Abdominal Fat Harvest Technique And

Abdominal fat harvest technique and its uses in
maxillofacial surgery
Dennis J. Kantanen, DDS," James J. Closmann, DDS,b and Henry H. Rowshan, DDS,'
Honolulu, Hawaii
DIVISION OF ORAL AND MAXILLOFACIAL SURGERY, TRIPLER
AR~IY
MEDICAL CENTER
Abdominal fat harvest and augmentation to the maxillofacial region is a relatively inexpensive, safe, and
readily available procedure. The use of abdominal fat free transfer has been well documented for cosmetic, trauma,
and temporomandibular joint reconstruction. Fat is the closest we have to an ideal filler, it is readily available and
inexpensive, it is autologous and therefore lacks a host immune response, it is safe and noncarcinogenic, and it is
easily acquired with a minimally invasive procedure. Abdominal fat donor site is the most commonly used owing to
ease of access and availability of fat stores. Complications are rare and easily managed in the office. Free abdominal
fat harvest is a predictable surgical technique that allows the maxillofacial surgeon access to autologous graft material
that is ideal for multiple facial procedures. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:367-371)
Abdominal fat harvest and augmentation to the maxillofacial region is a relatively inexpensive, safe, and
readily available procedure.' The use of abdominal fat
free transfer has been well docnmented for cosmetic,
trauma, and temporomandibular joint reconstruction. In
2009, autogenous fat is still the preferred method for
the treatment of frontal sinus obliteration. Abdominal
fat has been nsed since the 1890s for cosmetic procedures 2 En bloc resection and removal of abdominal fat
has been shown experimentally to contain a greater
percentage of surviving adipocytes compared with cannnla removal. 3 Therefore, the aim of the present article
is to discuss the suprapubic abdominal fat harvest technique to include the pertinent anatomy, complications,
and uses of the technique.
ABDOMINAL FAT
There are a myriad of autogenous and alloplastic
materials that can be used for maxillofacial procedures
for trauma, cosmetic, facial, and temporomandibular
joint (TMJ) reconstruction. Facial rejuvenation with
autologous fat has the advantage of replacing or augmenting tissue with like tissue. Over the past 10-15
The views and opinions expressed herein are those of the authors and
do not necessarily reflect those of the Department of the Defense or
the Department of the Army.
aChief resident, Division of Oral & Maxillofacial Surgery.
bChief and Program Director, Division of Oral & Maxillofacial
Surgery.
CAssistant Program Director, Division of Oral & Maxillofacial
Surgery.
Received for publication May 5, 2009; accepted for publication Sep
8,2009.
1079-2104/$ - see front matter
Published by Mosby, Inc.
doi: 10.1016/j .tri pleo.2oo9.09.037
years, more widespread clinical use of autologous fat
grafts for facial soft-tissue augmentation suggests that
this procedure is the best presently available. In many
ways, fat is the closest we have to an ideal filler: It is
readily available and inexpensive, it is autologous and
therefore lacks a host immune response, it is safe and
noncarcinogenic, and it is easily acquired with a minimally invasive procedure. Viable autogenous free abdominal fat along with the removal of mucosal lining
from the frontal sinus consistently prevents regrowth of
the mucoperiosteum. The use of autogenous fat for
frontal sinus obliteration purposes continues to be the
gold standard (Fig. 1).4-6 Areas of the maxillofacial
region that are routinely augmented during cosmetic
procedures include the malar region, lips, nasolabial
folds, and mental area. Facial reconstruction for the
treatment of facial lipodystrophy due to underlying
HIV disease has been documented (Fig. 2). 7 Free abdominal fat has been used dnring the treatment of TMJ
disorders (Fig. 3). During open joint surgery, free abdominal fat has been transplanted into the joint space to
replace joint space after complete removal of the disc
and associated capsule. The use of autologous fat grafts
in the treatment of TMJ ankylosis has been reported in
the literature as early as 1913 8 •9 Autologous transplantation of abdominal fat around the TMJ can minimize
occurrence of fibrosis and heterotopic bone formation,
leading to improved range of motion.'o Autologons
transplantation of fat has been used as a method to
prevent heterotopic bone formation after hip replacement surgery for many years.'o The use of dermal fat
for correction of contour defects in the head and neck
area from trauma, congenital defects, and neoplasm has
remained a well known and time-honored choice (Fig.
