adipocytes in a concentrated form which is believed to enhance the graft taken [16].

Filtration, centrifugation and sedimentation (decantation) are the most commonly used fat processing methods.

#### *2.6.1. Filtration*

The filtration technique uses a platform for concentrating fat cells and separating cells from fluids, oil and debris. Examples of platform used for filtering fat include filters or strainers with defined pore size, gauze, metal sieve, mesh and operating room cloth. During centrifugation process, the syringe containing the aspirate is placed in a centrifuge at a specified speed and time.

During the sedimentation process, the syringe containing the lipoaspirate is allowed to sit for decantation to occur under the effect of gravity.

A modification of this technique includes washing the lipoaspirate with 1–3 times the volume with normal saline or Lactated Ringer's solution and then left to decant under gravity. In all techniques, centrifugation, sedimentation and washing, the lipoaspirate is separated into three zones: an upper oil zone, a middle purified concentrated fat layer, and a lower aqueous zone consisting of blood and washing liquids. In the centrifugation technique, in addition, a pellet is seen at the bottom of the centrifuge.

#### *2.6.2. Centrifugation*

The Coleman technique is the most widely used centrifugation protocol in which the lipoaspirate is centrifuged at ~1200 × g (3,000 rpm) for 3 minutes.

In agreement with Coleman, Kurita et al. evaluated the effect of six centrifugation speeds ( from 0 to 4200 ×g for 3 minutes) on fat aspirates and graft taken from nude mice and concluded that centrifugation at more than 3000 ×g significantly damaged adipose-derived stem cells and recommended 1200 ×g as an optimized centrifugal force for obtaining good short- and longterm results in adipose transplantation [30].

Some studies concluded that lower centrifugal forces than in Coleman's protocol may be more adipocyte-friendly.

Hoareau et al. subjected fat tissue to soft (100 ×g/1 min and 400 ×g/1 min) and strong (900 ×g/3 min and 1800 ×g/10 min) forces and examined the grafts viability. Strong centrifugation resulted in 3-fold more adipocyte death than soft centrifugation suggesting that soft centrifugation (400 × g/1 min) seems to be the most appropriate protocol for the reinjection of adipose tissue.

Yet, others suggest that centrifugation has no effect on adipocyte viability as in Pulsfort et al. Pulsfort, using eight different centrifugal forces (up to 20,000 ×g) found no significant differences in the viability of centrifuged adipocytes. Furthermore, no apoptotic changes revealed during cultivation of isolated adipocyte after centrifugation. However, higher centrifugal accelerations were better in cleansing lipoaspirates from oil and cell debris, than lower centrifugal forces.

The authors do not advocate centrifugation forces above 5000 rpm for more than 5 minutes and more than 1200 G finding that it carries the risk of destruction to fat cells.

#### *2.6.3. Sedimentation*

**2.6. Processing**

174 Body Contouring and Sculpting

the graft taken [16].

processing methods.

*2.6.1. Filtration*

and time.

oil (from disrupted adipocytes) [29].

decantation to occur under the effect of gravity.

pirate is centrifuged at ~1200 × g (3,000 rpm) for 3 minutes.

is seen at the bottom of the centrifuge.

term results in adipose transplantation [30].

*2.6.2. Centrifugation*

adipocyte-friendly.

tissue.

The harvested fat is processed in order to eliminate tumescent fluid, blood, cell fragments and

Processing aims to retain viable adipocytes in a concentrated form which is believed to enhance

Filtration, centrifugation and sedimentation (decantation) are the most commonly used fat

The filtration technique uses a platform for concentrating fat cells and separating cells from fluids, oil and debris. Examples of platform used for filtering fat include filters or strainers with defined pore size, gauze, metal sieve, mesh and operating room cloth. During centrifugation process, the syringe containing the aspirate is placed in a centrifuge at a specified speed

During the sedimentation process, the syringe containing the lipoaspirate is allowed to sit for

A modification of this technique includes washing the lipoaspirate with 1–3 times the volume with normal saline or Lactated Ringer's solution and then left to decant under gravity. In all techniques, centrifugation, sedimentation and washing, the lipoaspirate is separated into three zones: an upper oil zone, a middle purified concentrated fat layer, and a lower aqueous zone consisting of blood and washing liquids. In the centrifugation technique, in addition, a pellet

The Coleman technique is the most widely used centrifugation protocol in which the lipoas-

In agreement with Coleman, Kurita et al. evaluated the effect of six centrifugation speeds ( from 0 to 4200 ×g for 3 minutes) on fat aspirates and graft taken from nude mice and concluded that centrifugation at more than 3000 ×g significantly damaged adipose-derived stem cells and recommended 1200 ×g as an optimized centrifugal force for obtaining good short- and long-

Some studies concluded that lower centrifugal forces than in Coleman's protocol may be more

Hoareau et al. subjected fat tissue to soft (100 ×g/1 min and 400 ×g/1 min) and strong (900 ×g/3 min and 1800 ×g/10 min) forces and examined the grafts viability. Strong centrifugation resulted in 3-fold more adipocyte death than soft centrifugation suggesting that soft centrifugation (400 × g/1 min) seems to be the most appropriate protocol for the reinjection of adipose

Sedimentation is the oldest and the cheapest way to treat fat before injection. The most advanced purification techniques seem to have replaced decantation but some studies still support this simple filtration process also with higher amount of live pre-adipocytes [31].

Condé- Green showed that cell count, per high-power field, of intact nucleated adipocytes was significantly higher in decanted lipoaspirates while centrifuged samples showed a greater majority of altered adipocytes. On the other hand, the MSC concentration was significantly higher in washed lipoaspirates compared to decanted and centrifuged samples. However, the pellet collected at the bottom of the centrifuged samples had the highest concentration [32].

The authors wash adipose tissue grafts and recommend that if centrifugation is used, the pellet containing mesenchymal stem cells should be added to the concentrated adipose phase to augment graft take.

#### **2.7. Fat placement**

Although there is no standardized fat placement technique, the Coleman technique is the most widely used. Fat grafts, in this technique, are injected using a blunt Coleman infiltration cannula attached to a 1 mL syringe while withdrawing the cannula. Different syringe sizes (3 and 10 mL) as well as various cannula tip shapes, lengths, gauges and curves can be used depending on the volume of fat to be placed and the recipient site [33].

### *2.7.1. Types of fat grafting*

Different sizes of fat graft obviously reflect the mean lobular size of each type**.**

Macrofat grafting: as the name implies, represents the largest lobular size and is the size obtained with a standard (3 mm and above) mostly Mercedes type liposuction cannula with large side holes (2 × 7 mm). This kind was mostly the standard practice since the start of fat grafting, indifferently injected to all parts of the body including the face. Probably that was the reason why patients previously had complications like lumpiness and cyst formation due to the unsuitable grafted lobular size to the delicate areas of the face like tear trough.

Macrofat grafting is best indicated in areas that need large volume transfers like buttocks and breasts. Macrofat graft contains both viable adipocytes and adipocyte derived stem cells (ADSCs).

Blunt injection cannulas ranging from 0.7 to 0.9 mm are usually used, with very good results, for microfat grafting, usually performed in the facial area. The fat particles need to be sufficiently small in order to provide a smooth injection through these fine cannulas. If the fat particles are too large, passage through the fine injection cannula would be difficult. As a result, disrupted injection will follow, which may lead to an unequal lipofilling with irregular fat deposits.

Trepsat used a multi-perforated harvesting cannula of 2 mm with 1-mm side holes and 19 gauge injection cannulas, to provide fat grafts with smaller particles for microfat grafting procedures at the lower eyelid. To harvest fat for injection of other parts of the face, a multiperforated liposuction cannula of 3 mm in diameter with 2-mm side holes was used [34, 35].

According to the authors' practice, the smaller lobular fat-graft size obtained with a (Tonnard) or (Sorensen) microfat harvester cannulas that are multi-port 2-3 mm cannulas (19-gauge) with sharp or bevelled 6–12 side holes of 1 mm in diameter. These are best mounted to a 10 mm luer lock tip syringe for a controlled low pressure microfat harvesting. Microfat-grafts were best used to fill the face, hands and delicate areas as tear trough. Microfat contains both viable adipocytes and adipocyte derived stem cells.

The radius of the fat particle is inversely proportional to its contact surface. This means that for the same volume of injected fat, reducing the diameter by half will double the contact surface. A larger contact surface means better contact with the capillaries in the recipient area and thus a better graft survival rate with less need for overcorrection. The authors do not advocate overfilling with microfat grafting. Microfat grafts due to their micro lobular size are easily injected with 0.7–0.9 mm micro-cannulas injected into different tissue layers in columns of fat pearls.

Aspirated fat has to be processed mechanically to provide a liquid fat emulsion, which is called nanofat. This is to ensure a smooth fat injection through 27-gauge sharp needles [34]. Using a nanofat processing procedure, a yield of 1 ml of nanofat per 10 ml of lipoaspirate can be expected.

For production of nanofat, the lipoaspirated fat is mechanically emulsified after rinsing by shifting the fat between two 10-cc syringes connected to each other by a female-to-female Luer-Lock connector. After 30 passes, the fat changes into an emulsion. At the end of the fragmentation process, the fat becomes liquid and has a whitish appearance. After emulsification process, the fatty liquid is again filtered over the sterile nylon cloth and the effluent is collected as nanofat. Nanofat does not add much volume as its filling capacity is pretty limited since it mostly lacks the viable adipocytes. However, nanofat grafts are rich in ADSCs that are capable of skin rejuvenation as in areas like perioral skin, glabellar skin, sun-damaged skin at the breast cleavage, dark eye hallows and scars. Nanofat is injected using a 23-gauge needle mounted to 1-cc syringe. The effect of nanofat usually appears with a delay of 4 weeks to 3 months.

