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Megavolume Autologous Fat Transfer

Part I. Theory and Principles

Khouri, Roger K. Jr. B.S.; Khouri, Roger K. M.D.

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Plastic and Reconstructive Surgery: October 2014 - Volume 134 - Issue 4 - p 657e
doi: 10.1097/PRS.0000000000000561
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Reperfusion injury is a well-recognized phenomenon in vascularized tissue transfer. Our review, however, studies nonvascularized tissue transfer and the factors essential for revascularization.1 In vascularized tissue transfer, perfusion is restored surgically, leading to a sudden infiltration of blood and inflammatory molecules that induce reperfusion injury. However, in nonvascularized tissue transfer, angiogenesis occurs biologically over the course of days, making reperfusion injury unlikely.

For the common two-dimensional skin grafts, angiogenesis requires only adequate contact between the grafted tissue and a functional recipient capillary bed.2 Our review attempts to clarify the surface area–to-volume limitations that occur when the third dimension is added. Extrapolating from the two-dimensional grafts, because thick grafts revascularize poorly, we need to avoid graft lobules with a greater than 2-mm radius and carefully disperse them within the three-dimensional recipient scaffold. Furthermore, just as overgrafting is counterproductive in two-dimensional grafts, and we cannot graft more than the size of the recipient wound defect, we need to recognize the limited capacity of a recipient site to accept additional graft volume before the interstitial fluid pressure increases to levels that compromise the capillary circulation.

If graft perfusion is not restored before the onset of tissue damage, we need not worry about reperfusion injury.3 It is only after we comply with these requirements for revascularization that we can start discussing reperfusion injury.


The author has no financial interest to declare in relation to the content of this communication.

Roger K. Khouri, Jr., B.S.

University of Michigan Medical School

Ann Arbor, Mich.

Miami Breast Center

Key Biscayne, Fla.

Roger K. Khouri, M.D.

180 Crandon Boulevard, Suite 114

Key Biscayne, Fla. 33149

[email protected]


1. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs TM. Megavolume autologous fat transfer: Part I. Theory and principles. Plast Reconstr Surg. 2014;133:550–557
2. Greenwood J, Amjadi M, Dearman B, Mackie I. Real-time demonstration of split skin graft inosculation and integra dermal matrix neovascularization using confocal laser scanning microscopy. Eplasty. 2009;9:e33
3. Rezkalla SH, Kloner RA. No-reflow phenomenon. Circulation. 2002;105:656–662


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