4)7 Dennafat is used owing to the dennal layer being
367
368
OOOGE
March 2010
Kantanen et at.
Fig. 1. Frontal sinus obliteration with autologous abdominal
fat.
Fig. 3. Free abdominal fat graft used in temporomandibular
joint reconstruction. Courtesy of Michael Doherty, DDS.
Fig. 2. Free abdominal dennafat graft for treatment of HIVassociated lipodystrophy syndrome. From Rowshan et a1. 7
the vasoinductive layer for the underlying adipose graft
and is nsually placed facing against the subadjacent
subcutaneous layer for optimal blood supply.
Fig. 4. Free abdominal derrnafat used during superficial parotidectomy to prevent Frey syndrome and to fill the cosmetic
defect. Courtesy of Henry H. Rowshan, DDS.
TECHNIQUE OF AUTOGENOUS FREE
ABDOMINAL FAT HARVEST
Extensive comparative studies between different donor sites and fat graft success have yet to be conducted.
The abdominal donor site is the most common owing to
ease of access and availability of fat stores. General
anatomic knowledge of the anterior abdominal wall is
critical for abdominal fat harvest (Fig. 5). The anterior
abdominal wall in the suprapubic area consists of 7
layers:
I.
2.
3.
4.
S.
6.
7.
Superficial skin.
Subcutaneous fat.
Superficial fascia.
Deep fascia.
Rectus abdominis muscle.
Subserous fascia.
Peritoneum.
OOOOE
Volume 109, Number 3
Kantanen et ai.
369
Fig. 5. Anatomy of anterior abdominal wall in umbilicus
region.
The subcutaneous fat layer can be accessed rather
easily immediately below the superficial skin and subcutaneous tissue, which normally measures 5-10 mm
deep. Depending on the size of the patient, a sufficient
layer of subcutaneous fat can be obtained without difficulty. Below the subcutaneous fat, the superficial and
deep fascias are encountered. The superficial fascia
overlies the entire anterior abdominal wall just below
the abdominal fat. The deep fascia surrounds the abdominal rectus muscles. The deep fascia of the abdominal wall is different than that found around muscles of
the extremities. It is of the loose connective tissue
variety. It is necessary in the abdominal wall because it
offers more flexibility for a variety of functions of the
abdomen. At certain points, this fascia may become
aponeurotic and serve as attachments for muscle and
bone, as for the linea alba. The rectus abdominis muscle
is a paired muscle running vertically on each side of the
anterior abdominal wall. The muscle is a key postural
muscle, responsible for flexing the lumbar spine. Subserous fascia, also known at extraperitoneal fascia, is a
layer of loose connective tissue that serves as a glue to
hold the peritoneum to the deep fascia of the abdominal
wall or to the outer lining of the gastrointestinal tract. It
may receive different names depending on its location
(i.e., transversalis fascia when it is below that muscle,
psoas fascia when it is next to that muscle, iliac fascia,
etc.) Lastly, before entering the abdominal cavity, the
peritoneum, a thin I-ceIl-thick membrane that lines the
abdominal cavity and in certain places reflects inward
to form a double layer of peritoneum. Double layers of
peritoneum are called mesenteries, omenta, falciform
ligaments, lienorenal ligament, etc.
The following surgical technique is currently used at
the our institution for fat harvest. The free abdominal
fat graft harvest begins by first outlining a 3-5 cm
transverse midline incision line approximately 2-3 cm
below the umbilicus (Fig. 6). One-percent lidocaine
with I: 100,000 epinephrine is injected into the proposed surgical site. A #10 blade is used to make an
Fig. 6. 3-5 cm transverse midline incision approximately 2-3
cm below the umbilicus.
