70
Liposuction and
Liposculpture
FRANCESCO M. EGRO, NATHANIEL A. BLECHER,
J. PETER RUBIN, AND SYDNEY R. COLEMAN
Introduction
Liposuction and liposculpture represent the evolution of
minimally invasive plastic surgery techniques developed in
an attempt at restoring shape and form. Liposuction was first
described in the 1920s but it was not until the 1970s that
the technique was popularized in Europe by Illouz, Fournier,
and Otteni whereby fat was harvested using a blunt cannula
and aspirated using negative pressure. Prior to liposuction,
fat was directly excised leaving unsightly scars and increased
morbidity. The effect of liposuction on the body has been
extensively studied and it has been shown to be safe and
effective. Other than producing improved contour cosmesis,
liposuction was shown to reduce body weight, BMI, waist
circumference, body fat, plasma leptin, and insulin levels.
Although fat grafting was first described back in 1893 by
Neuber, it was Coleman who popularized free fat transfer in a
minimally traumatic fashion leading to a consistently higher
graft retention compared to prior techniques.1 As research in
the field increased, the indications and quoted graft retention
rates also increased (20%–90%). Part of the reason for the
wide variation in the results is the sheer amount of factors
involved in graft survival. Though the Coleman technique
is often accepted as the standard, in the nascent field of fat
grafting, multiple strategies for liposuction, fat processing,
and grafting have evolved, which makes standardization and
optimization challenging. This chapter critically appraises
each step in the process of liposuction and fat grafting, from
harvesting to processing to injecting, to provide a detailed
overview for the plastic surgeon of the 21st century.
Harvest Site
Liposuction for body sculpting or for fat harvesting purposes
can be performed anywhere around the body as long as there
is sufficient adiposity. The most common sites include the
abdomen, flanks, and thighs. However, both animal and
human studies have shown that donor site does not influence
the quality of the lipoaspirate and the graft survival.2 In fact,
in a murine model Ullmann et al found no significant differ-
ences based on thigh, abdomen, and breast donor sites in graft
retention or histology after 16 weeks.2 Li et al repeated and
expanded upon these animal findings, finding no difference
in retention from five separate donor sites (flank, upper and
lower abdomen, and lateral and inner thigh) after 12 weeks.2
Human studies have also found no difference based on com-
parative symmetry scores of craniofacial patients grafted
with fat from the abdomen versus other areas (medial thigh,
suprapubic).2 Similarly, in breast reconstruction Small et al
found no significant difference in graft retention after 140
days in fat harvested from the abdomen versus the thighs.2
There is currently no evidence to support that harvest site
independently influences graft survival. However, this parity
has not been proven with higher-level prospective cohorts or
randomized control trials, and further research is needed. 
Donor Site Preparation
Liposuction can be performed dry (no wetting solution), wet
(200 mL/area), superwet (1 mL infiltrate per 1 mL of aspi-
rate), or tumescent (2–3 mL infiltrate per 1 mL of aspirate).
The wetting solution may contain lidocaine, epinephrine,
and/or sodium bicarbonate depending on surgeon’s prefer-
ence. The benefit of using a superwet or tumescent solution
is the significant decrease in blood loss down to 1%. Other
benefits of using a wetting solution is the analgesic effect
provided by lidocaine, volume replacement, and enhanced
cavitation and heat dissipation in ultrasound-assisted lipo-
suction. The concern of the use of wetting solutions in the
setting of fat grafting is the potential effect on adipocyte
viability and blood flow reduction to grafts.2 However, as
early as 2005 Shoshani et al demonstrated no significant dif-
ference in weight and volume retention at 15 weeks between
xenografts harvested with lidocaine and epinephrine versus a
control of saline.2 Livaoğlu et al further proved the safety of
local anesthesia showing no significant difference in reten-
tion at 180 days between control, lidocaine plus epineph-
rine, or prilocaine groups in an autologous murine model.2
1107
1108 PA RT V I I I     Esthetic Surgery
Lastly, Rohrich et al found no significant differences in adi-
pocyte viability among four donor sites (abdomen, flank,
thigh, knee) determined on an in vitro colorimetric assay of
cell proliferation.2 Overall, despite theoretical concerns for
the use of local anesthesia, graft survival does not seem to
be greatly affected by its use in animal models. This finding