Increased collagen, elastin synthesis and remodelling are the presumed mechanisms for this regenerative effect on improved elasticity. Stem cells rather than grafted adipocytes most likely trigger these effects. Presumably, the nanofat sample analysis revealed that adipocytes were destroyed during the emulsification process.

Another form of microfat graft, called SNIF (sharp needle intradermal fat injection), through which a 1 ml syringe is injected to the superficial dermal plane with a 23-gauge needle. SNIF is a cheaper and more effective filler for wrinkles in patients willing to have long-term results and would accept the process of fat harvesting and the post-operative swelling.

#### **2.8. Tips and pitfalls**

Blunt injection cannulas ranging from 0.7 to 0.9 mm are usually used, with very good results, for microfat grafting, usually performed in the facial area. The fat particles need to be sufficiently small in order to provide a smooth injection through these fine cannulas. If the fat particles are too large, passage through the fine injection cannula would be difficult. As a result, disrupted injection will follow, which may lead to an unequal lipofilling with irregular fat

Trepsat used a multi-perforated harvesting cannula of 2 mm with 1-mm side holes and 19 gauge injection cannulas, to provide fat grafts with smaller particles for microfat grafting procedures at the lower eyelid. To harvest fat for injection of other parts of the face, a multiperforated liposuction cannula of 3 mm in diameter with 2-mm side holes was used [34, 35]. According to the authors' practice, the smaller lobular fat-graft size obtained with a (Tonnard) or (Sorensen) microfat harvester cannulas that are multi-port 2-3 mm cannulas (19-gauge) with sharp or bevelled 6–12 side holes of 1 mm in diameter. These are best mounted to a 10 mm luer lock tip syringe for a controlled low pressure microfat harvesting. Microfat-grafts were best used to fill the face, hands and delicate areas as tear trough. Microfat contains both viable

The radius of the fat particle is inversely proportional to its contact surface. This means that for the same volume of injected fat, reducing the diameter by half will double the contact surface. A larger contact surface means better contact with the capillaries in the recipient area and thus a better graft survival rate with less need for overcorrection. The authors do not advocate overfilling with microfat grafting. Microfat grafts due to their micro lobular size are easily injected with 0.7–0.9 mm micro-cannulas injected into different tissue layers in columns

Aspirated fat has to be processed mechanically to provide a liquid fat emulsion, which is called nanofat. This is to ensure a smooth fat injection through 27-gauge sharp needles [34]. Using a nanofat processing procedure, a yield of 1 ml of nanofat per 10 ml of lipoaspirate can be

For production of nanofat, the lipoaspirated fat is mechanically emulsified after rinsing by shifting the fat between two 10-cc syringes connected to each other by a female-to-female Luer-Lock connector. After 30 passes, the fat changes into an emulsion. At the end of the fragmentation process, the fat becomes liquid and has a whitish appearance. After emulsification process, the fatty liquid is again filtered over the sterile nylon cloth and the effluent is collected as nanofat. Nanofat does not add much volume as its filling capacity is pretty limited since it mostly lacks the viable adipocytes. However, nanofat grafts are rich in ADSCs that are capable of skin rejuvenation as in areas like perioral skin, glabellar skin, sun-damaged skin at the breast cleavage, dark eye hallows and scars. Nanofat is injected using a 23-gauge needle mounted to 1-cc syringe. The effect of nanofat usually appears with a delay of 4 weeks to 3 months.

Increased collagen, elastin synthesis and remodelling are the presumed mechanisms for this regenerative effect on improved elasticity. Stem cells rather than grafted adipocytes most likely trigger these effects. Presumably, the nanofat sample analysis revealed that adipocytes were

deposits.

176 Body Contouring and Sculpting

of fat pearls.

expected.

adipocytes and adipocyte derived stem cells.

destroyed during the emulsification process.

The authors carry on the microfat harvesting and injection technique for purpose of fat injection of the face, hands, scars and breasts. In case of buttocks augmentation, macrofat harvesting and injection techniques are utilized as described formerly in the literature.

Our main steps are:

**Harvesting site choice.** Selecting area for fat harvesting depending on genetic fat theory asking the patient about his areas of fat deposits that are least affected with metabolism during weight loss. In case of face treatment, the planned amount is usually around 50–100 cc; however in buttocks it could range up to 1 litre. Infiltration: Tumescent technique is carried in a 1:1 ratio of infiltration to aspirate ratio. For every 1000-cc of normal saline, 1ml adrenaline, and 10 cc of sodium bicarbonate. Usually, regional or spinal anaesthesia is utilized or other wise 20 cc of 1 % lidocaine is to be added to the 1 litre solution.

**Harvesting.** Usually waiting around 10 minutes from the start of infiltration to start suctioning the first infiltrated area. 2 mm microfat harvester cannulas with 6 –12 (1 mm) holes are used. More than one type of microfat cannula harvesters is used. We prefer in our practice the bevelled smooth edged side holes better than cannulas with sharp bevelled edged holes since the sharp edges were found to cut more readily into the connective tissues opening tissue planes together so instead of suctioning from tunnels, changes to spaces and that leads to losing suction pressure fast after a while, especially while using syringe suction which necessitates harvesting other areas to get the needed amount of fat.

Lipoaspiration with a low suction pressure (under 700 mmHg) either using 10-cc syringes for harvesting of microfat or suction assisted motors for larger volumes as for macrofat grafting of the buttocks for augmentation.

**Processing.** It is carried out with a process of decantation where the fat is collected in syringes standing upright in a metal rack for the fat to sediment into an oil layer (top), fatty layer (middle) and fluid (lower) layer with remains of tumescent fluid and blood.

**Decantation.** The process is carried with suction of the oil layer with 23-G needle until purification and eliminating the bottom fluid portion. Adding plasma-rich platelets to the purified aspirate in a ratio of 1:9 is an optional step.

Preparing for injection by transferring the filtered, activated microfat into individual 1-cc syringe with a 0.7 or 0.9 mm micro-injector cannulas in case of microfat placement and in 2mm injectors for macrofat placement as in larger volumes as the buttocks.

Placement of the fat should be carried out in many columns of fat pearls with multi-strokes or retrograde filling in different tissue layers, never in one bolus neither in an over correction.

## **3. Stem cells and fat grafting**

Stem cells are present in many tissues of the human body.

The most common source of SC is the bone marrow, which is a relatively complicated location to perform a non-invasive harvesting procedure. Adipose tissue is a natural source of stem cells, which are at the edge of modern research for tissue regeneration, thanks to the easy, noninvasive harvesting and abundant availability of MSCs. Therefore, fat grafting has started to be considered not just a treatment to achieve morphologic improvement but a procedure of regenerative medicine. Beside the large availability of ADSCs, it has been demonstrated that ADSCs express CD3, CD14, CD19, CD34, CD44, CD45, CD73 and CD90 similar to cord tissue MSCs (CT-MSCs) [36], that confirms the same biological quality. ADSCs have been successfully extracted and used in many studies to seed specific tissues to obtain differentiation and local proliferation [37].

On the other hand, out of laboratory, most of the actual clinical applications do not use ADSCs alone but along with their adipose medium due to the easy, inexpensive harvesting and injection (liposuction/lipofilling) process.

Thus, concentration of MSCs is relevant to biological effect and various methods of concentration of cells inside adipose tissue have been invented. All commercially available system demonstrated to be effective but the concentration of MSCs can be quite heterogeneous [38].

Celution® (Cytori Therapeutics, Inc., San Diego, Calif.) demonstrated to be the most effective in concentrating MSCs (2.41 × 105 cells/g) also bringing endothelial cells.

These devices are a promising advance in reconstructive surgery to treat difficult wounds or irradiated tissues. The biggest downside is the elevated cost of maintenance, which limits their use in aesthetic field.

In private practice, an efficient purifying system of adipose tissue (i.e. Puregraft® or centrifugation) has the right balance between cost and effectiveness.

In our experience, high concentration of stem cells has been used in perioral treatment of sclerodermia to enhance tissue regeneration. It is authors' belief that stem cells may be of great help when active regeneration is needed but that aesthetic uses of MSCs may not justify the high processing price.

## **4. Applications and indications to fat grafting**

Fat grafting has relevant roles both in reconstructive and aesthetic fields; for the purpose of this book, only the latter will be discussed.

Lipofilling has become more and more popular, plus the indications are growing broader each year. Therefore, it is hard for the surgeon to have clear guidelines to choose the right technique for the right patient.

In 2007, the American Society of Plastic Surgery (ASPS) [29] developed evidence-based indications to the use of fat grafting supported by strong literature data.

The first applied criterion is safety. Despite some heterogeneity of fat processing among physicians (infiltration, harvesting, processing and fat layering), the overall risk is low. Considering the mild anaesthesia needed, anaesthetic complications are barely reported, which allows including a wider group of potential patients according to general health conditions and comorbidities. Infections, seroma and hematoma are reported but mostly treated conservatively [39, 40].

Doubts related to cancer (mostly breast) due to the biological role of fat and stromal cells have been cleared by several studies [41, 42], although in specific cases, like breast injection, a mammography or ultrasound are recommended.

In aesthetic field the most popular indications include facial and hand rejuvenation, breast and buttocks augmentation, scar revision and less commonly penis and calf enlargement; the most important are discussed in this chapter.

Beside safety, there are some relative limits to aesthetic fat grafting, which include adipose tissue availability, associated risk factors to fat survival, for example smoking, patient permission to possible multiple sessions (therefore, higher costs) and expectations.

In conclusion, standardization of fat manipulation and careful choice of patients can contribute to satisfactory results from both parts.

## **5. Scar correction**

**3. Stem cells and fat grafting**

178 Body Contouring and Sculpting

injection (liposuction/lipofilling) process.

proliferation [37].

use in aesthetic field.

high processing price.

for the right patient.

