Discussion: Enhancing the Take of Injected Adipose Tissue by a Simple Method for Concentrating Fat Cells

It was a pleasure to read this well-written article by Dr. Ramon et al. describing a technique for harvesting and processing fat grafts for use in the body. Having used a single technique for the past 15 years that is also a simple technique, I am an advocate of using methods to harvest fat that accomplish the job in the simplest fashion. Dr. Ramon et al. referenced my article in the literature published in 19901 describing that absorption of local anesthesia and excess liquid fat from aspirated fat could be done with neuro-cottonoids, which are absorbent cotton strips used primarily in the field of neurosurgery. I have used this technique for many years and feel that it has given me the best results when coupled with fat harvested from the best sites. It has also been my experience that removing fat grafts from posterior to the midlateral line allows me to obtain more cellular fat than I can harvest from the abdomen or inner thighs. I believe that the lipid composition of fat cells from the anterior part of the trunk is higher than that of the firmer and more cellular fat from the posterior areas. My favorite donor site is the upper lateral thigh in women and the “love-handle” area in men. In addition, I have harvested fat with a 14gauge open-bore needle rather than a liposuction cannula. Over the years, I have switched to cannulas but have always gone back to my original techniques. What I have found with this technique is that the fat appears to be more “intact” and does not have the mealy appearance of fat liposuctioned with a side-hole liposuction cannula. There is probably more bruising and discomfort postoperatively with the open-bore 15-gauge needle that I use, but I believe that the take of the grafts in my patient population over the past 15 years has shown it to be well worth the effort. In addition to the harvesting technique, I have used smaller needles for placing the fat grafts. I use 20-gauge, 11⁄2-inch needles, and it is quite easy to get the fat through these, provided one uses a Luer-Lok tuberculosis syringe. The advantage of the tuberculosis syringe is that the smaller piston in the syringe gives a higher pressure to force the fat graft through the needle. Using a “multistructuring” approach, much like filling in the spaces in a honeycomb, I am able to achieve homogenous fill of the recipient area and have achieved my best results in that manner. When there is a crease such as a nasolabial fold or a depression, I use the bevel of the 20-gauge needle to undercut the muscle attachment or retract scar tissue in these cases. This has been very satisfactory, but a word of caution is to be interjected here: if you do use the technique of release of muscle or contracted scar, the fat graft must be put in place before release of the contracture rather than afterward. If the space is freed up by dissection with a needle tip and then the fat graft is put in place, it is like a small “roll” or “sausage” of fat under the skin. My favorite areas of fat grafting include the nasojugal groove, but only after release of the undersurface of the orbicularis muscle fascia where it attaches to the arcus marginalis. This fat is injected into the orbicularis muscle from its undersurface, using a standard blepharoplasty or transconjunctival blepharoplasty approach. Other areas include the nasolabial folds, which are almost always undermined with a needle as described. The lateral chin area is also a good recipient area, where there