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SHIFTING VOLUME After Physicians are ���nding multiple indications for fat transfer, including hand and foot rejuvenation. to separate the liquid fractions���blood, free lipids and injectate���from the cellular component,��� says Dr. Eppley. These include straining and washing, free-standing decanting, machine centrifugation, hand-held separation using centripetal force and low-pressure forced straining using low-micron ���lters. ���Much debate surrounds which, if any, of these offers a superior number of viable fat cells for transfer,��� he says. ���I feel strongly about using a centrifuge to prepare the fat,��� says Dr. Coleman. ���Make sure you centrifuge at 1,200 Gs, because studies show that this is the optimal gravitational force to concentrate the growth factors and fat cells and minimize the rest.��� Injecting Fat The survival rate of transferred fat varies widely and the ���results of fat grafting are technique-dependent,��� says Dr. Khoobehi. Fat grafts are injected using small-bore blunt cannulae���ranging in size from 16 gauge to 26 gauge��� connected to a 1cc to 3cc luer-lok syringe for the face or a 10cc to 60cc luer-lok syringe for the body. ���Placing the fat grafts in small aliquots, say 0.1cc for the face and .5cc to 2ccs for the body, is well shown to allow for the best survival rates,��� says Dr. Eppley. Fat graft retention is related to how quickly the fat cells can be nourished by blood vessel ingrowth and the delivery of oxygen. ���Big globs of fat are hard to get perfused, while small droplets interspersed about the tissues allow the best opportunity for nutrient perfusion,��� says Dr. Eppley. Dr. Coleman agrees. ���It���s the one part of my technique that people rarely deviate from,��� he says. ���I use a blunt cannula, not a sharp one, and place the fat in little tiny amounts with each pass. I���m not squirting in a glob and trying to mold it; rather, I���m creating a three-dimensional structure. Recent innovations involve using smaller cannulae around the eyes and lips���the face in general, in fact���because it results in smoother layers of fat.��� The aliquot technique offers several bene���ts to the patient. ���For one thing, it means that each bit of the fat you���re placing is next to a blood supply,��� says Dr. 52 MARCH/APRIL 2013 | MedEsthetics Coleman. ���Second, if you���re squirting in large amounts of fat and accidentally get into an artery or vein, you could kill someone or cause stroke or blindness or loss of an extremity. That���s the biggest danger people need to understand, and most physicians and consumers don���t know that.��� Indeed, he adds, most cases of negative outcomes ���do not get written about in the literature. The point is: it���s not a totally innocuous procedure,��� he stresses. ���You can really do some damage if you don���t know what you���re doing.��� Dr. Khouri uses a farming analogy to explain the process. ���To have the greatest success, the good surgeon, just like the good farmer, has to abide by the four Ss. The soil is the recipient site, and it must be well-fertilized and of adequate size to accept all the seeds needed for the desired crop. Those seeds are represented by the fat graft, which must be gently harvested and carefully handled to preserve its sprouting ability. ���The sowing is the process of grafting, which must be done methodically and with craftsmanship, one seed at a time. We call the procedure micrografting,��� he says. ���While the patient is still under anesthesia, we inject the suctioned fat into the breasts one tiny droplet at a time, diffusely and evenly over the prepared breast site. We A New Appreciation for Fat Fat has long been reviled as the unsightly side effect of weight gain, but it is a critical component of many of the body���s key functions. ���What was once thought to be a useless and unwanted tissue has ironically turned out to be a depot of regenerative material,��� says Indianapolis-based plastic surgeon Barry Eppley, MD. ���Plastic surgery has just scratched the surface of what fat has to offer, and a whole new generation of research and clinical experience will take us much further than what we know today.��� Indeed, notes Syd Coleman MD, a pioneer in the arena of fat grafting, ���the portion of the fat that contains the stromal vascular fraction blood cells and stem cells is really the source of a great deal of interest worldwide. The stem cells in fat are more numerous than in bone marrow or any other place in the body, so fat can function as a repair organ in the body. You���re actually moving the part of your body that repairs damage, and it can do amazing things in the areas where you place it.��� Interestingly, he adds, ���the hormones in the area from which you move the fat control the fat you transferred. So it does act as if it���s following clues from the abdomen even though it���s in the face.��� PHOTOS COURTESY OF BARRY EPPLEY, MD Before