Stem cells are present in many tissues of the human body.

The most common source of SC is the bone marrow, which is a relatively complicated location to perform a non-invasive harvesting procedure. Adipose tissue is a natural source of stem cells, which are at the edge of modern research for tissue regeneration, thanks to the easy, noninvasive harvesting and abundant availability of MSCs. Therefore, fat grafting has started to be considered not just a treatment to achieve morphologic improvement but a procedure of regenerative medicine. Beside the large availability of ADSCs, it has been demonstrated that ADSCs express CD3, CD14, CD19, CD34, CD44, CD45, CD73 and CD90 similar to cord tissue MSCs (CT-MSCs) [36], that confirms the same biological quality. ADSCs have been successfully extracted and used in many studies to seed specific tissues to obtain differentiation and local

On the other hand, out of laboratory, most of the actual clinical applications do not use ADSCs alone but along with their adipose medium due to the easy, inexpensive harvesting and

Thus, concentration of MSCs is relevant to biological effect and various methods of concentration of cells inside adipose tissue have been invented. All commercially available system demonstrated to be effective but the concentration of MSCs can be quite heterogeneous [38]. Celution® (Cytori Therapeutics, Inc., San Diego, Calif.) demonstrated to be the most effective

These devices are a promising advance in reconstructive surgery to treat difficult wounds or irradiated tissues. The biggest downside is the elevated cost of maintenance, which limits their

In private practice, an efficient purifying system of adipose tissue (i.e. Puregraft® or centrifu-

In our experience, high concentration of stem cells has been used in perioral treatment of sclerodermia to enhance tissue regeneration. It is authors' belief that stem cells may be of great help when active regeneration is needed but that aesthetic uses of MSCs may not justify the

Fat grafting has relevant roles both in reconstructive and aesthetic fields; for the purpose of

Lipofilling has become more and more popular, plus the indications are growing broader each year. Therefore, it is hard for the surgeon to have clear guidelines to choose the right technique

in concentrating MSCs (2.41 × 105 cells/g) also bringing endothelial cells.

gation) has the right balance between cost and effectiveness.

**4. Applications and indications to fat grafting**

this book, only the latter will be discussed.

Bad scarring represent either a functional and aesthetic trouble that often needs revision, although surgery (excision and z-plasty) alone may not solve the problem; for example, postradiotherapy scarring often involves wide areas, which are not amenable of direct excision.

Scar depression and adherence to deep planes are common features of abnormal scarring that come along with pain and potential functional limitation.

For the reasons mentioned before about ADSCs, fat grafting plays a double role in scar revision: mechanical and biological.

In fact, fat layering corrects depressed scars, detach adherences and can release trapped nerves and tendons.

On the other hand, ADSCs enhance local regeneration and improve vascularity, which can become particularly relevant in unstable scars.

Timing is important, if there is room for ordinary surgical revision (for example a z-plasty), fat grafting may anticipate surgery to improve tissues quality. Moreover, various sessions may be required and it must be discussed with the patient when planning surgery.

In any case, it is wise to wait at least 6 months of scar maturation before attempting any correction. Further sessions may come at an interval of 3–6 months.

#### **5.1. Technique tips and pitfalls**

Anaesthesia and amount of fat to be transferred cannot be standardized, as the clinical scenario is always different.

The first problem the surgeon will encounter is the stiffness of the scarred tissues, which makes difficult to create the funnels with a blunt cannula: remember that excessive strength pushing the cannula through will lead to poor control of trajectory and potential perforation of superficial and deep organs with high-risk consequences.

Therefore, a V-shaped cannula is the ideal tool to safely create the passages to infiltrate fat. It is possible to use either a simple dissector or a sharp cannula to dissect and infiltrate at once.

In our experience, the latter is better, so you can infiltrate in a retrograde fashion each new tunnel without creating false planes.

Superficial subcutaneous scarring may be treated with percutaneous release (rigottomy) with a thick 14–16 G needle.

It is important to try to create a three-dimensional network of tunnels in all directions to neutralize all the vectors of scarring and improve the result.

## **6. Facial rejuvenation**

Facial aging is a complex phenomenon that includes all soft tissues and bones of the face.

A careful assessment must be made to address separately the loss of volume, the vertical displacement of soft tissues and worsening of skin texture [9, 10].

Volume loss mostly depends on soft tissues atrophy and secondarily on bone resorption.

As a matter of fact, when the bones profile becomes too visible it gives a skully aspect, which is instinctively recognized as aged.

Fat grafting is an excellent long lasting alternative to temporary hyaluronic acid (HA) filling.

Like HA, fat is used to correct nasolabial folds, marionette lines, and cheek prominence, tear trough, lip volume, jaw line and the temporal zone to restore a youthful oval face.

#### **6.1. Technique tips and pitfalls**

Fat grafting can be carried out as an outpatient procedure under sedation and local anaesthesia with or without nerve blocks.

Care must be taken to respect the principles of micrografting; a 1mm cannula is probably the best to retain more fat. On the other hand, the amount of resorption rate in the face is lower than other parts of the body; therefore overfilling is equally a potential mistake. The most critical areas of the face are the tear trough (TT) and the lips.

TT assessment must clarify whether there is a problem of a deep anatomical groove or an excess of eye bags near the lower lid, in the second case a blepharoplasty is indicated against lipofilling.

Moreover, due to the thin skin of this area, one must avoid injecting too superficially to avoid permanent visible and palpable lumps; an inexperienced surgeon should not perform TT correction as his/her first procedure.

Lips enhancement is technically easier and equally rewarding for the surgeon and the patient but may suffer of delayed complications if the patient gains weight with deformities and distortion of the lip due to asymmetric adipose tissue expansion. This point must be discussed with the patient prior to surgery and possibly included in the consent form.

## **7. Hand rejuvenation**

In any case, it is wise to wait at least 6 months of scar maturation before attempting any

Anaesthesia and amount of fat to be transferred cannot be standardized, as the clinical scenario

The first problem the surgeon will encounter is the stiffness of the scarred tissues, which makes difficult to create the funnels with a blunt cannula: remember that excessive strength pushing the cannula through will lead to poor control of trajectory and potential perforation of

Therefore, a V-shaped cannula is the ideal tool to safely create the passages to infiltrate fat. It is possible to use either a simple dissector or a sharp cannula to dissect and infiltrate at once. In our experience, the latter is better, so you can infiltrate in a retrograde fashion each new

Superficial subcutaneous scarring may be treated with percutaneous release (rigottomy) with

It is important to try to create a three-dimensional network of tunnels in all directions to

Facial aging is a complex phenomenon that includes all soft tissues and bones of the face.

Volume loss mostly depends on soft tissues atrophy and secondarily on bone resorption.

A careful assessment must be made to address separately the loss of volume, the vertical

As a matter of fact, when the bones profile becomes too visible it gives a skully aspect, which

Fat grafting is an excellent long lasting alternative to temporary hyaluronic acid (HA) filling. Like HA, fat is used to correct nasolabial folds, marionette lines, and cheek prominence, tear

Fat grafting can be carried out as an outpatient procedure under sedation and local anaesthesia

Care must be taken to respect the principles of micrografting; a 1mm cannula is probably the best to retain more fat. On the other hand, the amount of resorption rate in the face is lower

trough, lip volume, jaw line and the temporal zone to restore a youthful oval face.

correction. Further sessions may come at an interval of 3–6 months.

superficial and deep organs with high-risk consequences.

neutralize all the vectors of scarring and improve the result.

displacement of soft tissues and worsening of skin texture [9, 10].

**5.1. Technique tips and pitfalls**

tunnel without creating false planes.

a thick 14–16 G needle.

**6. Facial rejuvenation**

is instinctively recognized as aged.

**6.1. Technique tips and pitfalls**

with or without nerve blocks.

is always different.

180 Body Contouring and Sculpting

While face ageing has always been a concern for people, hand ageing awareness is a more recent discovery in our culture.

Hands more than anything else speak about us, our job, our hobbies and our lives.

With time subcutaneous tissues thin out making visible tendons, bones and veins, which give the typical 'skeleton hand' appearance perceived as aged.

Fat graft helps to restore the subcutaneous layers hiding the over mentioned structures [43].

#### **7.1. Technique tips and pitfalls**

The treatment can be performed as an outpatient procedure; thanks to the limited harvesting the procedure can be performed under mild sedation, local anaesthesia and nerve blocks at the wrist.

Once fat has been prepared with the preferred method, it can be injected through tiny access points in the second, third and fourth we space with a 1 and 2 mm cannula sliding dorsally in the superficial compartment immediately in the subcutaneous space. The correct plane of injection is above the dorsal veins, nevertheless it is advisable to aspirate before injecting in a retrograde fashion to avoid fat embolism.

The linear pattern in between the metacarpal bones can be enough for mild correction, crosslinear infiltration is indicated when major resurfacing is indicated, it is important to respect the micro-tunnelling principle, excessive lipofilling may lead to involuntary dissection of the plane with confluence of all the fat with fat necrosis/resorption.

The amount of fat depends on the correction we want to achieve, usually between 15 and 25 cc of fat per hand is enough.

Lipofilling can be safely combined with superficial peeling in the same session (30% trichloroacetic acid gave good results in the authors' experience) or laser to erase age marks and dyschromia.

A light bandage may be placed after surgery for a couple of days; no special care is needed afterwards.

