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General Surgery
SURGICAL TECHNOLOGY INTERNATIONAL XXV

Sonographic Evaluation of Autologous

Fat Transfer to The Biceps and Triceps
DAVID MATLOCK, MD, MBA, FACOG
CEO
VASER HI DEF LIPOSCULPTURING INSTITUTE OF BEVERLY HILLS
LOS ANGELES, CALIFORNIA

ALEXANDER SIMOPOULOS, MD, FACOG

MEDICAL DIRECTOR
VASER HI DEF LIPOSCULPTURING INSTITUTE OF BEVERLY HILLS
LOS ANGELES, CALIFORNIA

ABSTRACT
utologous fat transfer (AFT) for increased tissue bulk has been reported on since the 1990s, and has

A increased by 26.6% from 2009 to 2010. Despite this increase, there is relatively little published data.

While the described method of AFT to muscle tissue has advantages of being matched to the patient and

retaining all the properties of tissue, challenges arise due to the size of muscles, the ability to measure imme-

diate and long term placement and retention, and frequency of aberrant anatomy in order to avoid vascula-

ture and potential complications; reportedly 10% to 27%. We present the results of a study using ultrasound
visualization to assist in AFT to the biceps and triceps.

Ten male subjects were treated with AFT to the biceps and triceps under intraoperative ultrasonic

visualization. Pre- and post-operative circumferential measurements were collected as well as follow-up at

weeks six and 12.

A mean of 90 cc and 110 cc were injected subfascially into the biceps and triceps, respectively, of 10 study

subjects. Post-operative circumferential measurements increased by a mean of 3.0 cm and follow-up

measurements were found to have increased by a mean of 3.3 cm over baseline. No compartment syndrome,

fat emboli or significant pain were experienced by any subject in this study.

Autologous fat transfer to smaller muscle areas such as the bicep and tricep is both feasible and safe with

consistent and durable results. The addition of pre-operative ultrasound imaging provides a means to safely

avoid critical structures such as vasculature; and intra-operative ultrasound allows the surgeon to directly

visualize the relevant anatomy as each injection is performed confirming intramuscular placement.

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Sonographic Evaluation of Autologous Fat Transfer to The Biceps and Triceps
MATLOCK/SIMOPOULOS
INTRODUCTION
Body contouring has been a widely
accepted procedure since the 1980s 1
with the advent of artificial implants
combined with liposuction to achieve an
aesthetic result. Artificial implants how-
ever, do not completely replicate the
feel of living tissue and can suffer from
significant scar tissue encapsulation with
associated hardness and poor cosmetic
results.
Autologous fat transfer is the reinjec-
tion/reinsertion of a subject’s own fat
after it has been removed from another
body area. This treatment may be for
therapeutic or cosmetic benefit and has
been documented as early as the 1890s2
when upper arm fat was used to repair
the cheek of a subject. In the 1980s,
Bircoll 3 introduced the use of small
injections of fat using liposuction tech-
niques.
Autologous fat transfer to increase
bulk has been more widely reported
since the 1990s4-8 and offers the advan-
tages of being immunologically matched
to the patient. Autologous fat transfer
has been used in facial, lip, hand, breast,
buttock, and limb procedures by physi-
cians around the world. 9-11 In these
series, autologous fat has been trans-
ferred from one body area and injected
in target areas surrounding muscle to
provide a contouring effect. Mojallal12
reported a series of 20 subjects injected
with autologous fat to resolve limb atro-
phies. In these subjects, an average cir-
cumferential augmentation of 1.9 cm
per injection was achieved with high
subject satisfaction over two years of
follow-up. This cohort demonstrated
that autologous fat transfer could be
a b
Figure 1. The TouchView™ ultrasonic imaging probe.
#556-Matlock Galley - 01
performed safely in the extremities with
sustainable results, although a Medline
search did not yield literature on subfas-
cial intramuscular injection of autolo-
gous fat into the biceps and triceps.
One potential pitfall of this tech-
nique is the possibility of the injection
cannula intersecting with and/or punc-
turing blood vessels or nerves. Carde-
nas-Camarena 4 reported one case of
suspected fat embolism in their series of
62 patients (1.6%). To avoid this poten-
tially fatal complication, surgeons his-
torically relied solely on experience and
feel to avoid these critical nerves and
blood vessels. As autologous fat transfer
becomes more commonplace, an
increasing number of less experienced
surgeons will attempt the technique.
In this study, we evaluated the use of
non-invasive, high frequency, ultrasonic
imaging as a tool in the fat transfer pro-
cedure to assist the physician in both
avoiding critical structures and provid-
ing high specificity for placement of
injected fat into the muscle. Additional-
ly, imaging was used pre-operatively to
assess any aberrant anatomy and for
pre-measurement of the bicep and tri-
cep; as well as post-operatively both
short term and long to visualize the
retained volume and placement of the
re-injected fat.
Materials andAND
Methods
MATERIALS METHODS
Subject population
Observational data were collected
from subjects requesting muscle defin-
ing liposuction in conjunction with
autologous fat transfer to the biceps and
triceps at one center in the United
-2-
States. The study was registered on clin-
icaltrials.gov under study number
NCT01313000 and approved by Liberty
IRB (Deland, FL).
All male subjects presenting to the
investigator for treatment using ultra-
sound-assisted liposuction (VASER)
were considered potential study candi-
dates and were screened for interest and
eligibility. Subjects who did not meet all
inclusion/exclusion criteria were not
enrolled.
For inclusion in the study, subjects
must have fulfilled all of the following
criteria:

