Fat Grafting: Evidence-Based Review on Autologous Fat Harvesting, Processing, Reinjection, and Storage : Plastic and Reconstructive Surgery

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Fat Grafting

Evidence-Based Review on Autologous Fat Harvesting, Processing, Reinjection, and Storage

Gir, Phanette M.D.; Brown, Spencer A. Ph.D.; Oni, Georgette M.D.; Kashefi, Nathalie; Mojallal, Ali M.D., Ph.D.; Rohrich, Rod J. M.D.

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Plastic and Reconstructive Surgery: July 2012 - Volume 130 - Issue 1 - p 249-258
doi: 10.1097/PRS.0b013e318254b4d3
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Autologous fat is widely used in reconstructive and aesthetic surgery as a natural filler instead of commercially available products.13 Fat use to treat volume and contour defects is preferential because it is an autologous source of material that is abundant and easily available, with relative ease of harvesting. Adipose tissue transfer in the form of fat grafting has become a commonly used technique, but there are many variations on fat harvesting, preparation, and reinjection. According to the International Society of Aesthetic Plastic Surgery, in 2009, fat grafting represented 5.9 percent of the nonsurgical procedures within aesthetic surgery, with more than 514,000 procedures performed globally in 2009 and more than 84,000 patients treated in the United States alone.4

A national consensus survey by Kaufman et al. queried 508 surgeons regarding individual fat grafting techniques and outcomes.5 The survey concluded that fat grafting is relatively common, with 57 percent of surgeons performing more than 10 procedures annually. Furthermore, the vast majority of patients were pleased with the short-term and long-term results. One major concern is the lack of reliability and consistency of the final clinical results, which often creates the need for multiple fat grafting procedures.68 The survival rate of grafted fat has been reported to be variable, ranging from 40 to 80 percent, depending on the investigator, and the reasons for this are unpredictable.914

To date, there is no published consensus on the optimal technique for fat grafting or graft retention longevity data. This systematic review of the international literature was performed to better understand whether there is a correlation between the methods of fat harvest, preparation, application, and the subsequent clinical outcome. In particular, the focus was placed on studies that met specific criteria consistent with good levels of scientific evidence. Two previous publications have appeared in 200715 and then in 2009.16 Within this short time interval and using rigorous methods of publication selection, this review covers an additional 21 newly published studies and includes four clinical studies.


A thorough systematic review was performed of all English-language literature located in the PubMed database to August of 2011. The search was performed according to guidelines that mirrored the American Society of Plastic Surgeons Fat Graft Task Force Assessment methodology.16 A comprehensive search of comparative studies of harvesting, processing, and application of human fat grafting was performed using either single or a combination of search terms (Fig. 1). The retrieved articles were read in their entirety and their bibliographies were studied for additional relevant publications. Articles were then eliminated based on the inclusion and exclusion criteria (Table 1). Each article had to include a comparison between two experimental variables in the experimental design, either with subjects serving as their own controls or with a group-to-group analysis.

Fig. 1:
Literature search algorithm for fat grafting.
Table 1:
Inclusion and Exclusion Criteria

Search limits were restricted to English language articles that were indexed as fat grafting comparative studies (control group), clinical trials, and randomized controlled trials to improve the quality of the studies included. The examination of fat graft, adipocyte or adipose stem cell viability levels, biomarkers, or yields that had not been used or tested clinically were not considered. Animal studies, case reports, case series, retrospective studies, descriptive studies, and studies on fat grafting for non–plastic surgery applications were excluded. The results were then broken down into the following topics: fat harvesting, fat processing, fat reinjection, and fat storage (Fig. 2).

Fig. 2:
Fat graft literature retrieval results by topic.


Using “autologous fat grafting” as a search term, 956 articles were located, of which 23 articles met the inclusion criteria. Additional articles were located by combining the “fat grafting” search term with additional search terms: “fat harvesting” (n = 216), “fat processing” (n = 63), “adipose harvest” (n = 27), “adipose stem cells” (n = 170), “fat preparation” (n = 49), “adipocyte graft” (n = 96), “lipotransfer” (n = 8), “lipoinjection” (n = 15), “fat transfer” (n = 83), “fat augmentation” (n = 119), and “fat graft process” (n = 61). Of those found, only 37 articles, consisting of five clinical trials and 32 prospective comparative studies, were identified that met the inclusion and exclusion criteria. The numbers of articles found per topic are summarized in Table 2.