## **8. Body contouring: gluteal augmentation using fat graft**

The beauty of the buttock area is a difficult subject to address since racial and aesthetic preferences plays a major role in identifying the definition of an aesthetically pleasing buttock. There are some consensuses about the characteristics of a beautiful buttock area, which includes rounded shape, smooth projecting curves, short intergluteal crease and intragluteal crease that reach mid-thigh. The waist hip ratio (WHR) plays a crucial role in determining the upper extent of buttock and thus the back-to-buttock interface. Toledo [44] mentioned this ratio as 0.6 in South Americans and 0.7 in European females. In an attempt to understand the deformities in the buttock area, Murillo [45] had divided the buttock into A-direct areas (gluteus maximus, iliac, trochanteric and ischiorectal), B-indirect areas (sacral, femoral) and C-the border line area (gluteofemoral). We like to use a simple classification based in our mind, the WHR and the end shape we want to reach. This classification represents the buttock area and influencing areas around they are eight areas as shown in **Figure 1**. Based on these descriptions and deformities, there are four shapes of buttocks (triangular, trapezoidal, round and square) as given in **Figure 2**. Mendieta [46] describes point A, B and C. The foundation of this area is the pelvic skeletal system, which eventually share in forming the overall shape of buttocks, Caldewell-Moloy [47] described skeletal pelvis into gynecoid, anthropoid, platypelloid and android. We find this classification although explains different shapes of buttock area

**Figure 1.** The buttock area and influencing areas around (1,2) bilateral symmetric waist area, (3,4) bilateral symmetric buttock area, (5,6) bilateral symmetric thighs, (7) sacral area, (8) diamond shaped area.

yet from practical point is irrelevant since there is no technique that involves bone remodelling for buttock reshaping.

**Figure 2.** The four common shapes of buttocks A—triangular; B—trapezoidal; C—rounded; and D—square.

#### **8.1. Technique tips and pitfalls**

Lipofilling can be safely combined with superficial peeling in the same session (30% trichloroacetic acid gave good results in the authors' experience) or laser to erase age marks and

A light bandage may be placed after surgery for a couple of days; no special care is needed

The beauty of the buttock area is a difficult subject to address since racial and aesthetic preferences plays a major role in identifying the definition of an aesthetically pleasing buttock. There are some consensuses about the characteristics of a beautiful buttock area, which includes rounded shape, smooth projecting curves, short intergluteal crease and intragluteal crease that reach mid-thigh. The waist hip ratio (WHR) plays a crucial role in determining the upper extent of buttock and thus the back-to-buttock interface. Toledo [44] mentioned this ratio as 0.6 in South Americans and 0.7 in European females. In an attempt to understand the deformities in the buttock area, Murillo [45] had divided the buttock into A-direct areas (gluteus maximus, iliac, trochanteric and ischiorectal), B-indirect areas (sacral, femoral) and C-the border line area (gluteofemoral). We like to use a simple classification based in our mind, the WHR and the end shape we want to reach. This classification represents the buttock area and influencing areas around they are eight areas as shown in **Figure 1**. Based on these descriptions and deformities, there are four shapes of buttocks (triangular, trapezoidal, round and square) as given in **Figure 2**. Mendieta [46] describes point A, B and C. The foundation of this area is the pelvic skeletal system, which eventually share in forming the overall shape of buttocks, Caldewell-Moloy [47] described skeletal pelvis into gynecoid, anthropoid, platypelloid and android. We find this classification although explains different shapes of buttock area

**Figure 1.** The buttock area and influencing areas around (1,2) bilateral symmetric waist area, (3,4) bilateral symmetric

buttock area, (5,6) bilateral symmetric thighs, (7) sacral area, (8) diamond shaped area.

**8. Body contouring: gluteal augmentation using fat graft**

dyschromia.

182 Body Contouring and Sculpting

afterwards.

The key idea to reach the final shape of the buttock that is agreed upon with the patient is to remove and add fat in areas based on clinical analysis. The patient is instructed to shave related areas and take a shower the night before operation. Marking are done before operation while patient is standing in front of a mirror to double check the patient's will and opinion. Two colours are used in drawing areas to be injected and liposuctioned with estimate amount of fat to be added or removed on both sides. Although the choice of epidural anaesthesia is given, most patients pick up general anaesthesia. Scrubbing of patient is done after anaesthesia and towelling follows, the solution used is 500-cc Lactated Ringer's solution with adrenaline concentration (1/100000). Injection is done on a 1:1 ratio based on the amount of liposuction. The method used for liposuction is the conventional one using a 5-mm cannula and syringe .The amount depends on degree of deformity putting in mind to obtain an aesthetic WHR. The fat to be injected is decanted, usually we wait for 10 minutes and watery fluid is thrown and fat is taken to be injected .The buttock injection is done using same cannula in more than one plane avoiding intra-muscular injection. The average amount per side injected is 700cc, this is followed by gentle massage to settle injected fat and redistribute it evenly, suturing of incisions are done, the patient is encouraged to walk next day, have a shower and wear elastic garments for 4-6 weeks. A follow-up after 5 days and then every 10 days for one month to check on current condition and exclude any complications is carried out. Fat grafting in buttocks has two main issues that plastic surgeons do differ about; the first is resolution of the fat injected and longevity of the grafts injected. In our technique, we believe that intramuscular injection can produce more complications than the postulated benefit of increase survival of fat grafts and, hence increase projection. Some authors reported the increased survival of fat when injected intra-muscular, moreover this may be lethal and carry a mortality rate as described by Czerny [48]. Lexer [6] had demonstrated using MRI scan, the survival of fat grafting in buttocks conforming role of fat grafting to increase buttock projection. The other point is the choice of buttock implant rather than fat injection, in the Ref. [7] high complications as regard to augmentation of buttocks as exposure and infection are reported. This may even necessitate removal of implant with corrective operation later on.

## **9. Body contouring: breast reshaping using fat graft**

The word 'reshaping' is a more accurate description than 'augmentation' simply using fat grafts is one of techniques which result in ending up with an aesthetically pleasing breast and not only increasing the size of pre-existing breast. The history of breast augmentation dates back to more than a century. Many techniques were used; some worked, others did not. Substances that were used were paraffin, petroleum jelly and silicon [49]. The use of fat grafts had been used very early with a lot of changes to reach the final form we are using now. Berson [50] used dermofascial grafts with uncertain results. Complications like fat necrosis and major degree of resorption had been described by Watson [10] when injecting fat graft in the breast. Coleman [51] reported successful fat grafting in some of cases in 2007 . In 2009, the ASPS fat graft task force stated that, 'Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries; however, results are dependent on technique and surgeon expertise' [29].

#### **9.1. Indications**

In our experience, fat grafting has been used in various scenarios of breast surgery, from aesthetic to reconstruction.

For those patients, who do not want implants, primary breast augmentation in patients suffering from small sized breast and wish for modest increase about one cup. Sequential fat injections can increase the total amount injected reaching more than a one-cup size.

ringe .The amount depends on degree of deformity putting in mind to obtain an aesthetic WHR. The fat to be injected is decanted, usually we wait for 10 minutes and watery fluid is thrown and fat is taken to be injected .The buttock injection is done using same cannula in more than one plane avoiding intra-muscular injection. The average amount per side injected is 700cc, this is followed by gentle massage to settle injected fat and redistribute it evenly, suturing of incisions are done, the patient is encouraged to walk next day, have a shower and wear elastic garments for 4-6 weeks. A follow-up after 5 days and then every 10 days for one month to check on current condition and exclude any complications is carried out. Fat grafting in buttocks has two main issues that plastic surgeons do differ about; the first is resolution of the fat injected and longevity of the grafts injected. In our technique, we believe that intramuscular injection can produce more complications than the postulated benefit of increase survival of fat grafts and, hence increase projection. Some authors reported the increased survival of fat when injected intra-muscular, moreover this may be lethal and carry a mortality rate as described by Czerny [48]. Lexer [6] had demonstrated using MRI scan, the survival of fat grafting in buttocks conforming role of fat grafting to increase buttock projection. The other point is the choice of buttock implant rather than fat injection, in the Ref. [7] high complications as regard to augmentation of buttocks as exposure and infection are reported. This may even

The word 'reshaping' is a more accurate description than 'augmentation' simply using fat grafts is one of techniques which result in ending up with an aesthetically pleasing breast and not only increasing the size of pre-existing breast. The history of breast augmentation dates back to more than a century. Many techniques were used; some worked, others did not. Substances that were used were paraffin, petroleum jelly and silicon [49]. The use of fat grafts had been used very early with a lot of changes to reach the final form we are using now. Berson [50] used dermofascial grafts with uncertain results. Complications like fat necrosis and major degree of resorption had been described by Watson [10] when injecting fat graft in the breast. Coleman [51] reported successful fat grafting in some of cases in 2007 . In 2009, the ASPS fat graft task force stated that, 'Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries;

In our experience, fat grafting has been used in various scenarios of breast surgery, from

For those patients, who do not want implants, primary breast augmentation in patients suffering from small sized breast and wish for modest increase about one cup. Sequential fat

injections can increase the total amount injected reaching more than a one-cup size.

necessitate removal of implant with corrective operation later on.

**9. Body contouring: breast reshaping using fat graft**

however, results are dependent on technique and surgeon expertise' [29].

**9.1. Indications**

184 Body Contouring and Sculpting

aesthetic to reconstruction.

**Figure 3.** (a and b) Tuberous breast case treated with right mastopexy and left side lipofilling (two sessions) rigottomy and areola downsizing.

In association with silicone implants, fat injection could be used for masking apparent edges of breast implant or correction of associated wrinkles; it is an effective non-invasive procedure to correct visible rippling.

When implant explanation is required and the patient want to downsize the breast a combination of fat grafting and decreasing the pocket by sutures is usually a good choice for reaching the patient's goal.

Congenital breast deformity cases with tuberous breast where release of constricted base and fat injection would give a nice suitable breast size and shape when implant is not desired by patient or strictly necessary thanks to enough breast glandular volume (**Figure 3a** and **b**).

