Fat Harvesting Step by Step

Abstract

Before providing a step-by-step description of the procedure it is useful to recall some of the basic elements of the anatomy of the hip. The pelvic skeleton is formed, to the front, by the sacrum and coccyx bones and by a pair of hip-bones to the left and right. The two hip-bones connect the lower limbs to the spine, while the lower limbs are connected to each other anteriorly and attached to the sacrum posteriorly.

1 Microfat Preparation: Harvesting in the Hip-Pelvis Area

Before providing a step-by-step description of the procedure, it is useful to recall some of the basic elements of the anatomy of the hip. The pelvic skeleton is formed, to the front, by the sacrum and the coccyx bones and by a pair of hip-bones to the left and right. The two hip-bones connect the lower limbs to the spine, while the lower limbs are connected to each other anteriorly and attached to the sacrum posteriorly.

Each hip-bone comprises three sections: the ilium, the ischium, and the pubis. The name of the ilium comes from the Latin word ile or ilis, meaning “groin” or “flank”. The ilium is the largest of the coxal bones (Figs. 3.1 and 3.2).

Fig. 3.1

The ilium is the largest of the coxal bones (reproduced from Gray’s Anatomy, 20th edition, 1918, under public domain). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.2

The ilium is the largest of the coxal bones (reproduced from Gray’s Anatomy, 20th edition, 1918, under public domain). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

The iliac crest is the upper border of the wing of the ilium (Fig. 3.3, green points). Palpable along its entire length, the crest is situated between the anterior superior iliac spine (ASIS) (Fig. 3.3, red point) and the posterior superior iliac spine (PSIS) (Fig. 3.4). The anterior superior iliac spine (ASIS) is a bony projection of the iliac bone and an important landmark of surface anatomy. It refers to the anterior extremity of the iliac crest of the pelvis, which provides an anchor for the inguinal ligament and the sartorius muscle (Figs. 3.5, 3.6, 3.7, 3.8, 3.9, and 3.10).

Fig. 3.3

The iliac crest is the upper border of the wing of ilium (green points). It is palpable along its entire length. The crest is situated between the anterior superior iliac spine (ASIS) (Fig. 3.3, red point) and the posterior superior iliac spine (PSIS) (Fig. 3.4). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.4

The iliac crest is the superior border of the wing of ilium (green points). It is palpable along its entire length. The crest is included between the anterior superior iliac spine (ASIS) (Fig. 3.3, red point) and the posterior superior iliac spine (PSIS) (Fig. 3.4). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.5

Anatomical dissection of the harvesting area. The subcutaneous plane is exposed. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.6

An ultrasound image of the harvesting area. The red spot appears in correspondence to the anterior superior iliac spine. The use of ultrasound in thin patients can be supported by measuring the thickness of the adipose tissue in the aspiration site considered for harvesting and seeking the optimal position to prepare for the procedure. Ultrasound assistance may be considered for the initial learning curve or in thin patients. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.7

Marking the harvesting area: the entry-point is signed in correspondence to the anterior superior iliac spine (ASIS). The flank fat pad is pinched and marked. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.8

Marking the harvesting area: the entry-point is signed in correspondence to the anterior superior iliac spine (ASIS). The flank fat pad is pinched and marked. (Published with kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.9

Locating the pad of fat on the flank before harvesting. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.10

Posterior view of areas from which fat may be harvested. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

2 Low-Pressure Microfat Aspiration: Materials and Methods

Microfat harvesting can be carried out in a small operating thetare/medical practice. Oxygen, pulse oximetry, and a crash cart/box should be present. A standard procedure microfat box is used (Courtesy of Microfat.com) (Fig. 3.11). The microfat box is composed of some single-use elements: a ramp with a closed system for washing and filtration, 4 60-cc syringes, 2 10-cc syringes, one 1-cc syringe, a 30-gauge needle, a 16-gauge needle, a 21-gauge needle, and a 22-gauge 4-cm blunt cannula.

Fig. 3.11

The instruments used for harvesting using the Microfat Box. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

This microfat box can be used in conjunction with some autoclavable elements, in particular the microfat tray (Fig. 3.12, Published by kind permission of ©Mario Goisis 2018. All Rights Reserved) and the autoclavable 10-cm Goisis cannula (Microfat or Tulip). The Goisis tray is composed of a plastic support for the ramp and of two trays for the Klein and saline solutions. The autoclavable cannula is produced also in a single-use version.

Fig. 3.12

The Microfat Tray. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Other necessary supplies are a chlorhexidine-alcohol solution (2% chlorhexidine gluconate and 70% isopropyl alcohol), sterile drapes or towels, ice packs, sterile 2 cm x 2 cm gauze squares, and an occlusive dressing cover.

When initially performing lipoaspiration, ultrasound guidance can be very useful, but once one's level of competence improves, it is not always needed. However, it should be included in the procedure when operating on thin patients. Ultrasound is a useful tool to determine the thickness of adipose tissue and the optimal site for harvesting. When using ultrasound, a sterile ultrasound transducer condom is required.