should be further investigated in human studies.  age of graft that was more than 1.5 mm from the edge and
Harvest Technique
Depth of Liposuction
Fat can be aspirated at different depths of the subcutaneous
layer but one has to be aware of potential risks and variation
in quality of the fat (relevant if used for fat grafting). The
superficial subcutaneous layer contains dense fat, which is
adherent to overlying skin. The intermediate subcutaneous
layer is the safest and most commonly aspirated layer. The
deep subcutaneous layer contains looser and less compact
fat, and can be safely aspirated in most areas except the but-
tocks. Ideally, the surgeon should avoid violating the super-
ficial plane above the superficial fascia to ensure preservation
of subdermal structures, and prevent surface irregularities. A
variety of zones of adherence have been described, which
should not be violated during liposuction because of the risk
of contour deformity. These zones include the gluteal crease,
middle medial thigh, lateral gluteal depression, distal poste-
rior thigh, and distal iliotibial tract.  contain central cores that could not be cleared appropri-
Cannula Size
The use of single-bore blunt-tip harvesting cannula has been
standard practice since the description of the technique by
Coleman. There are very few studies examining the impact
of different parameter in cannula such as bore size and sin-
gle versus multiple perforation.3
To determine the impact of bore size, Erdim et al com-
pared fatty aspirate obtained from 2-mm, 4-mm, and 6-mm
blunt cannulas and found significantly higher in vitro adi-
pocyte survival in the 6-mm group compared to both the
2-mm and 4-mm groups. However, this viability assessment
was only based on brilliant cresyl blue supravital stained adi-
pocyte counts after collagenase digestion and centrifuging.3
A similar in vitro study by Alharbi et al comparing 3-mm
single-bore and 2-mm multiperforated St’rim cannulas
(Thiebaud Biomedical Devices), found no significant differ-
ence in cell viability between the groups when measured by
alamarBlue (ThermoFischer) reagent.3 Lastly, Kirkham et al
compared 3-mm and 5-mm Coleman cannulas in a murine
model using a dry technique, and found significantly higher
graft retention and histologically healthier grafts in the larger
cannula group at 6 weeks.3 These findings suggest that, gen-
erally, larger bore cannulas produce more viable cells leading
to better graft retention. However, we must balance these
results with data on parcel size discussed below. Given the
limited data on graft survival, further longer-term, in vivo
research with more modern viability assays is justified.  cell viability with varying pressures. Pu et al found that there
Parcel Size
The importance of parcel size in fat graft survival is based
on the same general theories of imbibition and neovascu-
larization that are vital to survival of all tissue grafts. Early
research theorized on how graft shape could affect percent-
how this would impact survival. This theory was expanded
upon by Eto et  al, who identified three distinct zones of
adipocyte survival. Outer surviving zone with cells located
within 300 μm of the graft edge; middle regenerating zone
with cells undergo necrosis but are replaced by adipose-
derived stem cells (ASCs); and central necrotic zone where
no viable fat survives.4 The same group published further
evidence of the behavior of grafts based on distance from
the edge, showing adipogenesis via CD34+/Ki67+ ASCs in
the regenerating zone (600–1200 μm thick) peaked at 4
weeks and concluded by 12 weeks, while stabilization via
MAC2+/CD206− M1 macrophages MAC2+/CD206+ M2
macrophages in the central necrotic zone persisted through
12 weeks.4 The importance of the relation between graft
and surrounding tissue has been further demonstrated in
injected fat. Our group demonstrated that as the total fat
volume transferred increases, grafted deposits coalesce to
form larger globules (especially at ratios beyond 1:4). There-
fore, increasing the likelihood of central necrosis and subse-
quent graft loss.5 Our group also showed that larger grafts
ately by macrophages, allowing for persistent necrosis that
skew retention as a measure of survival.6 The architecture
of fat grafts is clearly important, with the principles of dif-
ferent survival zones based on distance to the vascularized
edge providing insight into how parcel size may affect graft
survival. The research using cannula size surrogates has
not been conclusive and no research exists to date directly
examining lobule size in vivo. Further research must be per-
formed to determine the relationship between parcel size
and graft survival in vivo. 