Breast reconstruction cases that had resultant defect after lumpectomy or skin sparing mastectomy or breast reduction asymmetry could benefit from localized fat injection to correct contour of breast or recreate the whole breast (**Figure 4a** and **b**).

**Figure 4.** (a and b) Breast reshaping using fat graft after surgery complication. Two to three sessions may be needed.

Fat injection in breast had been used in combination with what is called the Brava system in cases of small breasts with very tight skin envelopes .The Brava system is an apparatus that induce external expansion to the skin to create a well-shaped cavity to be injected with fat thus forming a nice shaped breast. The apparatus is used for 3–4 weeks before surgery then breastreshaping using fat injection is done.

#### **9.2. Technique tips and pitfalls**

Harvesting of fat is done in the same way we use in gluteal augmentation, as regard to injection, the fat is placed using blunt cannula 17 gauge, injection is done in all levels but not intramuscular putting in mind that superficial injection plays a major role in the final shape of breast. The amount injected is about 300–400-cc per breast. In cases of depressed scars, a vshaped cannula is used to separate skin from underlying tissue. Incisions used are usually in inframammary crease or periareolar. All incisions are closed by 4/0 prolene, padding and a well-fitting bra are used while the patient is on table. In 1895, Czerny [48] had a 1 year stable result after lipoma transfer. In 1919, Lexer [3] had described positive results after fat grafting to all area including breast. In 1995 Coleman [52] had positive predictable results with their technique. In our experience fat injection in breast is a reliable technique with the potential to increase breast volume and reach an aesthetic shape even without using the Brava system (Brava, Inc., Miami, FL, USA), this can be done by multiple procedures specially in patients needing to increase the size more than one cup. We find the Brava technique helpful in cases with severe tight skin, we also used decanting only in fat preparation with no centrifuge with optimum results .it is obvious that although there are many indication for fat grafting in breast it is mainly for ' breast reshaping', rather than augmentation on the other hand breast prosthesis are still having a more popular and reproducible results but in breast augmentation. One point, which is still controversial, is the safety of fat injection especially in the breast.

The ASPS Task Force recommendations regarding fat grafts specified the high-risk patient who carries the BRCA-1, BRCA-2 gene and if they or their families have history of breast cancer. We agree on that and follow such recommendations, but the subject especially with the introduction of fat derived stem cells should be further studied.

## **10. Complications of fat grafting**

Fat transfer is a widely used procedure now with a wide range of indications and the surgeon being acquainted with complications and dealing with it is of utmost importance. We should remember that this procedure includes complications of liposuction as well as fat transfer. A resume of complications that can happen shortly after procedure within a week and late complications will help the reader to recognize and manage them.

*Infection*. Although rare nowadays, still it can be seen in some cases. The primary goal is to prevent it from happening as dealing with infected fat grafts is troublesome and usually results in deformity. This can be done by the presence of sterile operating room and instrumentation, using of prophylaxis antibiotics, proper screening of patient for HIV and hepatitis B and C.

*Embolism*. It may be due compression on the venous system as in calf injection with resultant thrombus formation and produce a serious complication like pulmonary thromboembolism that either resolves or result in an increased pulmonary infarction and hypertension. Accidental injection of air in subcutaneous tissue with opening of big veins like the ones present in the neck could be lethal and mimic picture of massive pulmonary embolism

*Blindness*. It can take place in cases where fat injection is done around the orbit either by directly injecting fat into veins or by penetrating the eye capsule with formation of thrombus and resultant in central retinal vein occlusion. This can be avoided by using blunt cannula and marking of any veins apparent, also injection while withdrawing the cannula. Not only blindness had been described but also brain insults in the form of infarction had been recorded [53].

**9.2. Technique tips and pitfalls**

186 Body Contouring and Sculpting

Harvesting of fat is done in the same way we use in gluteal augmentation, as regard to injection, the fat is placed using blunt cannula 17 gauge, injection is done in all levels but not intramuscular putting in mind that superficial injection plays a major role in the final shape of breast. The amount injected is about 300–400-cc per breast. In cases of depressed scars, a vshaped cannula is used to separate skin from underlying tissue. Incisions used are usually in inframammary crease or periareolar. All incisions are closed by 4/0 prolene, padding and a well-fitting bra are used while the patient is on table. In 1895, Czerny [48] had a 1 year stable result after lipoma transfer. In 1919, Lexer [3] had described positive results after fat grafting to all area including breast. In 1995 Coleman [52] had positive predictable results with their technique. In our experience fat injection in breast is a reliable technique with the potential to increase breast volume and reach an aesthetic shape even without using the Brava system (Brava, Inc., Miami, FL, USA), this can be done by multiple procedures specially in patients needing to increase the size more than one cup. We find the Brava technique helpful in cases with severe tight skin, we also used decanting only in fat preparation with no centrifuge with optimum results .it is obvious that although there are many indication for fat grafting in breast it is mainly for ' breast reshaping', rather than augmentation on the other hand breast prosthesis are still having a more popular and reproducible results but in breast augmentation. One point, which is still controversial, is the safety of fat injection especially in the breast.

The ASPS Task Force recommendations regarding fat grafts specified the high-risk patient who carries the BRCA-1, BRCA-2 gene and if they or their families have history of breast cancer. We agree on that and follow such recommendations, but the subject especially with the

Fat transfer is a widely used procedure now with a wide range of indications and the surgeon being acquainted with complications and dealing with it is of utmost importance. We should remember that this procedure includes complications of liposuction as well as fat transfer. A resume of complications that can happen shortly after procedure within a week and late

*Infection*. Although rare nowadays, still it can be seen in some cases. The primary goal is to prevent it from happening as dealing with infected fat grafts is troublesome and usually results in deformity. This can be done by the presence of sterile operating room and instrumentation, using of prophylaxis antibiotics, proper screening of patient for HIV and hepatitis B and C.

*Embolism*. It may be due compression on the venous system as in calf injection with resultant thrombus formation and produce a serious complication like pulmonary thromboembolism that either resolves or result in an increased pulmonary infarction and hypertension. Accidental injection of air in subcutaneous tissue with opening of big veins like the ones present

in the neck could be lethal and mimic picture of massive pulmonary embolism

introduction of fat derived stem cells should be further studied.

complications will help the reader to recognize and manage them.

**10. Complications of fat grafting**

*Skin necrosis*. This can happen from severe infection or over-injection with resultant oedema and too much compression, there is no definite volumes that is fixed, each individual varies from the other yet average amount injected depends on laxity of skin and under-injection is always better than over-injection as there is the chance to inject more later but it is difficult to treat skin necrosis.

*Haematoma and seromas*. This can happen occasionally. As regard to haematoma, this can be avoided by proper pre-operative management and evaluation stopping smoking for 4 weeks and non-steroidal medications for 1 week would protect against unwanted bleeding. The uses of blunt cannula and avoid injury of seen veins. Compression is the main line of treatment and in the case of seroma, persistence aspiration and compression is done

*Nerve injury*. Depending on the site, facial nerve branches may be affected in injection of face or dorsal nerves in cases of hand injection. The injury could be permanent or transient with recovery depending on degree and type of injury [54].

*Absorption (excessive)*. The rate of absorption depends a lot on atraumatic technique used in harvesting as well as areas where fat is harvested from, like upper abdomen and upper back. The rate of absorption varies from 0–50%. Some authors had prescribed over-correction by 30% [55]. This is suitable in areas like buttocks and breast but surely not the face in our opinion.

*Asymmetry*. Since fat injection is done on both sides of body, for example breasts gluteal area and hands, symmetrical injection should be done unless there is asymmetrical obvious difference, sometimes a combined liposuction and fat injection to reach symmetry is done. Minimal asymmetry can be accepted, as it is not obvious except for the patient only.

*Cysts and mass formation*. Cysts of various sizes can occur after fat injection it is mainly oily cyst, it can occur in any site but more common with increased fat injection. Various treatments had been described triamcinolone injection [56], aspiration and compression in big cysts. Hypertrophy of part of injected fat leads to formation of localized mass or sometimes generalized hypertrophy of the whole injected area. In order to avoid this, over-injection of fat is not recommended and the proper amount and plane of injection should be done. Fat also may migrate when over-injection is done and has been reported in the forehead where authors used botulinum toxin in association with fat injection [57].

*Calcifications*. Calcifications in breast are the most ones that invite worries yet for an experience radiologist both the size and form are quite different. Micro-calcifications from fat necrosis are Peri-parynchymal and do not exhibit multi-density, rod-like, punctate or branching spicule [58].

## **Acknowledgements**

Thanks to Dr. Carlos Oaxaca for contributing with clinical images of his own cases.

## **Author details**

Marco Romeo1\*, Ayman Elmeligy2 and Khalid Elsherbeny2

\*Address all correspondence to: doctor@drmarcoromeo.com

1 University Autonoma of Madrid and Fundación Jimenez Diaz, Madrid, Spain

2 Department of Plastic Surgery, Ain Shams University, Cairo, Egypt

## **References**


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#### **Pneumodissection: Enhancement of the Receptor Area before Fat Grafting Pneumodissection: Enhancement of the Receptor Area before Fat Grafting**

Guillermo Blugerman, Diego Schavelzon, Gabriel Wexler, Marcelo Lotocki, Victoria Schavelzon and Guido Blugerman Guillermo Blugerman, Diego Schavelzon, Gabriel Wexler, Marcelo Lotocki, Victoria Schavelzon and Guido Blugerman

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/64838

#### **Abstract**

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192 Body Contouring and Sculpting

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**Introduction:** Fat grafts have become a frequent procedure among plastic surgeons due to their versatility for different pathologies. Different techniques have been described about graft enhancement to increase survival; in this chapter, with CO2 pneumodissec‐ tion, a technique for improving the biological conditions of the receptor area is exposed. Already known effects of carboxitherapy, such as vasodilation, enhanced Bohr effect and neoangiogenesis, are applied to increase the chance of graft survival. Tissue pneumodissection reduces the fat infiltration pain, thus reducing the sedation requirements.