Male

Between 20 and 50 years of age,
inclusive, on the day of enroll-
ment

Scheduled for abdominal lipo-
suction

Desired autologous fat transfer
to the upper arms
The following were regarded as exclu-
sion criteria:

Current enrollment in another
device or drug study that had
not completed the required fol-
low-up period, or has completed
all other study-required follow-
up less than 30 days before
enrolment in this study

Undergoing body contouring for
reconstruction following injury
or disease

Deemed an inappropriate candi-
date for the surgical procedures
for any reason

Unwilling to undergo the study
procedures or participate fully in
all follow-up
 #556-Matlock Galley - 01

General Surgery
SURGICAL TECHNOLOGY INTERNATIONAL XXV

VASER® Ultrasonic Liposuction

System LIPOSUCTION SYSTEM
VASER® ULTRASONIC

The VASER ® Ultrasonic Assisted

Liposuction System (Sound Surgical
Technologies, LLC, Louisville, Col-
orado) consists of a low frequency
ultrasound generation system (36 kHz)
and a probe that delivers the ultrasonic
energy to surrounding tissue. The
VASER® is used as an adjunct to stan-
dard suction-assisted liposuction. The
ultrasonic energy delivered separates fat
cells from each other and surrounding
tissue, making aspiration of the targeted
fat deposits easier for the physician and
less traumatic for the patient. The
VASER® System is cleared for physician
Figure 2. Ultrasonic image showing large intra-muscular vessels. use by the FDA under K991791.

TouchView™ Ultrasonic Imaging

System IMAGING SYSTEM
™
TOUCHVIEW ULTRASONIC

The TouchView™ Ultrasonic Imaging

System (Sound Surgical Technologies,
LLC, Louisville, Colorado) comprises
an ultrasound imaging platform
(T2000+ system manufactured by Tera-
son Corporation) with a unique linear
probe (TouchView™ Probe, manufac-
tured by Blatek, Inc., State College, PA)
specifically designed for the use of aes-
thetic physicians. The system operates
in the 5 to 12 MHz range with a nomi-
nal frequency of 8 MHz. The design of
the finger probe allows the physician to
easily visualize subcutaneous structures
while maintaining tactile contact with
the patients’ tissue. The finger probe is
Figure 3. Ultrasonic image showing injection cannula.

non-sterile and may be used in a sterile

sleeve during aseptic procedures. The
Terason T2000+ Ultrasonic Imaging
System is cleared for physician use by
the FDA under K080234.

Subject preparation and

treatment
This was a non-randomized open-
label study in 10 human participants.
Each participant was consented by the
Principal Investigator, Co-Investigator
or Study Coordinator. Potential candi-
dates were screened by the study center
for inclusion in the study. If a subject
was suitable for inclusion he was
informed of the study, all the study
requirements, and the risks/benefits of
participation. He was also presented
Figure 4. Ultrasonic image showing injection of transferred fat. with an informed consent document to