Table 2:
Fat Grafts: Reporting Topics

Fat Harvest

No clinical articles were identified that included human studies in which fat was harvested in various forms and then evaluated in a clinical setting. Sixteen articles were located that included preclinical experimental prospective studies examining fat harvesting procedures using human fat in vitro and/or in vivo.

Infiltration Technique before Fat Harvest

Four studies were identified that looked at the effects of prior infiltration/local anesthesia. Moore et al. looked at the effect of epinephrine and lidocaine on human fat viability.17 They concluded that the use of epinephrine and lidocaine had no significant effect on cell attachment in culture, cell morphology, proliferation, or adipocyte metabolic activity. Shoshani et al. compared results of human fat harvested with either normal saline (control group) or with a saline solution containing 0.06% of lidocaine and epinephrine 1:1,000,000, grafted into nude mice.18 They demonstrated no significant differences in term of weight and volume of the fat grafts between the groups. This finding was corroborated by Kim et al., who studied fat cell viability with different epinephrine doses.19 Keck et al. specifically examined isolated preadipocytes from fat. They found that cell viability was reduced with lidocaine, ropivacaine, and prilocaine.20 In 2010, the same group demonstrated that local anesthetic agents significantly reduced preadipocyte cell viability, with the exception of bupivacaine. In addition, they found that there was impaired preadipocyte differentiation into mature adipocytes.21

These reports suggest that there is no effect of local anesthesia or epinephrine on fat grafts but that local anesthetic agents may modulate isolated preadipocyte viability rates. Extrapolating this finding clinically, one could say that the decision to use epinephrine/local anesthesia should be based on other clinical factors such as pain relief and bleeding control rather than fat cell viability.

Donor Site

Of the two articles found, Rohrich et al. found no differences in cell viability in fat removed from abdomen, flank, thigh, and medial knee.22 However, Padoin et al. reported that increased adipose stem cell levels were observed in fat from the lower abdomen compared with adipose stem cell levels in the other sampled anatomical locations.23

Effect of Liposuction Technique

Nine articles addressed the harvesting technique of fat and its role on fat graft outcomes. Rohrich et al. isolated fat using traditional liposuction, internal ultrasound-assisted liposuction, external ultrasound-assisted liposuction, or massage.24 They found no significant histologic or chemical effect of external ultrasound-assisted lipoplasty on adipocytes; however, internal ultrasound-assisted aspirates revealed a thermal liquefaction of mature adipocytes.

Shiffman and Mirrafati used various cannulas, needles, suction pressures, external ultrasound, or preoperative massage to determine whether there was an effect on cell viability.25 Cell damage of greater than 10 percent occurred when a –700-mmHg vacuum was used.

Leong et al. harvested fat using syringe liposuction and compared it to pump-assisted liposuction. They found that this produced no differences in cell viability, cell metabolic activity, or adipogenic responses.26

Ozsoy et al. in their prospective study demonstrated a greater number of viable adipocytes with a 4-mm-diameter cannula compared with 2- or 3-mm cannulas.27 Erdim et al. also recommended the use of larger cannulas to increase cell viability.28 Ferguson et al. demonstrated a significantly higher viable adipocyte count using the LipiVage system (Genesis Biosystems, Lewisville, Texas) (syringe aspiration at low vacuum pressure) compared with conventional liposuction.29

Pu et al. looked at the cellular function of adipose aspirates and demonstrated decreased metabolic activity.30 The same team performed a prospective and comparative study between two techniques of harvesting fat: the Coleman technique versus conventional liposuction on the same patient.31 Significantly higher viable adipocyte level and enzyme (glyceraldehyde-3-phosphate dehydrogenase) activity level were found in the Coleman technique group.

Crawford et al. examined the Viafill system (Lipose Corp., Maitland, Fla.) (hand aspirate, at low-g-force centrifuge) versus standard power-assisted liposuction.32 Significantly higher cell counts were observed when using the Viafill system.