**Materials and methods:** Carbon dioxide is infiltrated in the subcutaneous tissue with a needle before grafting procedure. The amount of CO2 injected varies according to the recipient area. Sixty patients treated in past 15 months were included in the study. Patients were followed up every week for the first month, 3 and 6 months postoperative.

**Results:** Grafts survived in all 40 patients according to clinical observation and follow‐ up. Sedation requirements were minimal. Special interest is the use of this technique when a scar is adherent to deep planes and skin elasticity is reduced.

**Keywords:** fat graft, carboxitherapy, receptor area, graft survival, lipofilling, fat graft enhancement, pneumodissection

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

The introduction of grafts and/or fillers within the subcutaneous tissue implies the creation of tunnels or planes of dissection within tissue. However, this is not without some significant degree of trauma to the dermis and hypodermis cellular structure and the fragile microcircu‐ lation and nerves found within these layers.

In addition, the struggle of the instrument against the resistance of these solid cellular tissues produces pain by transecting nerve endings or compression of the pressure sensors and/or direct distension of these fragile receptors within the skin.

Until now, the only possible solution to reduce these effects was the application of local anesthesia of different modalities, that is, blockades, infiltration or tumescent anesthesia. This implies the introduction of a set volume of liquid and chemicals, which modify the tissue composition both physically and chemically. This alteration to the biophysical composition of the host tissue and the direct limitation of surround tissue elasticity and expandability makes for a suboptimal graft host environment. The ideal environment for graft uptake includes contact with living tissue for nutrition, abundant vascularization in living tissue and consistent blood flow through this vascular net. These characteristics provide for nutrition of the graft and also remove free radicals, toxic for the grafts. We propose a new technique of pneumo‐ dissection using carbon dioxide in the gas state to expand and dissect tissue planes while preserving delicate microcirculation at the site, enhancing the host area conditions and decreasing pain to the patient.

## **2. Characteristics of carbon dioxide**

Carbonic acid gas, is also known as carbon dioxide, carbonic anhydride and dry ice in its solid phase, is composed of one carbon atom and two oxygen atoms, with a chemical formula of CO2.

Its properties have stamped its use as an industrial material as may be seen in fire extinguishers and welding gas. Commercially, it is added to carbonated beverages, including beer and champagne, and its solid form, known as "dry ice," has been used as a refrigerant and as an abrasive in dry ice blasting.

Within the living cell, a series of reactions in the effort to generate energy in the form of adenosine triphosphate (ATP) produces one of the main by‐products of aerobic respiration, that is, carbon dioxide gas (CO2). Within the presence of oxygen, each molecule of glucose produces 6 molecules of carbon dioxide, 6 molecules of water and up to 30 molecules of ATP. This CO2 is then excreted through diffusion from the cells into the blood stream, whereby its binding to hemoglobin ensures its passage to the lungs for exhalation.

Due to the increased solubility of carbon dioxide over oxygen in plasma, each time blood circulates through the body, 4 vol% of carbon dioxide is removed from the tissues and delivered to the lungs to be exhaled. However, this can increase 10 times during physical exercise.

## **3. Uses of carbon dioxide gas in medicine**

**1. Introduction**

194 Body Contouring and Sculpting

lation and nerves found within these layers.

decreasing pain to the patient.

abrasive in dry ice blasting.

**2. Characteristics of carbon dioxide**

direct distension of these fragile receptors within the skin.

The introduction of grafts and/or fillers within the subcutaneous tissue implies the creation of tunnels or planes of dissection within tissue. However, this is not without some significant degree of trauma to the dermis and hypodermis cellular structure and the fragile microcircu‐

In addition, the struggle of the instrument against the resistance of these solid cellular tissues produces pain by transecting nerve endings or compression of the pressure sensors and/or

Until now, the only possible solution to reduce these effects was the application of local anesthesia of different modalities, that is, blockades, infiltration or tumescent anesthesia. This implies the introduction of a set volume of liquid and chemicals, which modify the tissue composition both physically and chemically. This alteration to the biophysical composition of the host tissue and the direct limitation of surround tissue elasticity and expandability makes for a suboptimal graft host environment. The ideal environment for graft uptake includes contact with living tissue for nutrition, abundant vascularization in living tissue and consistent blood flow through this vascular net. These characteristics provide for nutrition of the graft and also remove free radicals, toxic for the grafts. We propose a new technique of pneumo‐ dissection using carbon dioxide in the gas state to expand and dissect tissue planes while preserving delicate microcirculation at the site, enhancing the host area conditions and

Carbonic acid gas, is also known as carbon dioxide, carbonic anhydride and dry ice in its solid phase, is composed of one carbon atom and two oxygen atoms, with a chemical formula of CO2. Its properties have stamped its use as an industrial material as may be seen in fire extinguishers and welding gas. Commercially, it is added to carbonated beverages, including beer and champagne, and its solid form, known as "dry ice," has been used as a refrigerant and as an

Within the living cell, a series of reactions in the effort to generate energy in the form of adenosine triphosphate (ATP) produces one of the main by‐products of aerobic respiration, that is, carbon dioxide gas (CO2). Within the presence of oxygen, each molecule of glucose produces 6 molecules of carbon dioxide, 6 molecules of water and up to 30 molecules of ATP. This CO2 is then excreted through diffusion from the cells into the blood stream, whereby its

Due to the increased solubility of carbon dioxide over oxygen in plasma, each time blood circulates through the body, 4 vol% of carbon dioxide is removed from the tissues and delivered to the lungs to be exhaled. However, this can increase 10 times during physical exercise.

binding to hemoglobin ensures its passage to the lungs for exhalation.

Carbon dioxide was first described in 1648 by the chemist Jan Baptist van Helmont upon observing the mass discrepancy when burning charcoal within a closed vessel. He surmised that the difference in mass of the ash to the original charcoal had been transmuted into an invisible substance, which he referred to as a "gas" or "spiritus sylvestre." Following Jan Helmont, much work was carried out on the niche properties of carbon dioxide in the 1700s and 1800s with Adrien‐Jean‐Pierre Thilorier in 1835, describing solid carbon "snow" CO2.

Carbon dioxide's high purity of 99.9% and nontoxic properties makes it suitable for therapeutic use. Most commonly employed in insufflation gas for minimal invasive surgery (laparoscopy, endoscopy and arthroscopies) [1–4] in order to enlarge body cavities, protect and facilitate manipulation of intra‐abdominal structures.

Possessing no hypersensitivity response, regardless of the volume used, it has been used as a contrast medium in angiography and venograms [5–7]. Its applicability as a supercritical fluid state has been marketed within the medical sterilization realm and also when temperatures of −60°C are reached its therapeutic use in cryotherapy or as local analgesia by external applica‐ tion onto the skin surface.

In 1964, Kumar Patel from the USA invented the CO2 laser, which is still available and which is one of the most useful varieties of medical, surgical, industrial and military applications.

Other uses have, in the addition to pure oxygen in medical grade oxygen, to help provoke breathing and stabilize the O2/CO2 balance within blood.

The uses of carbon dioxide gas on the surface and in the depth of the human body have proven to be highly safe and beneficial in different areas of medicine and surgery. The history of therapeutic use of carbon dioxide gas by either percutaneous or subcutaneous injection, otherwise known as carboxitherapy, began in 1932 at a thermal waters station in the Spy of Royat, France. There, a group of cardiologists utilized CO2 on patients with peripheral and functional artheropathies (artherosclerotics, Buerger, Raynaud) with significant success. In 1940, Jean Baptiste Romuef [8], a respected cardiologist published his 20‐year experience with carboxitherapy. By the mid‐1980s, over 400,000 patients had been treated at Royat providing carboxitherapy as not only an efficient therapeutic method but also a safe one.

The known therapeutic effects of CO2, such as arterial and capillary vasodilation, enhancement of Bohr and lipolytic effect, increased sympatholytic action and with experimental work demonstrating its neoangiogenetic effect means that its use continues to expand within the realms of its therapeutic properties to medicine. There is abundant bibliography that describes the utilization of carbon dioxide gas in patients with chronic obstructive artery disease and gangrene who were treated with CO2 injection with significantly good results [9–13].

Also acting on vascular pathologies, in 2002, Toryama et al. [14] showed an excellent improve‐ ment in the peripheral circulation in patients with critical ischemia, with a reduction of 83% of amputation cases.

For several decades, we have used the subcutaneous injection of carbon dioxide gas to improve local circulation of the skin and subcutaneous tissues, to produce detachment of fibrous tissues and to promote the formation of new collagen in the treated areas [15]. It is also used in its cryogenic state to perform procedures in cryosurgery.

## **4. Physiological effects**

#### **4.1. Stimulation of blood circulation**

Blood circulation is locally increased with pneumodissection due to a vasodilator effect and a neoangiogenic effect. Vasodilation is produced through two main mechanisms:


The inflammatory response to an "aggression" is immediate. It physically acts to destroy, dilute or block the offending agent, but, in turn, this triggers a series of events at the vascularized connective tissue level, including plasma, in cells circulating in the blood vessels and in the extravascular components of connective tissue, with the objective to heal and rebuild the damaged tissue. Acute phase inflammatory mediators, such as histamine, bradykinins and prostaglandins, produce vasodilation to increase to the local blood flow in order to deliver white blood cells to the insulted area. Changes in microcirculation occur, increasing the vascular permeability to cells and proteins.

Histological aspects in the repair process demonstrated the proliferation of small newly formed blood vessels and fibroblasts [16].