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Sonographic Evaluation of Autologous Fat Transfer to The Biceps and Triceps
MATLOCK/SIMOPOULOS
Figure 5. Upper arm change pre- and post-operatively.
review. If the subject consented to par-
ticipate by signing the informed consent
document, he was assigned a subject
identifier and underwent an initial eval-
uation, including photographs and mea-
surements of the area to be treated,
height, weight, and a subject history.
The subject was then treated under
the direction of the Principal Investiga-
tor using the VASER ® Ultrasound
Assisted Liposuction System in the tar-
get area (areas included in this study
were abdomen, obliques/flanks, infra-
axilla, biceps, and triceps) until the
desired aesthetic affect was achieved.
The fat removed from the subject
remained in a sterile, isolated container
for later injection into the subject. Once
the liposuction procedure was complete,
the upper arms of the subject were pre-
pared for cosmetic fat injection.
The adipose tissue removed during
the liposuction procedure was washed
with a gentamycin and cefazolin solu-
tion before injection into the subject. In
addition, before intra-muscular injec-
tion of the processed fat, the subject
was administered 600 mg of clin-
damycin intravenously.
Injection was accomplished using
custom 16G 7 cm, 15 cm and 30 cm
cannulae. These cannulae facilitate a sin-
gle injection site and are long enough to
reach the extremity of the muscle.
The Investigator then injected the
treated fat under sterile technique into
the muscles of the upper arms of the
subject, specifically the biceps brachii
and triceps brachii. Both arms were
treated to achieve the cosmetic effect.
The TouchView™ Ultrasonic Imaging
System was used to verify sub-facial
blunt needle placement into the muscle
and visualize the injection process.
Imaging was also used to identify vascu-
#556-Matlock Galley - 01
Figure 6. Upper arm circumferential change over follow-up.
lature to be avoided during the injection
process. The pre-operative measure-
ments, photography, and imaging were
repeated as soon as the subject was suit-
ably recovered from the surgical proce-
dure.
Follow-up
At approximately six and 12 weeks
after surgery, the pre-surgery measure-
ment, photographs and imaging were
repeated.
Statistical measures
Circumferential measurements from
the upper arms were analyzed separate-
ly and combined where paired data
were available. Subject satisfaction sur-
veys were also administered at follow-
up. All tests applied were two-tailed,
with ? set at 0.05. Paired t-tests were
performed for normally distributed
data and the Wilcoxon Signed-Rack test
was used for data that was not normally
distributed.
Results
RESULTS
Ten subjects were treated at one cen-
ter in the United States beginning in
March 2011 and ending in December
2011. All subjects were male with an
average age of 34.6 ±5.3 years [22.8 to
38.7]. The volume of fat transferred
into each tricep was 109.8 ± 40.7 cc
[18 to 160 cc] and into each bicep was
90.0 ± 30.8 cc [40 to 160 cc].
Pre-operatively, using Doppler func-
tions, large blood vessels in the target
muscle were readily identified (Fig. 2)
using the TouchView™ System, allowing
for safe, accurate injection and avoid-
ance of critical structures.
-4-
During each transfer, the injection
cannula and injected fat were visualized
using the TouchView™ System (Fig. 3
and Fig. 4 respectively). The amount of
fat injected was determined by the
amount of available harvested fat and
aesthetic effect as determined by the
surgeon. Subjects underwent average
injections of 90.0 +/- 30.8 cc (range
40–160 cc) to each bicep and 109.8
+/- 40.7 (range 18–160 cc) to each tri-
cep, yielding a total injection to each
upper arm of 199.8 +/- 66.0 (range
(58–320 cc).
Each subject was measured for upper
arm circumference at the level of the
peak of the bicep when relaxed. Pre-
operatively, subject measurements were
34.8 ± 3.1 cm. Subjects were again
measured immediately post-operatively
to reduce any artifact due to post-oper-
ative swelling. Post-operative measure-
ments averaged 37.5 ± 2.4 cm; a mean
increase of 2.6 ± 1.2 cm, which was
found to be statistically significant (p <
0.001 for a two-tailed test). There was
no correlation between the amount of
fat injected and the increase in circum-
ferential measurement either as
absolute measurement or as a percent-
age change. The post-operative circum-
ference did correlate with pre-operative
measurement, with an R 2 of 0.91
(Fig. 5).
Through the 12-week follow-up, cir-
cumferential changes seen immediately
post-operatively remained (Fig. 6) with
p < 0.001 at both six-week and 12-
week follow-up using a two-tailed,
paired t-test.
Aesthetically, each subject showed
improvement in appearance that was
sustained over follow-up (Fig. 7, Fig. 8,
and Fig. 9).
To determine if the increase in arm
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General Surgery
SURGICAL TECHNOLOGY INTERNATIONAL XXV

circumference was the result of the

autologous fat transfer or an increase in
activity by subjects, each arm was res-
canned for evidence of graft survival.
Figure 10 and Figure 11 show similarly
positioned ultrasound scans taken at six-
and 12-weeks post-operatively. As can
be seen from these images, the trans-
ferred fat has similar textural qualities
to the operative images (Fig. 4) and has
similar shape over time. There is a small
amount of remodeling, however the
areas of injected fat are readily identi-
fied three months after injection.

Subject satisfaction
Subjects were asked to rate their sat-
isfaction with their arms and overall
appearance pre-operatively and at fol-
low-up on a -5 to +5 integer scale. Sub-
Figure 7. Subject 007 pre- and post-operative photographs.

jects reacted positively to the procedure

and the immediacy of results, evidenced
by the significant increases over baseline
within six-weeks (p = 0.016 arms, p =
0.014 overall). Figure 12 and Figure 13
show the mean subject responses pre-
operatively and at follow-up.