In summary, the body of evidence does not support one harvesting technique above another as superior. However, techniques that use low-pressure suction by means of larger bore cannulas appear to increase adipocyte viability.

Fat Processing: The Role of Centrifugation/Washing

Four clinical trials and 10 experimental comparative studies were identified that focused on human fat processing. Butterwick performed a prospective, randomized, double-blind comparison study that compared centrifuged versus noncentrifuged fat, grafted in hands.33 At 5 months, the centrifuged fat demonstrated a clear advantage in longevity and aesthetics.

In a second study, Khater et al. compared centrifuged, noncentrifuged, and washed fat in 51 subjects.34 At 1 year, they found an improved clinical outcome with the washed fat.

A third study by Ferraro et al. evaluated fat grafting in 30 patients divided into three experimental groups: Coleman technique (3000 rpm, for 3 minutes); the authors' technique (1300 rpm for 5 minutes); and simple decantation of fat patients.35 In the Coleman group, all patients at 12 months showed almost 50 percent resorption of the graft. In the authors' group, 80 percent of patients showed no evidence of resorption.

In the fourth study, Botti et al. injected one half of the face with filtered and washed fat, and the other half of the face was treated with centrifuged fat (3000 rpm for 3 minutes) in 25 patients.36 At 12 months, the fat-grafted hemifacial regions produced comparable subjective and objective results.

Boschert et al. examined centrifugation times for fat samples obtained from 20 liposuction patients.37 All the samples were centrifuged at 50 g for 2, 4, 6, and 8 minutes. The results showed that the bottom layer consistently contained the highest number of viable cells after centrifugation and that centrifugation beyond 2 minutes did not increase the number or proportion of viable adipocytes.

Rohrich et al. found that there were no significant differences in cell viability between centrifuged (500 g for 2 minutes) and noncentrifuged samples.22 Using a different fat-processing technique, Ramon et al. studied two methods of fat processing: centrifugation technique (1500 rpm for 5 minutes) versus an open method with an operating room cotton towel.38 Isolated human fat specimens were injected into nude mice, and after 16 weeks there were no significant differences regarding fat graft weight and volume between the two groups.

Rose et al. performed a quantitative analysis of adipocyte viability after using different methods of fat processing: washing, centrifuging, or sedimentation.39 The results showed that cell counts per high-power field of intact adipocytes and nucleated adipocytes were significantly greater in samples processed by sedimentation.

Smith et al. compared different techniques of fat preparation in terms of adipocyte graft survival.40 Six different combinations of centrifugation and/or washing the cells with lactated Ringer's solution or normal saline were tested on fat samples obtained from three patients. No significant differences in fat cell viability, as assessed by fat graft weight, were observed between the groups.

In 2008, Kurita et al. investigated the effects of centrifugation on liposuction aspirates to optimize centrifugal conditions for fat transplantation and isolation of adipose stem cells.41 Liposuction aspirates were either noncentrifuged or centrifuged at various g forces for 3 minutes and injected into athymic mice. Excessive centrifugation destroyed adipocytes and adipose stem cells but appropriate centrifugation concentrated the respective cell types. They concluded that the optimal centrifugal force is 1200 g (3000 rpm). Likewise, Kim et al. in 2009 evaluated the centrifugation technique on fat cell viability in autologous fat transplantation.19 They concluded that excessive centrifugation with 5000 rpm or more than 5 minutes increased adipocyte destruction and recommended that centrifugal force be limited to 3000 rpm.

In 2010, Condé-Green et al. published a study regarding the influence of decantation, washing, and centrifugation (3000 rpm for 3 minutes) on adipocyte and adipose stem cell content of aspirated adipose tissue.42 Adipocyte counts were significantly greater in decanted lipoaspirates compared with centrifuged lipoaspirates, which showed a greater majority of altered adipocytes. The same team extended these studies by evaluating the effects of centrifugation on cell composition and viability of adipose tissue processed for transplantation.43 The author recommended that, if centrifugation is used, the centrifuged cell pellet should be combined with the middle layer of the lipoaspirate to increase graft survival.

In 2010, Minn et al. compared the effects of the preparation methods on the viability of fat grafts using fat obtained from the remnants of transverse rectus abdominis musculocutaneous flaps by syringe aspiration.44 No significant differences were observed in fat graft survival rates in nude mice when fat grafts were prepared by centrifugation, metal sieve concentration, and cotton gauze concentration.