Aspiration Technique
The amount of liposuction performed depends on the level
of lipodystrophy, desired result, and amount of fat needed
for grafting. Large-volume liposuction is usually considered
to be anything above 5 liters of fat aspiration. These cases
should be performed in an acute care hospital or an accred-
ited facility because of the increased complication rates asso-
ciated with larger volume liposuction. To ensure safety, vital
signs, urine output, overnight monitoring, and appropriate
fluid replacement are required.
Various aspiration techniques have been developed over
the years, including suction-assisted, ultrasound-assisted,
water-assisted, and laser-assisted liposuction.7–10 Use of
either hand aspiration or machine-assisted liposuction is a
compromise between efficiency and the risk of adipocyte
damage. Early studies in aspiration pressure were based on

was a significantly greater number of viable adipocytes har-
vested via hand aspiration compared to machine aspiration
at no greater than 20 cmH2O.8 In contrary, Lee et al found
that there was no difference in graft weight retention or
histology between −15 mmHg handheld aspirate and −25
mmHg machine-harvested fat.2
Ultrasound-assisted liposuction (UAL) was first described
by Zocchi, and it is a result of alternating currents that
cause piezoelectric crystals to expand and contract, releas-
ing ultrasonic waves that emulsify fat by micromechanical,
thermal, and cavitation action. Our group showed no dif-
ference in graft retention in a murine model between UAL
and traditional suction-assisted liposuction at 430 mmHg
in graft retention or histology.7 Yin et  al compared graft
survival between xenografts harvested via water-jet assisted
liposuction and traditional liposuction set to −0.5 bar and
found significantly improved graft retention and adipocyte
viability in the water-jet assisted liposuction group.9 Laser-
assisted liposuction (LAL) uses a laser fiber to disrupt fat cell
membranes and emulsifying fat. The most common wave-
lengths in LAL include 924/975 nm, 1064 nm, 1319/1320
nm, and 1450 nm. Prado et al showed no major differences
between SAL and LAL, other than higher concentrations of
free-fatty acids after LAL. However, limited conclusions can
be drawn given the small sample size.10
In the current literature, increased pressure from
machine-assisted liposuction does not appear to impact
actual graft survival though it may affect cell viability. While
many of these studies discuss graft survival, none compares
techniques based on esthetic outcomes. Thus the asser-
tion of superiority of nonvacuum techniques on esthetic
outcomes is not yet defined. With limited studies, more
research should be pursued comparing graft retention based
on aspiration method potential comparing hand, machine,
ultrasound, water-jet, and laser-assisted liposuction.  sis at 12 weeks, but did find significantly lower in vitro cell
Processing Technique
Centrifugation, Filtration, Decanting, and
Rolling Techniques
Four primary processing methods have been used clinically
to process fat graft: centrifugation, filtration, decanting, and
rolling techniques.
Centrifuging has been a mainstay in fat processing as
a method of separating viable adipocytes from additional,
undesirable lipoaspirate. As a commonly utilized technique,
it has been more highly researched with investigation into
ideal centrifuge speeds and how the method compares to
other processing techniques.2,6,7,11–13 Early research into
the utility of centrifuging for improving fat graft survival
in humans by Butterwick showed that, when compared
to noncentrifuged fat, centrifuged grafts to the hand were
rated by both patients and physicians as having better reten-
tion and more visual improvement as long as months after
the procedure.2 Ferraro et al also utilized digital photogra-
phy to compare resorption rates in patients grafted with fat
CHAPTER 70  Liposuction and Liposculpture 1109
centrifuged at 3000 rpm (1500 g) for 3 minutes, 1300 rpm
(250 g) for 5 minutes, or uncentrifuged and decanted fat
injected in the gluteal region and found the lowest resorp-
tion rates in the slow centrifuge group and highest in decan-
tation after 12 months.2 Quantitative research to evaluate
the effect of centrifuging speeds on graft survival has been
completed in murine models. Using percent oil extracted
after centrifuging as a surrogate for adipocyte damage,
Hoareau et al determined speeds up to 400 g had little effect
on harvested fat whereas a speed of 900 g had significantly
damaged adipocytes.2 On the other hand, higher centrifuge
speeds produced more concentrated adipocyte fractions
with maximal concentration being achieved at 5000 g.11
Thus, in determining the ideal speed, concentrating power
and cell damage must be balanced to produce optimal graft
survival. Kurita et al compared grafts either not centrifuged
or centrifuged at 400 g, 700 g, 1200 g, 3000 g, or 4200 g for
3 minutes and found significantly improved retention up
to 3000 g, but when balanced with ASC concentration and
volume compaction, suggested 1200 g was the ideal speed.2
Additionally, the group suggested that increased oil isolated
above 400 g was due to separation of existing oil rather than
cell damage as grafts up to 4200 g were histologically intact.