Medications include:

• 100 cc of cold saline solution

• 120 cc of cold Klein solution

1 litre of Klein solution is composed of 800 mg of lidocaine, 1 mg of epinephrine, 40 MEq of sodium bicarbonate, and 1000 cc of saline solution. The use of an anaesthetic with epinephrine will reduce local bleeding and help speed up recovery (Fig. 3.13).

Fig. 3.13

Medications. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

3 Preparation of the Klein Solution

Two 500-cc bottles of saline solution, four 200-mg bottles of lidocaine, two 0.5-mg bottles of epinephrine, and two 20-MEq bottles of sodium bicarbonate (Figs. 3.14, 3.15, 3.16, and 3.17).

Fig. 3.14

Preparation of 500 mg of Klein solution step by step. The elements contained in 500 cc of Klein solution: one 500-cc bottle of saline solution, two 200-mg bottles of lidocaine, one 0.5-mg bottle of epinephrine, one 20-MEq bottle of sodium bicarbonate. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.15

The contents of the two 200-mg bottles of lidocaine are mixed with 500 cc of saline solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.16

The contents of the 20-MEq bottle of sodium bicarbonate is added. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.17

Finally, the contents of the 0.5-mg bottle of epinephrine is added. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Assistance: An assistant should be present to transfer items to the procedure field in a sterile manner during the first stage of the procedure, nevertheless, the complete procedure may be performed by a single doctor: careful handling is recommended.

3.1 The Low-Pressure Lipoaspiration Technique

The initial steps will be quite difficult, and the aspiration of the fat will be limited. The aspirate will appear transparent, usually with a large component of local anaesthesia. The later steps will be easier and run  more smoothly, as the tissue is mobilised. The aspirate will appear yellow, preferably with a limited amount of blood.

The usual goal is 15–25 mL of adipose tissue. If a larger volume is desired, the use of a second site can be contemplated (Figs. 3.18, 3.19, 3.20, 3.21, 3.22, 3.23, 3.24, 3.25, 3.26, 3.27, 3.28, 3.29, 3.30, 3.31, 3.32, 3.33, 3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, 3.44, 3.45, 3.46, 3.47, 3.48, 3.49, 3.50, 3.51, 3.52, 3.53, 3.54, 3.55, 3.56, 3.57, 3.58, 3.59, 3.60, 3.61, 3.62, 3.63, 3.64, 3.65, 3.66, 3.67, and 3.68).

Fig. 3.18

If a patient is not too thin, the easiest sites from which to obtain lipoaspirate are those  above the area of the flank. The lateral decubitus position is preferred (Fig. 3.14). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.19

Once the site has been chosen , it should be marked, and the area then cleansed, with a chlorhexidine-alcohol solution, and draped. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.20

The first syringe is filled with 60 cc of Klein solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.21

The syringe is connected to the entry-duct marked “A” in the photograph. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.22

The second syringe is filled with 60 cc of Klein solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.23

The syringe is connected to the tube marked “D”. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.24

The third syringe is filled with 60 cc of the saline solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.25

The syringe filled with the saline solution is connected to position B (see the black arrow). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.26

An empty 60 cc syringe is connected to position C (see the black arrow). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.27

An empty 10-cc syringe is connected to position E (see the black arrow). (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.28

The local anaesthetic is transferred directly from the syringes A and D to the 10-cc syringe E. In particular, when the stopcock is in position “a” by pulling the plunger, the syringe E is filled with air and anaesthetic solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.29

By moving the stopcock to position “b,” the air is pushed out from the syringe. (Published with kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.30

A 30-gauge needle is connected to syringe E. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.31

1 cc of Klein solution is injected into the entry-point. The stopcock is in the "b" position, connecting the syringe to the needle. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.32

The 30-gauge needle is exchanged for a 16-gauge needle. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.33

The entire contents of the syringe is injected into the entry-point. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.34

The entire contents of the syringe is injected into the entry-point. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.35

The stopcock connected to the empty syringe is moved to position “a.” When the stopcock is in the "a" position, by pulling the plunger, syringe E is filled with Klein solution. In fact, it is aspirated directly from syringes A and D. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.36

With the stopcock in the "b" position, 10 cc of Klein solution is injected. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.37

Fan distribution of the Goisis cannula into the donor site. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.38

Fan distribution of the Goisis cannula into the donor site. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.39

Fan distribution of the Goisis cannula into the donor site. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.40

The cannula is inserted into the area, and a few slow passes are carried out to distribute the Klein solution. (Published with kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.41

An ultrasound image shows the relationship between the cannula and the anatomical structure of the area. The cannula is inserted into the subcutaneous tissue, at a depth of 1 cm from the cutis. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.42

An ultrasound image shows the relationship between the cannula and the anatomical structure of the area. The cannula is inserted into the subcutaneous tissue, at a depth of 1 cm from the cutis. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.43

The remaining 120 cc of the Klein solution is injected in small spots of 5 cc (blue circle). The injection of anaesthesia takes 3–5 min. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.44

The remaining 120 cc of Klein solution is injected into small spots of 5 cc (blue circle). The injection of anaesthesia takes 3–5 min. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.45

The Klein solution injected begins to break down/mobilise the adipose tissue. The infiltrated area is indicated with the blue arrows. (Published with kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.46

