Autologous fat grafting has been there with us since the last century, however it’s therapeutic benefits as a regenerative tool besides volumising   has increased its popularity only in the last two decades.

As a donor tissue  fat is abundantly available and very easy to harvest and inject. The procedure is  almost device/gadget independent  and can be used alone as well as  an adjunct to enhance  surgical  outcomes. Autologous fat being abundant and  inexpensive  has found a wide spectrum of use in augmenting breast , buttock and  correcting other contour asymmetries as well as  a filler for  the ageing face ,thus ,making it the most indispensable tool in our armamentarium .

Nano fat, popularised by Dr Patrick Tonnard in 2006 and used all over the world is basically lipoaspirate emulsified to a homogeneous solution .It is devoid of intact adipocytes but is a solution  rich  in  concentration of stem cells present in its stromal vascular fraction. With easy  harvesting and injecting  techniques and  practically  nil donor morbidity, its choice  as a skin  rejuvenating tool is second to none. Most fat injections to the face  can be done under  local anaesthesia thus making  it a very  popular office procedure in aesthetic surgery.

For a beginner, the use of fat in practice can be simplified by following a simple rule of using micro  fat (mostly  intact adipocytes)for volumising and nano fat( emulsified fat with SVF) predominantly for rejuvenation.This being based on clinical results obtained so far with both types rather thanon the precise mechanism of action ( yet unclear).

Many are of the opinion that the survival of fat  depends both on the recipient bed as well as the integrity and size of the fat particle injected. Harvesting is usually done with manual vaccum using 10 cc syringe on a 2 mm canula ensuring  minimum damage. Post harvest the fat could be either centrifuged (3000 rpm for 3 min/ Coleman method) or simply decanted using gravity over 20 -30 min. The fat is then separated from the blood and oil and transferred to 1-2 ml syringes for injection. Blood and cellular debris present in the lipoaspirate are said to be  detrimental to the survival of fat and hence  meticulous separation has been recommended

Fat used specifically for skin rejuvenation (nano fat) need not be decanted for long and is injected after emulsifying manually with the help of an adapter or a three way,roughly 30-35 times. This is to break the adipocytes and release the stromal vascular fraction, thus making it  rich in stem cells as well as the various growth factors needed for rejuvenation. Injecting this lipoaspirate rich in SVFunder the suborbital skin and tear trough area has shown excellent results. Here fat is  not used as a volumiser but only as a  skin rejuvenating tool.The  above protocol has been suggested by most surgeons and is largely an empirical one .Whether this is the  ideal method  that allows the harvested fat to get incorporated into the recipient tissue either  as a filler/volumiser  or enables it to regenerate tissue  still awaits scientific verification.

The results of autologous fat grafting to the face may not be as predictable as a filler ( hyaluronic acid),  however if recipient areas are well chosen and the procedure repeated a few times, the final outcome is not only long lasting but also superior in terms of skin rejuvenation.

Besides this  fat gives excellent results when used in treating scars  such as those post acne along with subscision or depressed, unstable traumatic and post surgical scars by making them supple and less visible ,and as a volumizer in facial asymmetry in Rhomberg’ s disease . Fat to the alar base and upper lip has shown great promise in improving the mid-face profile where normally these secondary corrections would involve prolonged surgeries with osteotomies . It can also be used in correcting visible surface irregularities of bony surfaces such as the bridge of the nose or the forehead.However, one must remember here that the mobile areas such as the lips and glabella are less predictable  when compared to the cheek and malar areas which retain fat much better.

Besides it’s aesthetic applications, the regenerative potential of autologous fat grafting is gaining application in many other clinical conditions.When used in the surgical treatment of Dupuytren’s contracture  after thorough release of the fibrotic bands ,fat is injected under  the skin over the  entire palm . No skin incisions are used .This method has shown excellent results , early recovery  with almost no morbidity.

Fat  injection in the parotid gland substance  has been found to  rejuvenate  parotid gland  function with patients suffering from dry mouth and sockets following radiation treatment  for head and neck malignancies  In breast cancer cases following irradiation and implant exposure, fat has become the only panacea  to achieving complete  healing and correcting an otherwise impossible situation.

Today the ‘off label’ use of fat in relieving pain,dysfunction  following arthritis and probably also regenerating the articular cartilage, as well as treatingother painful conditions such as fissure -in-ano, is also being recognised .

Fat can be stored by freezing at -20 degrees Celsius for 24 months. It can simply be injected by thawing the stored  fat discarding the top oily triglyceride layer ( which protects it during storage)  .This eliminates the cost of a subsequent procedure without the need of an operating room .

Stem cell therapies using blood derivatives and bone marrow have come under the scanner recently due to the manipulations that need to be done to extract the totipotential tissue fraction along with the growth factors .Fat, however , harvested and reinjected  in the same sitting and operating room, does fit the requirement of injecting with minimal manipulation .

In the coming years, the use of  fat  will  probably become an integral part of regenerative treatments. . Today research in this field regarding  the exact mechanism by which adipose tissue  helps in regeneration  to standardizing treatment protocols will also see more definitive and evidence based results.

Fat is tomorrows miracle worker and perhaps the most versatile and easily available tool with the highest potential to treat innumerable indications both within and as well as outside the realm of our branch  Thus  it has  opened the gates to a  totally new branch of “minimally invasive surgery ” in plastic and regenerative surgery.  We are now finding solutions under this common umbrella  where none existed,  not just  in the field of skin rejuvenation but as the most important building block in the field  of tissue regeneration and hence the future.

Dr Neeta Patel

Dr Neeta Patel, M.S, MCh

Consultant Plastic ,Cosmetic and Reconstructive surgeon

President, Indian Association of Aesthetic Plastic Surgery,

Course Director, Masterclass Series in Aesthetic Surgery,

Founding Member, International Society of Plastic and Regenerative Surgery (ISPRES).