Other studies have suggested the ideal speed to be as low
as 698.75 g or as high as 5000 g.7,13 Centrifuging at any
speed creates multiple layers of density, which Allen et  al
compared to determine if the density of the processed fat
affected survival. They found that the highest density frac-
tion had significantly higher retention and improved archi-
tecture at 2 and 10 weeks.2
Centrifuging has also been compared to other methods
of processing such as sieves and gauze rolling. When com-
paring these three methods in a murine model, Minn et al
found no significant differences in graft retention or necro-
viability in the metal sieve group based on XTT metaboliza-
tion.2 These results were echoed by Salinas et al when they
found centrifuging at 1200 g and mesh/gauze processing
produced equivalent graft retention and histology scores in
mice at 4 weeks, noting the result was expecting as the two
methods achieved the same level of adipocyte concentra-
tion.11 However, Canizares et al found that when compared
to centrifuging at 1200 g, telfa rolling produced superior
graft retention at 2 and 10 weeks in a murine model as
well as adipocyte functionality as determined by glycerol-
3-phosphate dehydrogenase assay.12 Fisher et  al similarly
found that xenograft retention at 6 weeks for the telfa roll
method was superior to both centrifuging via the Coleman
method and Tissu-Trans Filtron filtration.7
The current evidence suggests that fat should be pro-
cessed using centrifugation or rolling techniques. However,
one must consider the practical aspect of fat processing
technique, which must allow feasible workflow in the oper-
ating room. For this reason, a surgeon might need to tailor
the processing technique based on the volume of fat that
needs to be grafted. For instance, smaller volumes can be
processed with either centrifugation or rolling techniques;
1110 PA RT V I I I     Esthetic Surgery
whereas, larger volumes may be more efficiently processed
with filtering or decantation.  pattern on survival, other aspects of injection method have
Washing
Washing serves as another method of processing and purify-
ing lipoaspirate, which is performed often in isolation rather
than as an adjunct, by adding and removing solutions.2,14
Girard et al showed improved fat graft retention in immuno-
deficient mice at 4 weeks, by combining centrifugation with
Ringer’s lactate washing.14 Khater et al found better esthetic
results when lipoaspirate was washed 1:1 with physiologi-
cal serum instead of centrifugation, which they attributed
to the noncentrifuged graft’s higher leptin expression and
number of preadipocytes as identified by morphology.2 In a
similar study, Botti et al found no difference between centri-
fuging and washing with normal saline.2 Condé-Green et al
showed that while washing lipoaspirate with normal saline
three times in a 1:1 ratio leads to high histological fat graft
viability, cell assisted lipotransfer and centrifuged fat graft
had significantly more consistent volume retention of 0.3
mL grafts at 12 weeks in immunodeficient mice.2
Taken as a whole, current data seems to suggest washing
provides comparable retention to other methods of process-
ing but may provide benefits to cell viability. However, fur-
ther research is needed to determine its superiority.  While early studies suggested no effect, later investiga-
Pharmacological Additives
A multitude of individual additives have been tested to
improve graft retention including IL-8, PDGF, VEGF-
loaded microspheres, botulinum toxin-A, M2 macrophages,
N-acetylcysteine, phosphodiesterase inhibitors, insulin,
EGF, anti-TNF-α improved autograft, bone marrow aspi-
rate or concentrate. These pharmacological additives show
promising results. However, the majority of these studies
utilize non-ideal methods in their processing and assessment
of viability of their grafts. Whereas among those studies that
do, the heterogeneity in methodology makes comparison of
additives impossible. To determine the true benefits and
superiority of additives in the clinical setting, further stan-
dardized studies using methods that reduce spurious reten-
tion and demonstrate viability must first be pursued.  supramuscular layer had significantly improved retention
Injection Technique
The technique employed to inject fat is crucial to optimize
the esthetics and retention of the graft. Injection of the pro-
cessed fat into the recipient site requires significant care to
produce long-lasting desirable outcomes. The original tech-
nique described by Dr. Coleman uses Luer lock syringes
connected to a 17G blunt cannula to inject the processed
lipoaspirate. The cannula is withdrawn as the lipoaspirate
is injected, in order to allow the grafted fat to fall into the
natural tissue planes as the cannula is removed. A fan injec-
tion pattern is also recommended because as described by