Safety
There have been no adverse events
reported in this subject population.
There has been no compartment syn-
drome, embolism, edema or other
severe conditions.
Figure 8. Subject 009 pre- and post-operative photographs.

DiscussionDISCUSSION

The ASPS Fat Graft Task Force con-

cluded13 that there was a tremendous
need for high-quality clinical studies of
autologous fat grafting. Key to these
studies will be the adequate visualiza-
tion and quantification of fat grafts both
intra- and post-operatively. The general
procedure for autologous injection of
harvested fat into other body areas is
well established for large muscle
groups, but there has been a paucity of
consistent, scientifically based research
in the area. This study is one of the first
to evaluate healthy subjects with objec-
tive criteria; no underlying pathology in
Figure 9. Subject 010 pre- and post-operative photographs.

our series. The results of the study were
found to be durable up to 12 weeks fol-
lowing the initial fat injections. In addi-
tion to the lasting results, the procedure
is well tolerated with a high degree of
post-operative satisfaction. In contrast
to artificial implants in these areas,
autologous fat carries little risk of ero-
sion and virtually no risk of rejection, as
only soft tissues, completely compatible
with the patient are used. Another sig-
nificant contrast to artificial grafts is
that the treatment can be repeated sim-
ply, without the need to remove scar
tissue or prior implants. Up to 160 cc
was injected unilaterally in this study,
showing that a wide range of volumes
can be used to achieve the desired aes-
thetic effect without the risk of com-
partment syndrome.
The sub-fascial and intramuscular
nature of the injection process may be a
key factor in the consistent retention of
the graft over the course of follow-up

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 #556-Matlock Galley - 01

Sonographic Evaluation of Autologous Fat Transfer to The Biceps and Triceps

MATLOCK/SIMOPOULOS

Figure 10. Subject 008 six- and 12-week ultrasonic images. Figure 11. Subject 010 six- and 12-week ultrasonic images.

and the consistency in ultrasound
images over time. The fascia and muscle
tissue serve to contain the injected fat,
both maintaining its implanted configu-
ration and protecting it from external
manipulation. In the case of subcuta-
neous injection, the fat can be easily
moved in the subcutaneous tissue lay-
ers, increasing the likelihood of resorp-
tion and/or thinning of the injected
area, reducing the apparent volume
increase.
The subfascial injection process may
also assist in increasing fascial pliability
and thereby allowing for greater cir-
cumferential increase by hypertrophic
gain. In addition, adipose tissue is
increasingly being used as a source of
adult stem cells. Longer term studies
will be needed to determine the
amount of injected volume that remains
as fat and the amount that converts to
muscular tissue.
Inexperience is only one risk factor
for percutaneous procedures. Aberrant
anatomy may result in even experienced
surgeons unknowingly disrupting both
blood vessels and nerves. Cadaveric
studies have shown rates of aberrant
vessels ranging up to 27% in the

Figure 12. Subject satisfaction with arm appearance over time. Figure 13. Subject satisfaction with overall appearance over time.

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extremities, and there is at least one
case report of arterial damage due to
aberrant anatomy.14-16 In this case, the
superior gluteal artery was injured dur-
ing the percutaneous placement of
iliosacral screws. The injury was only
identified after excessive bleeding from
the puncture site was observed. The
authors advise that the possibility of
anatomical variance should be consid-
ered and sought after with preoperative
visualization. In cosmetic procedures,
the surgeon must also determine intra-
operatively the best sites for injection,
based on the result desired.
The TouchView™ System allows the
surgeon to not only pre-operatively
visualize major structures and aberrant
anatomy within the area targeted for
autologous fat injection, it facilitates the
injection process, reduces the amount
of manual manipulation required, and
allows objective measurement. This sys-
tem greatly enhances the ability of the
surgeon to quickly and safely produce
the desired results when performing
autologous fat injections.
Conclusion
CONCLUSION
Autologous fat transfer to smaller
muscle areas is both feasible and safe
with consistent and durable results. The
#556-Matlock Galley - 01
SURGICAL TECHNOLOGY INTERNATIONAL XXV
addition ultrasound imaging provides
pre-operatively a means to quickly eval-
uate potential vascular, nerve hazards,
and aberrant anatomy; intra-operatively
allows the surgeon to directly visualize
the structures as each injection is per-
formed; and post operatively to mea-
sure both short term and long term
sustainability and placement of the
injected fat. STI
Authors’ Disclosures
AUTHORS’ DISCLOSURES
The authors have no actual or poten-
tial conflicts of interest in relation to
this paper.
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