Inside the body, carbon dioxide reacts with water producing carbonic acid. This reaction acidifies the local medium where CO2is injected. The local increase of H+ stimulates vasodi‐ lation. In this way, carbon dioxide directly in microcirculation of the vascular connective tissue, promoting vasodilation [17, 18] and an increase in the venous and lymphatic drainage. According to researchers, this can be a reflection of the increase in parasympathetic activity by the decrease in sympathetic activity in these tissues. In addition to that, the persistence of clinical improvement or "temporary cure" of the blood vessel conditions can be explained by the neoangiogenesis [19], due to the formation of angiogenic factors, and vascular endothelial growth and fibroblast growth triggered by hypercapnia tissue.

With carboxitherapy, through the infusion of CO2, it is demonstrated that a persistent vasodi‐ lation is identified during assisted laparoscopy, which leads to a significant rise in the concen‐ tration of oxygen (O2) in the local body cavity. Studies with Doppler flow monometry have demonstrated the action of the carboxitherapy in improving blood flow locally.

#### **4.2. Bohr effect**

The affinity of hemoglobin for oxygen depends on the pH of the medium; the acidity stimulates the release of oxygen thus reducing this affinity. In addition to the acidity, the increase in the concentration of carbon dioxide (CO2) as described in the oxygen‐hemoglobin dissociation curve also lowers the oxygen affinity. The presence of higher levels of CO2 and protons (H+) in the capillaries of tissues in active metabolism promotes the release of O2 of hemoglobin, the reciprocal effect occurs in the capillaries of the alveoli of the lungs and the high concentra‐ tion of O2 releases CO2 and H+ of the hemoglobin. This relationship is known as Bohr effect [20, 21].

There is a consensus among authors about the existence of a significant increase in the concentration of oxygen (O2) locally after subcutaneous infusion of CO2 demonstrating an increase in the partial pressure of O2. These authors [22, 23] have reported that a decrease in affinity of hemoglobin for oxygen in the presence of carbon dioxide gas leading to more oxygen delivery to the cells, which would boost the metabolism of tissues in the region being treated (potentiation of the Bohr effect).

## **4.3. Role of CO2 in connective tissue**

For several decades, we have used the subcutaneous injection of carbon dioxide gas to improve local circulation of the skin and subcutaneous tissues, to produce detachment of fibrous tissues and to promote the formation of new collagen in the treated areas [15]. It is also used in its

Blood circulation is locally increased with pneumodissection due to a vasodilator effect and a

The inflammatory response to an "aggression" is immediate. It physically acts to destroy, dilute or block the offending agent, but, in turn, this triggers a series of events at the vascularized connective tissue level, including plasma, in cells circulating in the blood vessels and in the extravascular components of connective tissue, with the objective to heal and rebuild the damaged tissue. Acute phase inflammatory mediators, such as histamine, bradykinins and prostaglandins, produce vasodilation to increase to the local blood flow in order to deliver white blood cells to the insulted area. Changes in microcirculation occur, increasing the

Histological aspects in the repair process demonstrated the proliferation of small newly

Inside the body, carbon dioxide reacts with water producing carbonic acid. This reaction acidifies the local medium where CO2is injected. The local increase of H+ stimulates vasodi‐ lation. In this way, carbon dioxide directly in microcirculation of the vascular connective tissue, promoting vasodilation [17, 18] and an increase in the venous and lymphatic drainage. According to researchers, this can be a reflection of the increase in parasympathetic activity by the decrease in sympathetic activity in these tissues. In addition to that, the persistence of clinical improvement or "temporary cure" of the blood vessel conditions can be explained by the neoangiogenesis [19], due to the formation of angiogenic factors, and vascular endothelial

With carboxitherapy, through the infusion of CO2, it is demonstrated that a persistent vasodi‐ lation is identified during assisted laparoscopy, which leads to a significant rise in the concen‐ tration of oxygen (O2) in the local body cavity. Studies with Doppler flow monometry have

The affinity of hemoglobin for oxygen depends on the pH of the medium; the acidity stimulates the release of oxygen thus reducing this affinity. In addition to the acidity, the increase in the

demonstrated the action of the carboxitherapy in improving blood flow locally.

neoangiogenic effect. Vasodilation is produced through two main mechanisms:

cryogenic state to perform procedures in cryosurgery.

**4. Physiological effects**

196 Body Contouring and Sculpting

**•** Inflammation **•** Acidification

**4.2. Bohr effect**

**4.1. Stimulation of blood circulation**

vascular permeability to cells and proteins.

formed blood vessels and fibroblasts [16].

growth and fibroblast growth triggered by hypercapnia tissue.

Carboxitherapy produces a "mechanical trauma" post the insertion of the insufflation cannula and the direct trauma of the CO2 gas insufflating between tissue planes and creating a form of pneumodissection. This pneumodissection produces an inflammatory process and the consequent migration of fibroblasts to the region of insufflation, leading to the subsequent proliferation of fibroblasts and therefore the synthesis of collagen and activation of other extracellular matrix proteins such as fibronectin and glycoprotein, which are essential in the biological processes such as adhesion and cell differentiation, tissue repair, serving as a substrate for fibrinolytic enzymes and clotting.

Histological studies of the tissues treated with carboxitherapy have found an increase in the thickness of the dermis, as evidenced by the increased stimulus of neocollagenases. There is total preservation of the connective tissue layers, including its vascular and neurovascular structures as evident within these collagen fibers.

## **5. Carbon dioxide gas as pneumodissector of tissues—carboxitherapy**

Insufflating gases within tissue is not an innovative idea in current medicine. Ivån Goni Moreno, an Argentinean surgeon from the early 1900s, is credited with his operation of introducing progressive preoperative pneumoperitoneum for the repair of large hernias in 1940. Moreno progressively placed large amounts of room air preoperatively into the perito‐ neal cavity over a period of weeks. With this technique, the patient became adjusted to an increased intra‐abdominal pressure and tolerated the sudden reduction of the viscera during the repair, free from respiratory distress.

Currently, with the widespread of laparoscopic procedures, insufflation with carbon dioxide is widespread in all therapeutic and diagnostic laparoscopy as utilized in general, gynecolog‐ ical and urological surgeries.

Due to carbon dioxide's high degree of diffusion, this gas is rapidly absorbed and eliminated, leaving only the vasodilator effect (pneumodissection) in the tissues, without the increased risk of fatal air embolism.

Subcutaneous infiltration of CO2 began to be used for aesthetic purposes in the 1970s in France, with the object of treating cellulite and localized areas of adiposities in the subcutaneous tissue. More recent work of Brandi et al. [24, 25] showed measurable reductions in maximum circumference of abdomen, thigh and knee regions with the transcutaneous administration of CO2 and improved skin irregularity after repeated sessions of carboxitherapy.

## **6. Theory behind the use of carboxitherapy for pneumodissection during fat grafting**

The ideal conditions for adipose (fat) grafting within tissue includes (1) ease of dissection of tissue planes with the advancement of the infiltrating cannula, (2) the ability to layer this fat by placing minimal amounts of adipocytes in multiple tunnels in order to maximize contact with the surrounding tissues therefore increasing the grafts survival rate, (3) good vasculari‐ zation and oxygenation of tissue recipient site, (4) minimal trauma to reduce the risk of bruising, (5) the absence of vasoconstriction, (6) the absence of toxic chemicals in the recipient tissue and (7) good elasticity of the adjacent tissues to comply with the additional volume. The use of carbon dioxide gas as a pneumodissector of the tissue planes may be the one way to achieve these ideal conditions in the host tissue.

The resistance of the tissues to the advancement of a needle or cannula is predetermined by the density of cell structures and fibrosis of the tissue area on the body. Some of the causes of pain during the introduction of fluids and grafts into tissues are due to the compression of pressure receptors (baroreceptors) and also by the stretching of the nerve endings by direct mechanical pressure from the advancing cannula or needle. Also, the pH of the solutions being injected produces pain and burning. The slow insufflation of the carbon dioxide in its gaseous state by percutaneous injection produces tissue plane dissection, which subsequently decreas‐ es the tissues' overall resistance while increasing its three‐dimensional space, yet preserving the neurovascular characteristics of that tissue by pneumodissecting these structures away with the advancement of the needle/cannula and therefore decreasing the possibility of direct pain.

## **7. Clinical experience**

The pneumodissection flow and the total volume of gas infiltrated subcutaneously are controlled with CARBOTECH F650 from Axt Medical Systems®, with complete control over the speed and volume of CO2 gas infiltrated (**Figure 1**).

**Figure 1.** Pneumodissector console.

Due to carbon dioxide's high degree of diffusion, this gas is rapidly absorbed and eliminated, leaving only the vasodilator effect (pneumodissection) in the tissues, without the increased

Subcutaneous infiltration of CO2 began to be used for aesthetic purposes in the 1970s in France, with the object of treating cellulite and localized areas of adiposities in the subcutaneous tissue. More recent work of Brandi et al. [24, 25] showed measurable reductions in maximum circumference of abdomen, thigh and knee regions with the transcutaneous administration

**6. Theory behind the use of carboxitherapy for pneumodissection during**

The ideal conditions for adipose (fat) grafting within tissue includes (1) ease of dissection of tissue planes with the advancement of the infiltrating cannula, (2) the ability to layer this fat by placing minimal amounts of adipocytes in multiple tunnels in order to maximize contact with the surrounding tissues therefore increasing the grafts survival rate, (3) good vasculari‐ zation and oxygenation of tissue recipient site, (4) minimal trauma to reduce the risk of bruising, (5) the absence of vasoconstriction, (6) the absence of toxic chemicals in the recipient tissue and (7) good elasticity of the adjacent tissues to comply with the additional volume. The use of carbon dioxide gas as a pneumodissector of the tissue planes may be the one way to

The resistance of the tissues to the advancement of a needle or cannula is predetermined by the density of cell structures and fibrosis of the tissue area on the body. Some of the causes of pain during the introduction of fluids and grafts into tissues are due to the compression of pressure receptors (baroreceptors) and also by the stretching of the nerve endings by direct mechanical pressure from the advancing cannula or needle. Also, the pH of the solutions being injected produces pain and burning. The slow insufflation of the carbon dioxide in its gaseous state by percutaneous injection produces tissue plane dissection, which subsequently decreas‐ es the tissues' overall resistance while increasing its three‐dimensional space, yet preserving the neurovascular characteristics of that tissue by pneumodissecting these structures away with the advancement of the needle/cannula and therefore decreasing the possibility of direct

The pneumodissection flow and the total volume of gas infiltrated subcutaneously are controlled with CARBOTECH F650 from Axt Medical Systems®, with complete control over

of CO2 and improved skin irregularity after repeated sessions of carboxitherapy.

risk of fatal air embolism.