our group the distribution of the injected fat is of utmost
importance to survival.6,15 Given the impact of injection
also been researched.2,16–18
Much as with harvesting, a focus on injection tech-
nique has been needle size. Erdim et al found no difference
in in  vitro adipocyte count between 14G, 16G, and 20G
injection needle gauges.2 Their findings were reinforced by
Nguyen et al, who found no significant differences in graft
retention or histology when comparing injections of 0.7 mL
of fat with 17G, 20G, 23G, or 25G needles.16 Contrarily,
Luan et al suggest injection cannula does impact survival,
finding that injection of 0.2 mL xenograft through a 14G
8-cm cannula led to significantly better histology than fat
injected through longer or narrower cannulas, and that
volume retention was significantly better than a 18G 8-cm
cannula.18 Possible differences in outcomes with different
injection cannulas have been attributed to shear stress dur-
ing injection. Lee et al proposed that the increase in shear
stress with fast injection rate (3–5 mL/second) over slow
injection rate (0.5–1 mL/second) was the cause of decreased
retention and histology scores in their - mL xenografts at
4 weeks.2 Chung et al investigated how a low shear, auto-
mated adipose tissue injector device affected grafts, finding
a significant increase in in vitro viability and proliferation,
and improved in vivo retention and histology at 12 weeks.17
tion using more ideal models demonstrated clear preference
toward low-shear stress injection methods. Further research
pursuing these methods should be completed in clinical tri-
als to confirm their success. 
Recipient Site
Researchers have suggested differences in retention due to
recipient site may be due to factors such as site mobility,
existing vascularity, and injection effect on architecture.19–21
Fat graft retention depends on revascularization among
many factors, which means that lipoaspirate injection into a
vascularized bed is essential. Karacaoglu et al tested optimal
recipient bed by comparing fat grafting in the subcutane-
ous, supramuscular, and submuscular layer of the bucco-
mandibular area of rabbits, and found that grafting into the
and histopathological scores.21 Shi et al showed that 0.1-mL
allografts to the fat pad had the highest weight retention
compared to the intramuscular and subcutaneous layers.
However, angiogenesis and vascularized connective tissue
were more prominent in fat injected in the intramuscular
layer, likely being the reason for the highest survival rates
among the three recipient sites.20
A potential factor impacting graft retention is the degree
of mobility of the underlying tissue. The face is a prime
example with areas like the glabella and lips that are less
amenable to correction, compared to less mobile areas like
the malar and lateral cheek.
Denadai et  al demonstrated radiologically that fat
graft retention was better in the cheek unit at 12 months

compared to the forehead or the chin units.22 Furthermore,
Mojallal et al showed in their clinical trial that fat injected to
the malar region had significantly better esthetic result than
grafts to the temporal and lip areas.2
The manipulation of recipient site offers the chance
to enhance graft survival and predictability. Much of the
research in the area has been dedicated to preexpansion,
where the mechanotransduction properties of preexpansion
lead to conversion of mechanical tension into growth-pro-
moting signals creating a vascularized scaffold that allows
for larger graft volumes and better retention rates.2 The
BRAVA (Brava, LLC, Miami, FL) preexpansion device is
a prime example and the benefit of this technology was
demonstrated in a prospective multicenter study highlight-
ing the significant improvement in weighted mean graft
retention rate and the ability to inject much larger volumes
of fat graft.2 Lee et  al used posttransplant negative exter-
nal pressure on 1-g en bloc autografts, finding a signifi-
cant improvement at 3 months in the experimental group’s
weight retention and viability.23 Sezgin et al examined the
effect of microneedling prior to fat grafting and found that
it had significantly better retention and histopathologi-
cal scores at 15 weeks of 100-mg grafts, but did not find
a significant difference in the grafts triglyceride content.24
By housing posttransplant mice in oxygen-enriched envi-
ronments, Kato et al investigated the effect of normobaric
hyperoxygenation on a perilipin staining and weight reten-
tion calculated engraftment score for 0.2-mg murine auto-
grafts, proving that this pretreatment significantly increased
survival at 12 weeks by increasing the surviving and regen-
eration zones over the central necrotic zone of grafts.25
These techniques are promising strategies to support
the recipient bed and should be further explored in human
trials.
