LETTERS AND INVITED COMMENTARY Autologous Fat Grafting Current State of the Art and Critical Review To the Editor: e read with interest the article entitled ‘‘Autologous fat grafting: current state of the art and critical review.’’1 We would like to congratulate Dr Richard J. Ross, Dr Mark W. Ashton, and colleagues for their publication, reviewing scientific databases to critically appraise the current body of literature in fat grafting, providing a framework to guide application and comparison. We believe that a systematic elaboration analyzing donor site, effect of infiltration solution, harvest method, effect of centrifugation, reinjection method, supplementation, role of adipose-derived stem cells, and scaffolding encourages a scientific debate. Considering all currently available reinjection methods listed in the article, we would like to add our personal experience using an 18-gauge angiographic sharp needle (Cordis Corp, Bridgewater, NJ) as published first time in 2008.2 Our studies gave evidence of better results in treatment of burn scars, surgical scars, hard-to-heal wounds, and radiodystrophic tissues. These conditions are all characterized by hard fibrous tissue. Performing fat grafting using the sharp angiographic cannula, compared with the blunt ones, we achieved better results.3Y6 Because of needle cannula, we can overcome tissue resistance, thus obtaining better control in fat depositioning and ‘‘creating space’’ for fat transplant. Our technique has 2 key points, namely, multiple skin accesses breaking scar tissue and retrograde fat injection into the scar tissue. By multiple skin accesses, we obtain scar release, stimulating new collagen deposition and remodeling scar fibrous tissue as demonstrated in our studies. Histologic examination of scar tissue punch biopsies showed patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue. Treated tissue magnetic resonance imaging showed optimal fat survival too. By retrograde fat replacement, we avoid intravascular fat injection, leading us to have low complications incidence, and we obtain lower cysts formation, increasing surface between graft and recipient bed. In conclusion, we believe that our technique can be considered in a systematic review about state of the art of fat grafting, our
W
Conf licts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0633 DOI: 10.1097/SAP.0000000000000017
Annals of Plastic Surgery
clinical results support autologous fat transplant using an 18-gauge angiographic sharp needle in selected cases as we demonstrated.
Luca Maione, MD Department of Translational Medicine (BIOMETRA) Humanitas Clinical and Research Center University of Milan School of Plastic Surgery Rozzano, Milan, Italy [email protected]
Davide Forcellini, MD Plastic Surgery Department MultiMedica Holding S.p.A University of Milan School of Plastic Surgery Sesto San Giovanni Milan, Italy
Marco Klinger, MD Department of Translational Medicine (BIOMETRA) Humanitas Clinical and Research Center University of Milan School of Plastic Surgery Rozzano, Milan, Italy REFERENCES 1. Ross RJ, Shayan R, Mutimer KL, et al. Autologous fat grafting: current state of the art and critical review. Ann Plast Surg. 2014;73:352Y357. 2. Klinger M, Marazzi M, Vigo D, et al. Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. 3. Caviggioli F, Forcellini D, Vinci V, et al. Employment of needles: a different technique for fat placement. Plast Reconstr Surg. 2012;130:373eY374e. 4. Klinger M, Caviggioli F, Klinger F, et al. Autologous fat graft in scar treatment: our clinical experience in 694 patients. J Craniofac Surg. 2013;24: 1610Y1615. 5. Caviggioli F, Maione L, Vinci V, et al. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;126:1130Y1131. 6. Caviggioli F, Maione L, Forcellini D et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg. 2011;128:349Y352.
Autologous Fat Grafting Current State of the Art and Critical Review: Reply Dear Editor: e would like to sincerely thank Drs Maione, Forcellini and Klinger for their
insightful commentary regarding our previous article entitled ‘‘Autologous Fat Grafting: Current State of the Art and Critical Review.’’1 Further, we acknowledge and congratulate those authors on their solid body of work investigating autologous fat grafting over many years. Maione et al2Y5 have conducted an interesting series of studies describing their outcomes using an 18-gauge needle-tipped angiographic cannula (Cordis Corp, Bridgewater, NJ) for reinjection of harvested fat. Although many of these earlier studies were smaller series and case studies, later articles have described consistently improved outcomes compared to the authors’ experience with a blunt-tipped cannula.6,7 The basis behind these successes remains to be confirmed, however, as Maione et al suggest, the ability of the needle-tipped cannula to release scar, in a similar vein to a ‘‘Rigottomy.’’8,9 In addition, the benefit of their technique is unlikely to be related to cannula gauge, as previous studies have shown no difference between 14-, 16-, and 20-gauge cannulas for reinjection of harvested fat and others have shown degrees of success when cannula gauge is tailored to the specific recipient site.10,11 Later, long-term outcome studies by Cavaggioli and colleagues6 have shown both the low complication rate and significantly more compliant scar tissue after autologous fat injection. In such an heterogeneous patient population, large subject sizes are needed to provide a representative outcome. Although these long-term outcomes are encouraging, few were available for inclusion in our previous review article. Further, the subjective method of evaluating outcomes in earlier work was unfortunately not conducive to comparison with other investigations. Considering the rapid evolution of autologous fat grafting, we anticipate the work of Dr Maione and colleagues to feature prominently in the many future reviews in the interesting and challenging subject.