In 2010, Xie et al. compared different centrifugal forces for fat processing in terms of cell viability.45 Results showed that centrifugation had a harmful effect on the viability of harvested fat, and this effect is more significant with increased centrifugal force, especially when rotation speed is greater than 1145 g (4000 rpm).

In 2011, Pulsfort et al. published a study concerning the effect of centrifugal forces on viability of adipocytes in centrifuged lipoaspirates.46 Centrifugation has no effect on the survival rate of isolated adipocytes in the purified fat. In contrast, lipoaspirates centrifuged with higher accelerations seem to be better cleansed of oil and cell debris than samples treated with lower centrifugal forces.

In summary, the body of evidence does not support one processing technique above another as superior. Furthermore, when centrifugation is used, several of the articles suggested that forces greater than 3000 rpm (1200 g) cause more cellular damage.

Fat Reinjection

Only two studies were found. The first was performed by Ozsoy et al., who compared three different diameters of injection Coleman-type cannulas. They found that adipocyte viability was significantly greater with 2.5-mm-diameter injection cannulas compared with smaller diameter cannulas (1.6 or 2 mm).

The second study by Erdim et al. compared three types of needles for reinjection: 14, 16, and 20 gauge. They showed no significant differences between needle gauge and cell viability.

Fat Storage

One clinical trial and six prospective experimental studies were identified that investigated fat storage for future use. Butterwick et al. published a clinical, randomized, double-blind study comparing fat augmentation by using freshly isolated fat in one hand and frozen fat (–40°C) in the contralateral hand in 10 subjects.47 They found that the aesthetic results at 1, 3, and 5 months were equivalent or superior in the hand injected with frozen fat.

MacRae et al. examined the differential effect of incubation temperature on adipose viability versus storage at low temperature.48 Their results showed that cell viability was superior in the frozen groups than in the incubated group. In another study by Wolter et al., 92.7 percent of adipocyte metabolic activity was lost after freezing, but the addition of a cryoprotective agent led to preservation of up to 54 percent of baseline metabolic activity.49 Lower storage temperature showed more cell destruction but yielded higher viability of the surviving cells.

Moscatello et al. performed a study comparing different methods of freezing human fat samples obtained after liposuction procedures: no cryoprotectant at –20°C, 10% dimethylsulfoxide, 7.5% polyvinylpyrrolidone 40/7.5% dimethylsulfoxide, 10% glycerol or 10% glycerol/10% fetal bovine serum at –80°C.50 Results showed that few viable adipocytes and no viable adipose stem cells were recovered when fat was frozen instantly at –20°C. In contrast, nearly all aliquots frozen with either cryoprotectant yielded growing cultures of both adipocytes and other stromal vascular associated cells. They concluded that the use of cryopreservative, controlled rate freezing, and storage in nitrogen maintains adipocyte and adipose stem cell viability.

Matsumoto et al. compared cell viability of adipose tissue in different storage temperatures and observed that preservation for 4 hours at room temperature significantly damaged adipocytes but that adipose stem cell yield was maintained.51 Adipose stem cell yield from cryopreserved fat was decreased compared with fresh isolated aspirated fat. They concluded that aspirated fat can be transported to a cell-processing center for cell isolation on the day after harvesting and for subsequent tissue banking if it is kept at 4°C. In addition, optimization of the methodology used for freezing was necessary.

Pu et al. showed that there was no significant difference between fat graft mixed with cryoprotective agent and fresh fat graft without cryopreservation in terms of adipocyte viability; however, the level of enzyme activity (glyceraldehyde-3-phosphate dehydrogenase) was decreased in the former group.52 In 2010, Son et al. also conducted a study on cryopreservation of fat cells and concluded that an appropriate cryoprotective agent should be used in addition to cryopreservation.53 In summary, these studies report that frozen fat can be used for autologous fat transfer but that the addition of a cryoprotective agent and a strict methodology of freezing improve subsequent cell viability.


