Fat graft success starts with Liposuction

Patients routinely get fat grafts to the face, breast, and buttocks. However, some patients do not get the results they wanted because the fat graft did not ‘take.’  So, what happened? Why do fat grafts sometimes die (or fail to ‘take’)? In this post, I will explain one of the most important factors in creating a long-lasting fat graft.

When the recipient tissue is normal, there really should be no need for a touch-up, or revision. Plastic surgeons have all of the tools they need to create a good fat graft on the first try!

What is fat grafting?

Fat grafting, aka Fat transfer, is a process which removes fat from one area (the donor area) and transfers it into another area where enhancement is desired (the recipient area). The procedure involves these three steps:

  1. Removal of fat from the donor site using liposuction techniques
  2. Decanting/centrifugation of the extracted fat
  3. Re-injection of the processed fat into the area receiving enhancement

All three steps are important to fat graft longevity, and a deficiency in any one of the three steps can result in poor fat graft retention. I have previously discussed the best protocols for decanting and centrifugation (step 2), so today I would like to specifically address the best methods for removing fat from the donor area (step 1) in order to yield a fat graft that has high retention, with a long lasting result. In other words, this article focuses on the best Liposuction technique to extract the fat, which is then used to create the fat graft.

Fat extraction from donor site

In the fat removal process, a surgeon’s primary tool is the liposuction cannula. These are the long slender rods that the surgeon uses to extract the fat from the stomach, love handles, back, and other anatomical regions with fat deposits. The cannulas come in different sizes and they have different size holes near the tips. The holes are the areas through which the fat enters the cannula from inside your body.

Cannula size

In the plastic surgery community there is a lot of talk these days about whether you should use large (5mm) or slender (3mm) cannulas for liposuction. If you have read my blog posts in the past, you know I have a preference for using the thin, 3mm cannulas. There are other surgeons, however, that insist larger cannulas are better.

SMALLER fat particles make BETTER fat grafts!

With respect to their use in fat grafting: Is the size of the cannula a matter of opinion or is it something that can be verified by science?

A recent publication by a prominent plastic surgery researcher concludes that smaller fat particles make better fat grafts. This has huge implications for the type of cannula that should be used for liposuction as part of the fat grafting procedure!

Size of fat particles influences fat graft retention

In an article published by the Plastic and Reconstructive surgery journal with Dr. Kotaro Yoshimura as the lead author, the answer is unequivocally that small fragments of fat are better for fat graft survival (or fat graft ‘take’).

Dr. Yoshimura determined that small fat particles have a higher concentration of viable fat cells than large fat particles. Compared to small fat particles, large fat particles have a higher volume of necrotic or dead cells.

The takeaway message from the article is that you want the liposuction cannula to remove the highest concentration of small fat particles to get the best fat graft take.

An illustrating showing the reasons why small particles are better for fat grafting.

To visualize the areas described in Dr. Yoshimura’s paper, think of a fat particle as a small sphere, or small ball of fat. In the diagram above, the three regions of a fat particle are shown with different colors. The outermost portion of the fat particle is green, the innermost portion is black, and the region between the inner and outer shell is yellow.

Because of their position near the surface of the particle, the cells in the outermost green zone of the fat particle gets lots of nourishment inside the body. In other words, the cells that are on the outside rim of a fat particle are the cells that are the most viable and will survive in a fat graft.  Dr. Yoshimura found that cells in the yellow area will yield a mix of viable, repaired, and dead fat cells. The black zone is the innermost area of any fat particle, and it is referred to as the necrotic zone. Inside the body these fat cells do not get any nourishment and are dead from the start. The fat cells in this zone make poor contributions to fat grafts and should be avoided.

A closer examination of Dr. Yoshimura’s article details that the necrotic, or black zone, starts at a depth approximately .6mm from the outside perimeter of the fat particle. This would apply to any size of fat particle. Since the good viable fat cell zones are somewhat narrow and close to the edge, large fat particles would therefore have huge black zones of necrotic cells.

How to get small fat particles during Liposuction

A liposuction cannula is a long, hollow rod with holes located at the end. A lot of attention has been placed on the diameter of the rod (3mm vs 5mm), but I feel that for fat grafting longevity the size of the hole in the cannula is even more important than the diameter of the cannula.

Compared to a 5mm cannula, a 3mm cannula will give smoother, finer extraction results for the donor area (stomach, etc). However, it is the cannula hole size which will dictate the viability quality of fat cells which are used for the fat graft. The cannula hole is the first contact point with the fat particle inside the body. A small hole will only accept small particles.

An illustration showing how cannula hole size matters to the longevity of the fat graft.

Therefore, I  feel the best combination for extracting fat is a 3mm diameter cannula with 1mm holes at the tip. If you have a piece of fat that is about 1 millimeter in diameter, a large percentage of the fat cells will survive, there will be very little inflammation, and most of the fat graft will take. That is why I use a cannula that has the smallest hole possible, which is a 1mm hole. That way I am sure I harvest small, 1 millimeter diameter, pieces of fat.

If a surgeon uses a larger 5mm cannula with larger holes to extract the fat, the fat graft may be doomed from the start. With big holes, the fat graft particles will be larger than 1 millimeter in diameter and a large proportion of the cells in the graft will die.

Take the example of the thick, 5mm cannula with 3mm hole openings.
Remember, only the cells in the outer .6 millimeter rim stand a chance of survival. Large particles will have huge necrotic zones and make poor contributions to the fat graft. Likewise, these necrotic cells can cause inflammation, loss of fat graft, and in some cases scarring, cysts, or other complications.

An illustration showing why thin cannulas with 1mm holes are best for fat grafting.