The Klein solution injected begins to break down/mobilise the adipose tissue. The infiltrated area is indicated with the blue arrows. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.47

The infiltration of the Klein solution ceases automatically when syringes A and D are empty. In fact, when all of the content of these syringes has been injected, it is impossible to fill syringe E either with the stopcock in position “a”. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.48

The stopcock is moved to position “b,” and the harvesting of the fat can start. It is mandatory that the aspiration holes of the cannula remain in the skin the whole time. When the plunger of the syringe is pulled back, a negative pressure is created, and the syringe is progressively filled with fat. The practitioner can then easily move the cannula back and forth inside the anaesthetized region. Pinching the tissue to raise it up often makes the process simpler. Additionally, pinching the tissue can reduce procedural pain by stimulating mechanoreceptors. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.49

A rotational movement is applied to the cannula by rotating the wrist. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.50

Design of the Goisis cannula. By bring a rotational movement to bear, it is possible to increase the harvesting of the fat. In particular, the depressed edge of the holes increases the entrance of the fat into the cannula and the barbed edge favours its dissection. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.51

Design of the Goisis cannula. A rotational movement makes increasing the amount of fat to be harvested possible. In particular, the depressed edge of the holes increases the entrance of the fat into the cannula and the barbed edge favours its dissection. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.52

Design of the Goisis cannula. A rotational movement makes it possible to increase the amount of fat to harvest. In particular, the depressed edge of the holes increases the entrance of the fat into the cannula and the barbed edge favours its dissection. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.53

Ultrasound image of the position of the cannula (in blue). It is important not to aspirate too large a volume close to the skin, because this can result in dimpling of the skin. The correct depth of the cannula is at least 1 cm from the dermis. It is also mandatory to minimise trauma to the underlying muscle, by avoiding entinto the muscular plane. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.54

Ultrasound image of the position of the cannula (in blue). It is important to not aspirate too large a volume close to the skin, because this can cause dimpling of the skin. The correct depth of the cannula is at least 1 cm from the dermis. It is also mandatory to minimise trauma to the underlying muscle, by avoiding to enter into the muscular plane. (Published with kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.55

If one of the aspiration holes is removed from the skin, the air enters the syringe, and the vacuum is lost. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.56

Then it is necessary to remove the cannula, leave the plunger, hold a sterile gauze over the cannula holes, express the excess air from the syringe, and repeat the initial steps. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.57

Then it is necessary to remove the cannula, leave the plunger, hold a sterile gauze over the cannula holes, express the excess air from the syringe, and repeat the initial steps. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.58

Then it is necessary to remove the cannula, leave the plunger, hold a sterile gauze over the cannula holes, express the excess air from the syringe, and repeat the initial steps. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.59

When the syringe E is completely filled, move the stopcock into position “a”. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.60

The fat mixed with blood and anaesthesia is pushed and transferred directly from syringe E to syringe A. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.61

The fat mixed with blood and anaesthesia is pushed and transferred directly from syringe E to syringe A. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.62

The fat mixed with blood and anaesthesia is pushed and transferred directly from syringe E to syringe A. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.63

Repeat the procedure 4–6 times in order to obtain a sufficient amount of fat. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.64

At the end of the procedure, syringe E is filled with 10 cc of saline solution. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.65

The saline solution is transferred into the system in order to wash the tube. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.66

When the cannula is removed, compression is applied to the insertion site, and the area is cleaned. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.67

A 2 x 2 cm gauze square, without antibiotic gel, and a clear occlusive bandage (e.g., Tegaderm) are applied. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

Fig. 3.68

A 2 x 2 cm gauze square, without antibiotic gel, and a clear occlusive bandage (e.g., Tegaderm) are applied. (Published by kind permission of ©Mario Goisis 2018. All Rights Reserved)

4 Complications

With the widespread use of micro-cannulas, few complications are now reported. A patient may be intolerant to the addition of epinephrine, which may increase anxiety. Bleeding, bruising, and post-procedure pain in the area of harvesting are commonly reported. Microfat procedure harvests a relatively low volume of aspirate, and therefore skin dimpling is uncommon.

The clear occlusive bandage (e.g., Tegaderm or similar) is removed the day after the treatment. Ice is applied to the donor site for 20 min every hour for 6 h, in order to minimize bleeding and pain and to speed recovery. Close attention and the time of application of ice should be observed, because the skin is anesthetized. After 10–15 min of observation, vital signs should be obtained, and if the patient is stable, he or she is discharged. The area should be kept clean and dry for 24 h. No soaking in a hot tub, pool, or bath is permitted for 3 days. Written instructions assist in getting compliance because the patient can refer to them. The area may be painful for several days to a week, but the soreness should not be increasing. Increased donor site soreness, erythema, sweating, or fever should prompt the patient to return, so the harvesting area can be inspected for infection. Rehydration by drinking abundantly of water for 24 h after the procedure should be encouraged. Vigorous activity or heavy lifting should be avoided for 5–6 h. A treatment with antibiotic (azithromycin 500 mg for 3 days) and pain killers (acetilsalicilic acid) is usually prescribed.