Richard J. Ross, BSc (Hons) MBBS PGrad Dip Surg Anat Ramin Shayan, MBBS, FRACS, PhD Keith L. Mutimer, MBBS, FRACS Mark W. Ashton, MBBS, MD, FRACS University of Melbourne Parkville, Victoria, Australia
W
Received January 3, 2015, and accepted for publication, after revision, January 7, 2015. Conflicts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0633 DOI: 10.1097/SAP.0000000000000489
REFERENCES 1. Ross RJ, Shayan R, Mutimer KL, et al. Autologous fat grafting: current state of the art and critical review. Ann Plast Surg. 2014;73:352Y357. 2. Caviggioli F, Forcellini D, Vinci V, et al. Employment of needles: a different technique for fat placement. Plast Reconstr Surg. 2012;130:373eY374e.
& Volume 74, Number 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
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Letters to the Editor
3. Caviggioli F, Maione L, Vinci V, et al. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;126:1130Y1131. 4. Klinger M, Marazzi M, Vigo D, et al. Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. 5. Caviggioli F, Klinger F, Villani F, et al. Correction of cicatricial ectropion by autologous fat graft. Aesthetic Plast Surg. 2008;32:555Y557.
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6. Maione L, Vinci V, Klinger M, et al. Autologous fat graft by needle: analysis of complications after 1000 patients. Ann Plast Surg. 2014;4. 7. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24:1610Y1615. 8. Kakagia D, Pallua N. Autologous fat grafting: in search of the optimal technique. Surg Innov. 2014; 21:327Y336. 9. Rigotti G, Marchi A, Galie` M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate
& Volume 74, Number 5, May 2015
transplant: a healing process mediated by adiposederived adult stem cells. Plast Reconstr Surg. 2007; 119:1409Y1422. 10. Trepsat F. Periorbital rejuvenation combining fat grafting and blepharoplasties. Aesthetic Plast Surg. 2003;27:243Y253. 11. Erdim M, Tezel E, Numanoglu A, et al. The effects of the size of liposuction cannula on adipocyte survival and the optimum temperature for fat graft storage: an experimental study. J Plast Reconstr Aesthet Surg. 2009;62:1210Y1214.
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
W
Conf licts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0633 DOI: 10.1097/SAP.0000000000000017
Annals of Plastic Surgery
clinical results support autologous fat transplant using an 18-gauge angiographic sharp needle in selected cases as we demonstrated.
Luca Maione, MD Department of Translational Medicine (BIOMETRA) Humanitas Clinical and Research Center University of Milan School of Plastic Surgery Rozzano, Milan, Italy [email protected]
Davide Forcellini, MD Plastic Surgery Department MultiMedica Holding S.p.A University of Milan School of Plastic Surgery Sesto San Giovanni Milan, Italy
Marco Klinger, MD Department of Translational Medicine (BIOMETRA) Humanitas Clinical and Research Center University of Milan School of Plastic Surgery Rozzano, Milan, Italy REFERENCES 1. Ross RJ, Shayan R, Mutimer KL, et al. Autologous fat grafting: current state of the art and critical review. Ann Plast Surg. 2014;73:352Y357. 2. Klinger M, Marazzi M, Vigo D, et al. Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. 3. Caviggioli F, Forcellini D, Vinci V, et al. Employment of needles: a different technique for fat placement. Plast Reconstr Surg. 2012;130:373eY374e. 4. Klinger M, Caviggioli F, Klinger F, et al. Autologous fat graft in scar treatment: our clinical experience in 694 patients. J Craniofac Surg. 2013;24: 1610Y1615. 5. Caviggioli F, Maione L, Vinci V, et al. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;126:1130Y1131. 6. Caviggioli F, Maione L, Forcellini D et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg. 2011;128:349Y352.
