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SHIFTING VOLUME ���The fact that fat is natural and that most everyone would love to give some up does not make injectable fat grafting a completely reliable treatment method,��� warns Barry Eppley MD, an Indianapolis-based plastic surgeon. ���It is important to understand that the biologic behavior of fat cells and the stem cells that accompany them is not well understood. The techniques we use are based on what we know today���and that will likely change signi���cantly a decade from now.��� ���The biologic behavior of fat cells and the stem cells that accompany them is not well understood.��� Syd Coleman MD, plastic surgeon, founder of Tribeca Plastic Surgery in New York City and creator of the Coleman technique for fat transfer, notes that, ���the thing to remember always is that fat is living, fragile tissue that was not meant to be taken outside the body, moved around and put back in. It can be easily killed.��� Fat that is being removed for transfer must be handled differently than fat that is being removed and discarded. ���Most doctors believe that low-pressure vacuum extraction preserves fat cell structures and improves their viability after transfer,��� says Dr. Eppley. ���Whether this is done through syringe extraction or a traditional liposuction machine that generates less than 720mm/Hg (-1 atm) negative pressure depends on how much fat is needed.��� Kamran Khoobehi, MD, FACS, clinical professor of surgery and director of aesthetic surgery training at Louisiana State University, in New Orleans, notes that the syringe technique���where the physician removes the fat by hand using the pressure of the syringe���is the most common harvesting technique. ���The surgeon uses a 10cc to 30cc syringe and creates negative pressure by pulling on the plunger,��� he explains. ���The problem with this technique is the ���uctuation of the negative pressure based on the degree of the pull. It is also time-consuming.��� Dr. Khoobehi harvests fat with the help of a liposuction machine used on a low setting. ���We have done laboratory studies to ���nd the safest pressure,��� he says, ���and it is 10 inches/Hg or 230 mm/Hg. There is no need for expensive collection equipment, and most plastic surgeons already have access to a liposuction machine, cannulae and collection devices.��� Roger Khouri, MD, FASC, a surgeon who specializes in breast reconstruction at the Miami Breast Center in 50 MARCH/APRIL 2013 | MedEsthetics Miami, also uses a liposuction device to harvest fat. ���The most common fat donor areas are the abdomen, thighs and waist,��� he says. ���From our experience, we���ve found no patient too thin for fat transfer.��� Using his method, the patient���s fat is extracted by using a crisscross technique during liposuction. ���We remove the fat in layers carefully so as not to remove too much fat from one area,��� he says. ���By doing this, we avoid the common liposuction complaints like uneven liposuction, sagging skin and excessive removal of fat, leaving visible divots and dents.��� It is a ���two-for-one��� procedure, Dr. Khouri adds. ���There are six to eight entry points per liposuction area, and by crisscrossing the path of the cannula through those multiple puncture sites, we are able to achieve the most even fat extraction,��� he says. The size of the nick or puncture created by the entry point of the cannula is about the size of an intravenous catheter puncture site. The entry points do not require stitches and eventually heal without visible scarring in most people. Dr. Khouri and his colleagues use one of the smallest cannulae in the industry to perform the liposuction. ���We developed the instrument ourselves,��� he says. ���It���s called the Khouri Cannula. We also developed a syringe called the K-VAC. And to make sure the procedure is smooth and practical, we developed our own instrument Before After Fat transfer to the face offers longer-lasting results than ���llers and is becoming a popular adjunct to facelifts. set called the Lipografter (Lipocosm, lipocosm.com). The harvested fat ���lls up the syringe and is then routed through the valve to the clear plastic collection bag.��� The Coleman technique involves harvesting the fat by hand using a syringe ���with very low negative pressure,��� says Dr. Coleman. ���The syringe is connected to a cannula. It���s sort of a combination of curetting and negative pressure that moves the fat into the cannula and then into the syringe.��� Preparing Fat For Transfer There are several techniques currently employed to prepare harvested fat for re-injection, ���all of which strive PHOTOS COURTESY OF BARRY EPPLEY, MD Harvesting Fat