Fig. 7. Two Kocher clamps aiding in fat harvest.
incision through skin and subcutaneous tissue to expose
the abdominal fat pad. Electrocautery is then used to
control and obtain surgical site hemostasis. Two Kocher
clamps are placed on the superficial subcutaneous fat to
apply tension to aid in the fat harvest (Fig. 7). Care is
taken to limit the dissection to superficial of the abdominal muscular fascia. During the harvesting, the
overlying skin is undermined to maximize the abdominal fat harvest and minimize the length of the skin
370
OOOOE
March 20JO
Kantanen et ai.
Fig. 8. En bloc fat harvest.
incision. A 3-5 mm layer of fat on the skin side is
maintained to decrease the likelihood of an uncosmetic
result and wound dehiscence. With adequate tension on
the fat graft, the fat is then widely undermined superficial to the rectus abdominis muscle fascia to a similar
extent as the overlying skin dissection. The desired
amount of graft is harvested from the midline region
(Fig. 8). To allow for shrinkage and errors in frontal
sinus volume estimation, the fat harvest should be
-30% more than the estimated amount needed to fill
the dead space of the frontal sinus or whereever it is to
be used. Before closure, meticulous hemostatis is
achieved with electrocautery and the need for a drain is
not indicated. The dissection should not violate the
abdominal muscular fascia and should remain solely in
the underlying fat layers. The wound is closed by
advancing the superior and inferior fat flaps toward the
surgical incision and sutured with 3-0 vicryl popoffs in
an interrupted fashion. The subcutaneous tissue is
closed with 4-0 monocryl in a subcuticular closure
fashion (Fig. 9). To minintize the incidence of hematoma and seroma formation, a pressure dressing of
Kerlix (Hamilton Medical Products, Mill Valley, CAl
fluffed gauze and elastic tape is applied and maintained
for a period of 3 days before removal. The harvested
autogenous free abdominal fat is wrapped in a moist
saline gauze sponge (Fig. 10). Metabolic analysis has
shown improved cell viability in fat tissue specimens
undergoing ntinimal manipulation. II Once the maxillofacial graft site is accessed and prepared, the en bloc
Fig. 9. Final closure of abdominal fat harvest site.
Fig. 10. Fat wrapped in gauze sponge.
autologous fat can be placed into the prepared area.
Patients are maintained on appropriate antibiotics, typically cephalexin, 500 mg 4 times a day for 7 days, as
well as analgesics after surgery.
COMPLICATIONS
Although fat transfer is generally regarded to be a
safe procedure, there are reports of associated morbidity. Possible complications of abdominal fat graft har-
OOOOE
Volume 109, Number 3
vest include seroma, infection, hematoma, ileus, and
inadvertent peritoneal perforation. The most common
complication, although still rare, is a seroma formation
at the abdominal fat harvest site. Wolford et al. 12 reported a 6.9% incidence of seroma fonnation requiring
aspiration. Postsurgical abdominal seromas are typically evacuated with percutaneous drainage and aspiration under local anesthesia. Infection rates are consistent with any other surgical procedure, with an
incidence of around 3%. J2 Abdominal subcutaneous
hematoma formation is a rare occurrence during abdominal fat harvest, with a reported incidence between
0% and 3.2%, owing to the small surgical field, short
surgical time, and ease to obtain hemostatis. J3 With
careful attention to hemostasis, drain placement into the
harvest site is rarely needed. Adequate placement of
fluffed gauze and elastic dressing minimizes the incidence of hematoma formation. Postsurgical ileus and
inadvertent peritoneal perforation are possible sequelae
during abdominal fat harvest. An ileus occurs from
hypomotility of the gastrointestinal tract in the absence
of a mechanical bowel obstruction. Frequently, an ileus
occurs after intraperitoneal operations, but it may also
occur after retroperitoneal and extra-abdominal surgery. No documented cases of postsurgical ileus or
peritoneal perforation after abdominal fat harvest could
be found in the literature.