This is not a matter of surgeon preference or opinion. This is science. Ask your surgeon what type of cannula he uses to harvest fat for your fat graft. If he is using larger cannulas to remove the fat, he is not giving you your best shot for a successful fat graft.

By Dr. Ricardo L. Rodriguez MD Board Certified Plastic Surgeon Cosmeticsurg Baltimore, Maryland Ricardo L. Rodriguez on American Society of Plastic Surgeons.

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16 thoughts on “Fat graft success starts with Liposuction”

  • Rachael says:

    Yes, this is one very good article i think there many benefits but and many risks that we can accept with fat grafting or also called fat transfer. We should not ignore it may require 4 to 6 individual sessions to get the best potential results. The injected fat may be reabsorbed by the body and you may lose some or all of the breast volume over time. Because some fat cells can stimulate cell growth, some doctors are concerned that fat injected into the breast area may cause dormant breast cancer cells to grow; research needs to be done to find out if this is true. And many other thinks.. For this i consult with my best friend and your college XXXXXXXXXXX - maybe one of the best in this area
    • Dr. Ricardo L Rodriguez says:

      Rachael I don't know who you are but you are misinformed. Anybody who takes 4-6 sessions to get "best potential results" is clearly doing something wrong. The overwhelming majority of my grafts are done only once. When you use the correct techniques for harvesting and purifying fat grafts it is VERY reliable. Finally, a fat graft that properly "takes" or is properly engrafted will not be reabsorbed. On the contrary, as time goes on, the grafts may enlarge if you gain weight.
  • Maria Rosa says:

    I am interested in BBL I'm 5" tall, 105 lbs. although I'm slim, I have a prominent belly. I want a big butt. How much does the procedure cost? Sincerely , María
    • Dr. Ricardo L Rodriguez says:

      Maria: Kelly at kelly@cosmeticsurg.net will get in contact with you regarding costs. If you have had babies or have a lot of stretch marks you may also need a Tummy Tuck with the BBL, and those are questions you may want to discuss before deciding on a final choice of procedure. Thank you for your interest, María. De donde eres?
  • s says:

    Sorry a slight correction to the question I asked on sept 8, 2016. Point number 3 : So I split it into about 2 OR 3 OR 4 sessions with 175 cc (if 2 sessions), approx 115 cc (if 3 sessions), approx 87.5 cc (if 4 sessions) in EACH breast during EACH session with gentle lipo done during each session. Is this possible and how many days apart should each session of fat transfer be?
  • s says:

    Hello! 1. Say I want 700 cc of fat transferred to each breast. So total 1400 cc. Is it possible? 2. But if that is a bit too much to put in a single go? 3. So I split it into about 2 OR 3 OR 4 sessions with 350 cc (if 2 sessions), approx 230 (if 3 sessions), approx 175 cc (if 4 sessions) in each breast during each session with gentle lipo done during each session. 4. Is this possible and how many days apart should each session of fat transfer be?
    • Dr. Ricardo L Rodriguez says:

      S This is an addendum to the other question I answered for you. There are techniques to "game" the content of stem cells per volume of fat, such as centrifuging the fat and using only the bottom part of the fat centrifuged portion. That part is denser because it contains a higher proportion of stem cells. As far as sessions, split sessions are better and wait a good couple of months between sessions.
    • Dr. Ricardo L Rodriguez says:

      See my answer to your other post. But not necessarily. Gaining weight will affect areas where the cells are programed to accept increased volume. This depends on the individual. Secondly, "fat pocket" tissues are slightly different than the superficial structural fat layer. The best option for you is fat grafting to those areas where the fat was lost and to regenerate new tissue. You should look into our blog post section on stem cells from adipose tissue.
  • Beem says:

    I lost fat from my face because I did ultherapy. I did not know it causes fat loss until after I did it. Can fat graft restore the same NATURAL look of my face? My concern about the fillers is that they are injected in certain areas but the face shape may change. Another question : what is more durable natural fat or fillers? Also can natural fat graft be done on patient who had previous juvederm fillers in their faces?
    • Dr. Ricardo L Rodriguez says:

      Beem: Any energy source directed at skin (Coolsculpting, ultra therapy, radio-frequency, etc) damages some cells. These cells release "DAMPS" (Damage associated molecular pattern molecules) which can act as signals for other cells to die (a process called "apoptosis" or programmed cell death). I wrote a post about this a few years ago related to Laser but it applies to all of these "noninvasive" energy therapies. As a result of this you did lose some fat under your skin. The proper way to restore your tissue is to do fat grafting because it not only gives you back the volume that was lost but also the stem cells in the fat will regenerate other cell types (Sebaceous glands, elastic collagen, etc). Fat grafting, when properly done is permanent. I will let Kelly at kelly@cosmeticsurg.net know about your case, I think there are many women in your position and they could be helped by fat grafting.
  • Valerie shell says:

    Im a 52year old women from Brooklyn with lots of extra skin on my abdomin area and extra back fat with no wist line and a flat butt which i would like very much to change all of that so i can have more confidence and hopefully start a new life
    • Dr. Ricardo L Rodriguez says:

      Valerie: I will put you in contact with Kelly at kelly@cosmeticsurg.net We can definitely help you reach your goals and we have helped MANY patients in your situation. 52 is still young and you have a lot of life ahead of you. Take charge and get it done! You CAN do this, I have seen many others do it and there is no reason you cannot do it. We have done many cases of Tummy tuck combined with Brazilian Butt lift and it seems that would suit you well. Looking forward to hearing from you!
  • Milover says:

    Great blog. I really appreciate the finding and exploration you've done. I have been scheduled for the liposuction surgery for the next week in Dr. Hugh McLean’s cosmetic surgery clinic in Mississauga. I wasn't completely aware how this procedure is actually going to be. Your blog has given me an apparent picture of the procedure. Thanks for sharing.