Loss of tissue volume is one of the components of the aging process. Many even consider that changes in the skeleton and in muscle, fat, and skin tissues are more integral to the aging process than the effect of gravity [1].
Loss of skin firmness or tissue volume can also occur after rapid weight loss. Autologous fat grafting offers a very simple solution for restoring a deformed contour, e.g., of the breasts or the labia majora. This graft was first introduced by Neuber’q in 1893 as a method for filling depressed scars. [2] The currently used technique, combining liposuction with grafting of the harvested autologous fat to the breasts, was described by Bircoll in 1987. [3]
When transferring adipose tissue to any area, e.g., to the labia majora, the survival of adipocytes is of paramount importance. Fat cells are implanted into a loose and poorly vascularized space. Therefore, for better survival, the fat requires close contact with the host tissue. This is ensured by adequate nourishment and immobilization of the cells for the first few days, until the adipocytes become integrated (engrafted). [4] Thus, the key factor is the surface with which the graft is in contact. This facilitates revascularization, which occurs as early as 48 hours after transplantation [5-7]. This explains the high rate of resorption of transplanted fat reported in the literature. [2] It should be remembered that fat is a source of adipose-derived stem cells (ADSCs), which have a differentiation potential similar to that found in other mesenchymal cells, and also a higher yield upon isolation and a higher proliferation rate in culture than stem cells derived from bone marrow. [8-10]
This potential and the ease of obtaining large quantities of material, with minimal risk of complications for the donor, make TKM particularly promising in regenerative therapy. [8,11] The regenerative features of TKM include their paracrine action: these cells secrete endothelial growth factor, hepatocyte growth factor, and transforming growth factor-β under the influence of various stimuli, e.g., hypoxia, and they strongly affect the differentiation of other stem cells, support angiogenesis and wound healing, and potentially promote the growth and development of new tissues. [11-14] Therefore, autologous fat grafting is a highly beneficial procedure for health and is widely used in aesthetic gynecology.
There are many techniques that allow for the harvesting and transplantation of adipose tissue, as well as many sites from which this tissue can be obtained. The most commonly chosen site is the abdomen, which has the largest and most accessible surface area. In aesthetic gynecology, the mons pubis region can also be used by combining liposuction of this area with subsequent filling of the labia majora.
The most commonly used fat harvesting technique
(the so-called harvesting) is the “wet” method. It consists of injecting Klein’s solution, composed of normal saline, adrenaline, and a local anesthetic, e.g., lidocaine. [15]
Another technique is the “dry” method; however, it requires greater use of analgesics. [16]
Every procedure should be performed with minimal burden on the patient and with maximal protection of the harvested fat cells. However, the procedure can also be performed under general anesthesia or short intravenous sedation, depending on the extent of the procedure and the patient’s preference. The fat-harvesting technique described by Coleman et al. minimizes adipocyte trauma. [17] It should be noted that the use of lidocaine in Klein’s solution may contribute to adipocyte death; therefore, after harvest the fat should be centrifuged quickly, i.e., within 30 min, or anesthesia should be administered only superficially (subcutaneously) while harvesting the graft deeper, or the procedure should be performed under intravenous general anesthesia. After aspirating an appropriate amount of fat (for planned augmentation of the labia majora, 50-100 ml may be sufficient), the syringe is placed in the centrifuge. Centrifugation should last 3 minutes at 3000 rpm. After separating the purified fat, it is injected using a 2 mm cannula into, for example, the labia majora. The graft is placed in multiple compartments and planes, and at various depths, with a small volume of fat injected in each. This is consistent with the principle described by Coleman.[18] The amount of fat injected depends on the size of the labia and the degree of deficiency, and ranges from 10-40 ml for each labium. When performing the transfer, remember that some of the fat will resorb; therefore, the graft volume should be approximately twice that required to achieve the planned final effect. A final, very important step is to massage the labia in a way that prevents the formation of fat nodules. Such massage is recommended for the next 2 days.
In post-procedural care, in addition to the aforementioned massage, routine hygiene of the cannula insertion sites is recommended. A very important component of post-liposuction management is compression of the area from which the fat was harvested. A compression dressing (for the abdomen, this may be an appropriate corset) should be worn continuously for one month, and then for another month with breaks for nighttime rest. This is intended to protect against the formation of skin irregularities over the donor site.
References
- Buckingham ED. Fat transfer techniques: general concepts, Facial Plast Surg. 2005 Feb;(1):22-8
- Simonacci F, Grieco MP, Bertozzi N, Raposio E. Autologous fat transplantation for secondary breast reconstructtion: our experience, G.Chir. 2017 May-Jun; 38(3): 117-123
- Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg. 1987;79:267–271
- Claro F, Jr, Figueiredo JC, Zampar AG, Pinto-Neto AM. Applicability and safety of autologous fat for reconstruction of the breast. Br J Surg. 2012;99:768–780
- Chan C.W., McCulley S.J., Macmillan R.D. Autologous fat transfer–a review of the literature with a focus on breast cancer surgery. J. Plast. Reconstr. Aesthet. Surg. 2008;61:1438–1448.
- Fagrell D., Eneström S., Berggren A., Kniola B. Fat cylinder transplantation: an experimental comparative study of three different kinds of fat transplants. Plast. Reconstr. Surg. 1996;98:90–96.
- Moscona R., Shoshani O., Lichtig H., Karnieli E. Viability of adipose tissue injected and treated by different methods: an experimental study in the rat. Ann. Plast. Surg. 1994;33:500–506.
- Raposio E., Bertozzi N., Bonomini S., Bernuzzi G., Formentini A., Grignaffini E. Adipose-derived stem cells added to platelet-rich plasma for chronic skin ulcer therapy. Wounds. 2016;28:126–131.
- Higuci A., Chuang C.W., Ling Q.D. Differentiation ability of adipose-derived stem cells separated from adipose tissue by a membrane filtration method. J. Memb. Sci. 2011;366:286–294.
- 10.Salibian A.A., Widgerow A.D., Abrouk M., Evans G.R. Stem cells in plastic surgery: a review of current clinical and translational applications. Arch. Plast. Surg. 2013;40:666–675.
- 11.Caruana G., Bertozzi N., Boschi E., Pio Grieco M., Grignaffini E., Raposio E. Role of adipose-derived stem cells in chronic cutaneous wound healing. Ann. Ital. Chir. 2015;86:1–4
- 12.Tang W., Zeve D., Suh J.M. White fat progenitor cells reside in the adipose vasculature. Science. 2008;322:583–586. [PubMed]
- 13.Kapur S.K., Katz A.J. Review of the adipose derived stem cell secretome. Biochimie. 2013;95:2222–2228.
- 14.Salgado A.J., Reis R.L., Sousa N.J., Gimble J.M. Adipose tissue derived stem cells secretome: soluble factors and their roles in regenerative medicine. Curr. Stem Cell Res. Ther. 2010;5:103–110
- 15.Bieniek A, et al. Use of tumescent anesthesia – a new method of infiltration anesthesia. Anest. Int. Ter. 2006;3;172-177
- 16.Simonacci F, Bertozzi N, Grieco MP, Grignaffini E, Raposio E. Autologous fat transplantation for breast reconstruction: A literature review. Ann Med Surg (Lond) 2016;12:94–100
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