Kaufman et al.\" found that fat transfered into subcutaneous tissue demonstrated 30% survival after 6
months. Keerl et al. \5 studied fat implanted into the
frontal sinus of 11 patients for obliteration of the frontal
sinus cavity. Postoperative magnetic resonance imaging evaluation showed viable fat in 6 of the II patients
4-24 months after surgery. In the remaining 5 patients,
the fat demonstrated necrosis and had been replaced by
granulation tissue and connective tissue.
CONCLUSION
Free abdominal fat harvest is a predictable surgical
technique that allows the maxillofacial surgeon access
to autologous graft material which is ideal for multiple
facial procedures. Minimal morbidity and ideal graft
material will enable abdominal fat to continue to be the
gold standard upon which all filler materials are compared.
Kantanen et ai.
371
REFERENCES
1. Butterwick 10. Nootheti PK. Hsu rw, Goldman MP. Autologous
fat transfer: an in-depth look at varying concepts and techniques.
Facial Plast Surg Clin Nonh Am 2007;15:99.
2. Kaufman MR. MiUer TA, Huang C, Roostaien J, Wasson KL.
Ashley RK. et al. Autologous fat transfer for facial recontouring:
is there science behind the art? Plast Reconstr Surg 2007;119:
2287-%.
3. Guymon B, Majzoub RK. Facial augmentation with core fat graft:
a preliminary report. Plast Reconstr Sw-g 2007; 120:295-302.
4. Bergara AR, Itoiz AD. Present state of the surgical treatment of
chronic frontal sinusitis. Arch Dto1aryngol 1955;61:616-28.
5. Bergara AR, Itoiz AG. Experimental study of the behavior of
adipose tissue within the frontal sinus of dog. Argent Rev 010rhinolaryngoI1951;12:184-92.
6. Montgomery WW. The fate of adipose implants in a bony cavity.
Laryngoscope 1964;74:816-27.
7. Rowsban HH. Hart K. Arnold JP, Thompson SH, Baur O. Keith
K, Skidmore P. Treatment of human immunodeficiency virosassociated facial lipodystrophy syndrome wilh dermafat graft
transfer to the nasolabial fold areas: a case report and review of
the literature. J Oral MaxiUofac Surg 2008;66:1932-8.
8. Blair VP. Operative trealment of ankylosis of the mandible.
Trans South Surg Assoc 1913;28:435.
9. Murphy JB. Arthroplasty for intra-articular bony and fibrous
ankylosis of the temporomandibular articulation. JAMA 1914;
62,1783.
10. Wolford LM. Karras Sc. Autologous fat transplantation around
temporomandibular joint total joint prostheses: preliminary treatment outcomes. J Oral Maxillofac Surg 1997;55:245-52.
11. Smith P, Adams WP, Lipschitz AH, Chau B. Sorokin E, Rohrich
RJ, et al. Autologous human fat grafting: effect of harvesting and
preparation techniques on adipocyte graft survival. Plast Recon~
str Surg 2006; 117: 1836-44.
12. Wolford LM, Morales-Ryan CA, Morales PG, Cassano OS.
Autologous fat grafts placed around temporomandibular joint
total joint prostheses to prevent heterotopic bone fonnatioo. Proc
Baylor Univ Moo Cent 2008;21:248.
13. Sanna M, Taibah A, Russo A, Falcioni M, Agarwal M. Perioperative complications in acoustic neuroma (vestibular schwan~
noma) surgery. Olol Neuroto1 2004;25:379-86.
14. Kaufman MR, Bradley JP, Dickioson B, HeUer JB, Wasson K.
O'Hara C. et at. Autologous fat transfer national consensus
survey: trends in techniques for harvest, preparation, and application. and perception of short- and long-term results. Plast
Reconstr Surg 2007;119:323-31.
15. Keerl R, Weber R, Kable G, Drat W, Constantinidis J. Saba A.
Magnetic resonance imaging after frontal sinus surgery with fat
obliteration. J Laryngol 0101 1995; 109: IlIS·19.
Reprint requests:
Dr. Dennis J. Kantanen
Tripier Army Medical Center
1 Jarrett White Road
Honolulu. Hawaii 96859-5000
[email protected]