198 Body Contouring and Sculpting

**fat grafting**

pain.

**7. Clinical experience**

achieve these ideal conditions in the host tissue.

the speed and volume of CO2 gas infiltrated (**Figure 1**).

The pneumodissector console is connected to the pure carbon dioxide gas tank. The CO2 is injected under the control of the surgeon for speed of flow, time of injection and overall administered dose through a disposable tube with 25G needle attached through luer‐lock. This needle is then inserted directly under the skin of the patient within the designated site.

The flow of CO2 through the pneumodissector is fixed at 80 ml per minute. Insufflation between 100 and 1000 ml per area depending on the procedure to be carried out and the site on the body to be performed is undertaken. CO2 easily distributes to all of the injected area and its sur‐ rounding tissue (**Figure 2**).

**Figure 2.** Histology of pneumodissected tissue (hematoxylin‐eosin). Left, Normal subcutaneous tissue. Right, Subcuta‐ neous tissue after pneumodissection, note the air spaces between septums and vessels.

During the past 12 months, we have used the pneumodissection technique intraoperatively prior to the grafting of adipocytes at various quantities in 60 patients (**Table 1**).


Pneumodissection: Enhancement of the Receptor Area before Fat Grafting http://dx.doi.org/10.5772/64838 201


**Table 1.** Patients table. Details of volume of fat grafted and CO2 infused.

**Area Amount injected (cc) Volume of CO2 infused (cc)**

200 Body Contouring and Sculpting

Areas of both the body (abdomen, buttocks, arms, breast, and legs) and face have been successfully pneumodissected prior to fat grafting with clinically superior results compared to commonly used hydrodissection technique (**Figures 3**–**11**).

**Figure 3.** Patient with abdominal flaccidity, lipodystrophy and gluteal hypoplasia. Preoperative (left) and 3 months postoperative of TULUA, liposuction and pneumodissection‐assisted fat grafting to gluteal area in the subcutaneous plane (right).

**Figure 4.** Patient with abdominal flaccidity, lipodystrophy and gluteal hypoplasia. Preoperative (left) and 3 months postoperative of TULUA, liposuction and pneumodissection‐assisted fat grafting to gluteal area in the subcutaneous plane (right).

**Figure 5.** Patient with hand aging. Note skin quality, flaccidity and prominence of vascular network (left). Three months postoperative of pneumodissection‐assisted fat grafting in hands in the subcutaneous plane (right).

**Figure 6.** Patient with hand aging. Note skin quality, flaccidity and prominence of vascular network (left). Three months postoperative of pneumodissection‐assisted fat grafting in hands in the subcutaneous plane (right).

**Figure 4.** Patient with abdominal flaccidity, lipodystrophy and gluteal hypoplasia. Preoperative (left) and 3 months postoperative of TULUA, liposuction and pneumodissection‐assisted fat grafting to gluteal area in the subcutaneous

**Figure 5.** Patient with hand aging. Note skin quality, flaccidity and prominence of vascular network (left). Three

months postoperative of pneumodissection‐assisted fat grafting in hands in the subcutaneous plane (right).

plane (right).

202 Body Contouring and Sculpting

**Figure 7.** Patient with gluteal hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in the gluteal area in the subcutaneous plane (right).

**Figure 8.** Patient with gluteal hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in the gluteal area in the subcutaneous plane (right).

**Figure 9.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in the subcutaneous plane (right).

**Figure 10.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in the subcutaneous plane (right).

**Figure 11.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in the subcutaneous plane (right).

Upon pneumodissection of the tissue planes, the subsequent ease with which the introduction and advancement of the infiltrating cannula allows for ease of larger amounts of grafting tissue (adipocytes) with greater uniformity to be placed, less resistance from normal tissue planes and decrease in both intra‐ and postoperative discomfort to the patient. There was less bruising of the skin noted within the postoperative period.

## **8. Complications and adverse events of carboxitherapy**

As already mentioned, carbon dioxide gas is a versatile gas utilized within many industries. It is a by‐product present in the blood circulation as a consequence of aerobic respiration. Based on current literature, carboxitherapy can be considered as a safe therapeutic treatment, without adverse effects or major complications, both local and systemic.

The amount of gas injected during a therapeutic dose of carboxitherapy is below the volume produced by the body itself. Our body produces 200 cc of CO2 when at rest and during vigorous exercise this amount may rise to 10 times that value. In addition, the patients in our study subjected to subcutaneous injections of CO2 show no damage to the connective tissue or its microcirculation.

Therefore, we know that CO2 works in the affected area and is rapidly eliminated from the body with no possibility of air embolus. However, in our study, minimal complications were noted with the administration of subcutaneous CO2 therapy. These included and were limited to (1) local pain at the injection site of the 25G needle, (2) small bruising and ecchymosis from the needle entering the dermis, (3) A "cracking sensation" experienced by patients due to the formation of local emphysema that disappears within 30 minutes of the procedure.

## **9. Contraindications to carboxitherapy**

Contraindications to the treatment include acute myocardial infarction, unstable angina, heart failure, hypertension, acute thrombophlebitis, gangrene or localized infections at the site therapy, epilepsy, respiratory failure, renal failure, pregnancy and psychiatric disorder. But in any case, these patients would not be candidates for an elective body contouring surgery. So, in healthy patients with usual comorbidities, there are no contraindications.

## **10. Conclusion**

**Figure 9.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in

**Figure 10.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in

**Figure 11.** Patient with breast hypoplasia (left). After 3 months of pneumodissection‐assisted fat grafting in breasts in

the subcutaneous plane (right).

204 Body Contouring and Sculpting

the subcutaneous plane (right).

the subcutaneous plane (right).

Carbon dioxide is an abundant gas found in every living species on Earth. Its role in many industries, including medicine, have stemmed from its early discovery in 1648. With respect to its effect on both the skin and subdermal layers, CO2 has sound physiological principles confirmed through histological studies.

Our technique of pneumodissection prior to adipocyte grafting has worked with these principles in mind. Using CO2 to establish volume within given tissue planes yet preserv‐ ing the fragile microcirculation of the tissue is a valuable prerequisite to the survival of the graft.

## **Author details**

Guillermo Blugerman1\*, Diego Schavelzon1 , Gabriel Wexler2 , Marcelo Lotocki3 , Victoria Schavelzon1 and Guido Blugerman1

\*Address all correspondence to: drblugerman@gmail.com

1 Centro ByS, Buenos Aires, Argentina

2 Estetica Wexler, Cordoba, Argentina

3 Genesis, Obera, Misiones, Argentina

## **References**


[7] Lang EV, Gossler AA, Fick LJ, Barnhart W, Lacey DL. Carbon dioxide angiography: effect of injection parameters on bolus configuration. J Vasc Interv Radiol. 1999 Jan; 10(1): 41‐49.

Our technique of pneumodissection prior to adipocyte grafting has worked with these principles in mind. Using CO2 to establish volume within given tissue planes yet preserv‐ ing the fragile microcirculation of the tissue is a valuable prerequisite to the survival of

, Gabriel Wexler2

[1] McMahon, AJ, Baxter, JN, Murray, W, Imrie, CW, Kenny, G, O´Dwyer, PJ. Helium pneumoperitoneum for laparoscopic cholecystectomy: ventilatory and blood gás

[2] Wolf, JS Jr, Carrier, S, Stoller, ML. Gas embolism: helium is more lethal than carbon

[3] Yau, P, Watson, DI, Lafullarde, T, Jamilson, GG. An experimental study of the effect of gas embolism using different laparoscopy insufflation gases. J Laparoendosc Adv Surg

[4] Vilos, GA, Vilos, AG. Safe laparoscopic entry guided by Veress needle CO2 insufflation

[5] Zwaan W, Kloess W, Kagel C, Kummer‐Kloess DR, Matthies‐Zwaan S, Schutz RM, Weiss HD. Carbon dioxide as an alternative contrast medium in peripheral angiography, Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 1996; 165(2):

[6] Roberts, MW, Mathiesen, KA, Ho, HS, Wolfe, BM. Cardiopulmonary responses to intravenous infusion of soluble and relatively insoluble gases. Surg Endosc 1997; 11:

pressure. J Am Assoc Gynecol Laparosc, 2003 Aug; 10(3): 415‐420.

, Marcelo Lotocki3

,

the graft.

**Author details**

206 Body Contouring and Sculpting

Victoria Schavelzon1

**References**

180.

341‐346.

Guillermo Blugerman1\*, Diego Schavelzon1

1 Centro ByS, Buenos Aires, Argentina

2 Estetica Wexler, Cordoba, Argentina

3 Genesis, Obera, Misiones, Argentina

Tech 2000; 10: 211‐216.

and Guido Blugerman1

\*Address all correspondence to: drblugerman@gmail.com

changes. Br J Surg 1994; 81: 1033‐1036.

dioxide. J Laparoendosc Surg 1994; 4: 173‐177.


**Section 5**