Over the past 20 years, there has been a resurgence in the use of autologous fat grafting for soft-tissue defect reconstruction for a variety of indications such as facial rejuvenation,5457 facial lipodystrophy,5860 hand rejuvenation,33,61 lower limb atrophy,6265 buttock aesthetic augmentation,6668 and aesthetic or reconstructive breast surgery.12,6972 For the operative surgeon, there are a large number of technical options for fat harvest and grafting. The purpose of this systematic review was to identify the scientific evidence base for this technique. However, it has highlighted a paucity of high-quality clinical studies for any of the identified technical steps involved with fat grafting, whether it be optimal donor-site selection, fat harvesting procedures, fat processing and injection techniques, or the storage of stored fat for future fat grafting. This fact was noted in the earlier systematic reviews15,16 and continues to be the case at the present time.

In addition to the method of fat harvest and processing, there is a school of thought that soft-tissue regeneration may be attributable, in part, to the associated stem cells in adipose tissue7377 that possess several interesting angiogenic, antiapoptotic, and antioxidative properties.7883 Additional processing steps to isolate, prepare, and store adipose stem cells73,74,84 are yet to be explored in a clinical setting because of stringent guidelines on stem cell use.

Harvested fat contains various cell types that include mature fat cells, adipose-derived stem cells, fibroblasts, and endothelial cells.85 The percentages of cell populations may differ widely between different patients. The viability of the respective cell types between the various fat harvesting and preparation techniques is unknown. Equally, the respective roles that these cell types play in fat graft take is also not known and further studies would be required to deduce the effect of the cell milieu on fat graft take.

Future Directions

Currently, fat grafting is successfully executed to the satisfaction of plastic surgeons and patients. There are numerous articles in the literature that attest to individual surgeons and their success.2,6,7,12,86 Patient satisfaction with this procedure has always been relatively high, even with the necessity for multiple fat-grafting sessions,9,74,8789 with adverse events low and limited to ecchymoses, fat resorption, necrosis, and rarely infection.6,12,66,9092

Having performed a thorough review, seeking high-quality clinical or preclinical studies and finding very few, it begs the question: Why is such a body of evidence not being generated? This may be in part attributable to the demands of evidence-based medicine, which raise very high experimental standards, which in the clinical arena may not be practically possible to achieve. To optimize and validate a fat grafting study, this would demand a multicenter, randomized, blinded protocol that enlists numerous plastic surgeons and a large cohort of patients who are prepared to be randomized to a technique that their operative surgeon may not frequently use. Several obstacles could be envisaged. First, there are obvious ethical issues and recruitment challenges that could influence protocol approval by academic or national institutional review boards, plastic surgeons, or the public.

Second, even if protocols could be ethically approved, the issue of funding such a large study with numerous experimental arms could be problematic. The question of who would finance such an effort at a national level (e.g., National Institutes of Health, plastic surgery bodies such as the American Society for Aesthetic Plastic Surgery or the American Society of Plastic Surgeons, or even device companies) is important to ensure the quality of results.

Third, there is still the challenge of identifying the primary and secondary endpoints and how to measure them. Using validated patient and surgeon satisfaction assessments, three-dimensional image techniques10,93,94 and blinded evaluators would all be required. In addition, the inherent difficulty associated with conducting a long-term follow-up study is that subjects should be followed for at least 1 year to assess fat graft take and long-term survival or even longer if safety concerns are raised.

Fourth, the principal pathways for tissue regeneration using fat grafts and the metabolic pathways that may affect the resorption rates of fat grafts are not known completely. It is against this background of incomplete knowledge that drafting a protocol based on a cellular hypothesis is not possible. This review has identified a void in large numbers of high-quality research articles, but those that we did identify seek to answer the role of individual processing steps in fat grafting. In addition, the importance of adipose stem cells as the major cell type in fat graft outcomes and soft-tissue regeneration8,74,95 needs further investigation.


This review has highlighted that published data thus far have failed to produce a cohesive algorithm of the required components for successful, consistent, and durable fat transplantation. There is a need for well-devised, high-level clinical studies that include longitudinal experiments that focus on long-term fat transplant viability and retention. After almost 20 years of varying applications of fat transfer, surgeons and scientists alike are attempting to provide insights into fat grafting techniques so that patients are provided with optimized clinical outcomes as the field moves forward into future decades.


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