Autologous Fat Grafting Current State of the Art and Critical Review: Reply Dear Editor: e would like to sincerely thank Drs Maione, Forcellini and Klinger for their
insightful commentary regarding our previous article entitled ‘‘Autologous Fat Grafting: Current State of the Art and Critical Review.’’1 Further, we acknowledge and congratulate those authors on their solid body of work investigating autologous fat grafting over many years. Maione et al2Y5 have conducted an interesting series of studies describing their outcomes using an 18-gauge needle-tipped angiographic cannula (Cordis Corp, Bridgewater, NJ) for reinjection of harvested fat. Although many of these earlier studies were smaller series and case studies, later articles have described consistently improved outcomes compared to the authors’ experience with a blunt-tipped cannula.6,7 The basis behind these successes remains to be confirmed, however, as Maione et al suggest, the ability of the needle-tipped cannula to release scar, in a similar vein to a ‘‘Rigottomy.’’8,9 In addition, the benefit of their technique is unlikely to be related to cannula gauge, as previous studies have shown no difference between 14-, 16-, and 20-gauge cannulas for reinjection of harvested fat and others have shown degrees of success when cannula gauge is tailored to the specific recipient site.10,11 Later, long-term outcome studies by Cavaggioli and colleagues6 have shown both the low complication rate and significantly more compliant scar tissue after autologous fat injection. In such an heterogeneous patient population, large subject sizes are needed to provide a representative outcome. Although these long-term outcomes are encouraging, few were available for inclusion in our previous review article. Further, the subjective method of evaluating outcomes in earlier work was unfortunately not conducive to comparison with other investigations. Considering the rapid evolution of autologous fat grafting, we anticipate the work of Dr Maione and colleagues to feature prominently in the many future reviews in the interesting and challenging subject.
Richard J. Ross, BSc (Hons) MBBS PGrad Dip Surg Anat Ramin Shayan, MBBS, FRACS, PhD Keith L. Mutimer, MBBS, FRACS Mark W. Ashton, MBBS, MD, FRACS University of Melbourne Parkville, Victoria, Australia
W
Received January 3, 2015, and accepted for publication, after revision, January 7, 2015. Conflicts of interest and sources of funding: none declared. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0633 DOI: 10.1097/SAP.0000000000000489
REFERENCES 1. Ross RJ, Shayan R, Mutimer KL, et al. Autologous fat grafting: current state of the art and critical review. Ann Plast Surg. 2014;73:352Y357. 2. Caviggioli F, Forcellini D, Vinci V, et al. Employment of needles: a different technique for fat placement. Plast Reconstr Surg. 2012;130:373eY374e.
& Volume 74, Number 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
633
Annals of Plastic Surgery
Letters to the Editor
3. Caviggioli F, Maione L, Vinci V, et al. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;126:1130Y1131. 4. Klinger M, Marazzi M, Vigo D, et al. Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008;32:465Y469. 5. Caviggioli F, Klinger F, Villani F, et al. Correction of cicatricial ectropion by autologous fat graft. Aesthetic Plast Surg. 2008;32:555Y557.
634
www.annalsplasticsurgery.com
6. Maione L, Vinci V, Klinger M, et al. Autologous fat graft by needle: analysis of complications after 1000 patients. Ann Plast Surg. 2014;4. 7. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24:1610Y1615. 8. Kakagia D, Pallua N. Autologous fat grafting: in search of the optimal technique. Surg Innov. 2014; 21:327Y336. 9. Rigotti G, Marchi A, Galie` M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate
& Volume 74, Number 5, May 2015
transplant: a healing process mediated by adiposederived adult stem cells. Plast Reconstr Surg. 2007; 119:1409Y1422. 10. Trepsat F. Periorbital rejuvenation combining fat grafting and blepharoplasties. Aesthetic Plast Surg. 2003;27:243Y253. 11. Erdim M, Tezel E, Numanoglu A, et al. The effects of the size of liposuction cannula on adipocyte survival and the optimum temperature for fat graft storage: an experimental study. J Plast Reconstr Aesthet Surg. 2009;62:1210Y1214.
* 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
