Autologous Fat Re-Injection (Lipostructure)

As soon as the first liposuctions were performed, Plastic Surgeons had the idea of reusing the extracted fat and re-injecting it into another part of the body for filling purposes.

This technique of autologous fat re-injection, called lipofilling, long proved disappointing: the re-injected fat tended to be reabsorbed in a significant proportion, rendering results uncertain and ephemeral.

However, Plastic Surgeons did not stop at these initial disappointments and sought to understand the reasons for these failures. Step by step, results improved, but it was especially from 1995 that autologous fat re-injection, also known as Lipostructure, became a truly reliable method (S. COLEMAN).

Lipostructure can be applied to a large number of natural, post-traumatic or iatrogenic depressions (hollows).

The objectives and indications for this type of procedure can be summarised as follows:

1. Aesthetic indications

• Filling and attenuation of certain wrinkles, particularly at the facial level,
• Restoration of "fullness" to a thinned face or during the early stages of facial ageing.
• Restoration of facial volumes and shapes: this may involve the restoration of a face emaciated by ageing.
• A complement associated with certain cervico-facial facelifts to improve facial harmony.
• Secondarily, after an initial facelift, to improve the contour of the mid-face without resorting to a new facelift.
• Correction of irregularities following liposuction.
• Body silhouette remodelling, also called Lipomodelling: it consists of harvesting fat from an area where it is excessive (saddlebags, for example) and reimplanting it in an area where volume is lacking (upper buttocks, for example).
Treatment of aesthetic imperfections does not warrant health insurance coverage.

2. Reconstructive surgery indications

• Filling of tissue depression following trauma,
• Correction of fat atrophy after antiretroviral therapy in HIV+ patients.
• Aesthetic improvement of breast reconstruction results after mastectomy, or after breast implant placement.

In these reconstructive surgery indications, lipostructure may be covered by health insurance under certain conditions.

However, it should be kept in mind that lipostructure must always be considered as a genuine surgical procedure that should be performed by a competent and qualified Plastic Surgeon, specifically trained in this type of technique and practising in a truly surgical setting.

A meticulous clinical and photographic study of the corrections to be made will have been carried out.

A preoperative assessment is carried out in accordance with prescriptions.

The anaesthetist will be seen in consultation no later than 48 hours before the procedure.

Smoking is not an absolute contraindication, but cessation one month before the procedure is recommended given its adverse effect on healing.

No medication containing aspirin should be taken in the 10 days prior to the procedure.

Type of anaesthesia: Lipostructure is usually performed under local anaesthesia deepened by tranquillisers administered intravenously ("twilight" anaesthesia). Simple local anaesthesia or general anaesthesia may also be used.

The choice between these different techniques will result from a discussion between you, the surgeon and the anaesthetist.

Hospitalisation: This surgery is most often performed as a day case, with admission and discharge on the same day. An overnight hospital stay may be indicated.

Each surgeon adopts a technique of their own, which they adapt to each case to achieve the best results. However, common basic principles can be identified:

The procedure begins with precise mapping of the fat harvesting zones and re-injection sites.

Fat tissue harvesting is performed atraumatically through a micro-incision hidden in natural folds, using a very fine aspiration cannula.

A discreet area is chosen where there is a reserve or even an excess of fatty tissue.

The harvested material then undergoes centrifugation for a few minutes, to separate the intact fat cells, which will be grafted, from elements that cannot be grafted.

Fat tissue re-injection is performed through 1 mm incisions using micro-cannulas.

Micro-particles of fat are thus injected into different planes and in multiple divergent directions, to increase the contact surface between the implanted cells and the recipient tissues, which improves the survival of the grafted fat cells.

Since this is a genuine grafting of living cells, and provided the technique is sound and the graft take is effective, the grafted cells will remain alive within the body, making lipostructure a permanent technique since the grafted fat cells will live as long as the surrounding tissues.

