Safe, cost-effective filler ideal for correcting large defects
Stanford, Calif. - Autologous fat transfer offers many advantages as a facial rejuvenation treatment, says Hayes B. Gladstone, M.D., who spoke at the Next Step: Mastering Cutaneous Outpatient Procedures, a continuing education program sponsored by the Stanford University department of dermatology.
"As a filler material, fat is associated with excellent safety and can be used very effectively to correct large defects with satisfying, long-lasting results. When large volumes are needed, it is more cost-effective than any other filler, and it is an optimal solution for patients who are wary about receiving any foreign substance. Dermatologists have played a large role in developing this technique, and it is something we should continue," Dr. Gladstone says.
Dr. Gladstone is director, Division of Mohs Micrographic Surgery, Cutaneous Laser Surgery, and Aesthetic Dermatologic Surgery, Stanford University, and one of the organizers of "The Next Step" program (see story, next page).
However, it also has an important role for treating volume loss associated with medical conditions. For example, Dr. Gladstone indicates his use of this technique to treat hemifacial atrophy in patients with stable severe morphea has been particularly gratifying.
"The outcomes have been excellent and the change in appearance achieved makes a significant difference in those patients' lives," he says.
Noting that techniques for harvesting, processing and storing fat vary among users and are a subject of continuing controversy, as well as a fertile area for research, Dr. Gladstone described his current protocol.
For harvesting fat, Dr. Gladstone prefers the abdomen, which is in contrast with some other surgeons who favor the lateral hips and buttocks as donor sites. To preserve adipocyte viability, he accesses the fat gently using manual suction with a syringe, and performs the procedure under tumescent anesthesia, using a volume of anesthetic solution less than would be administered if performing tumescent liposuction.
"No one knows for sure whether the benefits of fat as a long-lasting filler relate to growth of the fat or because it causes fibrosis. Most likely, both mechanisms are important, and on that assumption, it is important to handle the fat with a protocol that will minimize destruction of the cells. Use of tumescent anesthesia is important in that regard, as it reduces the amount of blood withdrawn that has been shown to decrease adipocyte viability," Dr. Gladstone says.
For separating the fat, he manually decants the supernatant fluid instead of centrifuging the material. A potential advantage of centrifuging is that it may more effectively separate the fat to yield a purer sample that may last longer. However, Dr. Gladstone opts to separate the fat mechanically, noting that it is easy to perform, gentler and has not seemed to compromise his results, and he does not add insulin or any other growth factors prior to injection.
For transplantation, Dr. Gladstone uses an 18-gauge needle, although Coleman cannulas are also an option. The fat is delivered by creating a small tunnel and injecting the material in a retrograde fashion while threading and layering it in two or three layers to achieve an even result.
The procedure is repeated at two-month intervals for a series of three or four treatments. When filling the nasolabial folds, the average injected volume per side is about 3 cc with a goal of overcorrecting by about 20 percent, recognizing that there is some resorption. Patients are told to expect maintaining 70 percent correction for three to five years, with even longer persistence as a possibility.
"Longevity depends on the anatomic site. Fat is resorbed more quickly from areas of greater mobility, and that is one reason why I tend not to use it in the lips," Dr. Gladstone says.
After processing, fat withdrawn at an initial session can be placed in double-labeled containers for subsequent use and stored in a commercial freezer equipped with a back-up generator and kept at minus 8 degrees Celsius.