The duration of the procedure depends on the amount of fat to be re-injected and the number of sites to be treated. It can vary from 30 minutes to 2 hours for isolated lipostructure.

In the postoperative period, pain is generally mild.

Tissue swelling (oedema) appears during the 48 hours following the procedure and generally takes 5 to 15 days to fully resolve.

Ecchymoses (bruising) appear within the first hours at the fat re-injection sites: they resolve within 10 to 20 days after the procedure.

Thus, while physical recovery is usually rapid due to the light and superficial nature of the procedure, the social inconvenience caused by oedema and ecchymoses should be taken into account when planning family, professional and social activities.

The treated areas should not be exposed to sun or UV light for at least 4 weeks, which would carry a risk of permanent pigmentation.

After resolution of oedema and ecchymoses, the result begins to appear within 2 to 3 weeks after the procedure.

It is assessed within 3 to 6 months after the procedure.

It is most often satisfactory whenever the indication and technique have been correct: depressions are generally filled and volumes restored.

There is a variable difference of 20 to 40% between the amount of fat re-injected and the amount of graft take. The practitioner will have accounted for this in evaluating the fat re-injection.

Since the fat cell graft has effectively taken, we have seen that these cells remain alive as long as the tissues within which they have been grafted remain alive.

It should be known that the re-injected fat that has taken as a fat graft is sensitive to future weight fluctuations; therefore, in cases of weight loss or weight gain, the areas that benefited from lipostructure will become hollow or increase in volume.

Over time, the result will progressively deteriorate due to the natural continuation of ageing in these same tissues.

The goal of this surgery is to bring about an improvement, not to achieve perfection. If your expectations are realistic, the result obtained should give you great satisfaction.

We have seen that, in most cases, a correctly indicated and performed lipostructure provides a real benefit to patients, with a satisfactory result conforming to expectations.

In some cases, localised imperfections may be observed (without constituting real complications): localised under-correction, slight asymmetry, irregularities.

These are generally amenable to complementary treatment: a small lipostructure "touch-up" under simple local anaesthesia from the 6th postoperative month onward, of which the patient will have been informed of the possible benefit in perfecting the result.

Possible complications

Lipostructure, although performed for essentially aesthetic motivations, remains a genuine surgical procedure, which implies the risks associated with any medical act, however minor.

A distinction must be made between complications related to anaesthesia and those related to the surgical procedure.

Regarding anaesthesia, during the consultation, the anaesthetist will personally inform the patient of the anaesthetic risks. It should be understood that anaesthesia induces sometimes unpredictable reactions in the body that are more or less easy to control: having recourse to a fully competent Anaesthetist practising in a truly surgical setting means that the risks incurred have become statistically very low.

Indeed, techniques, anaesthetic products and monitoring methods have made immense progress over the past thirty years, offering optimal safety, especially when the procedure is performed electively and on a healthy person.

Regarding the surgical procedure: by choosing a qualified and competent Plastic Surgeon, trained in this type of intervention, you minimise these risks as much as possible, without however eliminating them entirely.

In fact, true complications are rare after quality lipostructure: great rigour in indication assessment and surgical execution should provide effective and genuine prevention, notably as the blunt cannulas preserve the skin, vessels and nerves.

Infection is normally prevented by prescribing per- and/or postoperative antibiotic treatment.

The most frequent complication after lipostructure is over-correction, which may be related to the re-injection of an excessive quantity of fat, resulting in a volume excess that can be unsightly.

Such over-correction quickly becomes permanent and its treatment is typically delicate since it cannot generally be corrected by simple liposuction: most often, only reoperation with actual surgical excision of the excess fat will correct such over-correction.

Overall, risks should not be overestimated, but one should simply be aware that a surgical procedure, even an apparently simple one, always involves a small element of uncertainty.

Choosing a qualified Plastic Surgeon ensures that the practitioner has the training and competence required to prevent these complications, or to treat them effectively should they arise.