Intrinsic Patient Variability in Adipose Tissue
The unpredictability of fat graft retention remains a major
issue and intrinsic patient factors are likely to play a role.
Much of the research into the efficacy of fat grafting has
focused on how technique affects graft survival, and only
few papers have directly examined the effect of different
patient characteristics on the grafts they receive.2,16,19,22,26–30
Commonly, patient factors will be reported in studies to
show standardization between study groups but will not be
subject to analysis for potential significance. Furthermore,
while some studies have performed patient factor analysis,
this is rarely the primary focus of the paper, rather being
a secondary finding. Geissler et  al examined the fat of 24
female patients harvested from the flanks, lower abdomen,
and inner thigh and showed that younger patients had
greater adipocyte viability in the lower abdomen than in the
flank, whereas older patients did not show any differences.
Younger lower abdominal fat showed superior adipocyte
viability compared to older patients. However, flank fat had
higher adipocyte viability in older patients. Patient weight
did not appear to affect adipocyte viability.30 In the only
CHAPTER 70  Liposuction and Liposculpture 1111
prospective study found specifically designed to examine
the effect of patient factors on graft survival, Dendai et al
identified several factors which impacted fat graft survival
in patients with unilateral craniofacial contour deformities.
The authors identified Parry–Romberg syndrome, previous
craniofacial bone surgery, forehead unit, grafted volume,
and older age as independently negative predictors of fat
graft retention, whereas injection in the cheek unit was an
independently positive predictor.22 It therefore appears that
age and underlying pathology of the recipient play a role in
adipocyte viability and retention. Another factor that has
been studied is exposure to radiation. Choi et al and Small
et  al found that prior radiation exposure did not signifi-
cantly affect graft retention over time in breast reconstruc-
tion.2,28 However, when radiation exposure was examined
in a murine case–control trial by Garza et  al, they found
radiation to be significantly detrimental to graft survival.27
Due to this discrepancy, further clinical trials specifically
examining radiation exposure are warranted. The role of
other factors like gender, smoking, obesity, diabetes, and
hypertension on the impact of graft retention and adipocyte
viability remains uncertain. Özalp and Çakmakoğlu looked
into the impact of smoking on facial fat grafting in their
18-patient retrospective cohort study, and highlighted a low
fat graft survival rate and reduced skin quality improvement;
however, no controls were included.19 Jung et  al demon-
strated in their murine model the negative impact of dia-
betes on graft retention and histological quality.26 Whereas
Herly et al showed in their long-term retention study that
the only factor having a significant positive impact on graft
retention was male gender.29 Among the current literature,
there is discrepancy of the impact of variables such as radia-
tion exposure, age, and gender. Larger-scale, prospective
human studies specifically examining multiple patient fac-
tors are required for the different applications of fat grafting. 
Volume Retention Over Time
Animal studies have shown that active remodeling, resorp-
tion, and adipogenesis stabilize around the 12-week
mark.4,25 How this process of stabilization effects long-
term volume retention has been observed in various clinical
trials.2,26,29,31,32
Early photographic assessment supports the later
observed laboratory kinetics, with facial grafting generally
stabilizing around 3–4 months and breast grafting around
4–6 months, though there may be subtle volume decreases
out to a year.31,32 Denadai et al confirmed these findings in
their study, showing with ultrasound measurements a steady
decrease of soft tissue thickness over 3 months with no sig-
nificant decrease after that point out to a year.22
Counter to these studies, Herly et al reached steady state
point much later, as demonstrated by MRI analysis that loss
of <5% original volume per year was not reached until 806
days after grafting.29 However, this study was performed
with en bloc fat grafted to the postauricular region, making
it less applicable to routine clinical practice. On the other
1112 PA RT V I I I     Esthetic Surgery

• Fig. 70.1  Preoperative and 2.5 years postoperative photographs of bilateral breast augmentation using
two rounds of fat grafting. Fat was harvested from the patient’s abdomen, and bilateral thighs using 10-mL
syringes and Coleman harvesting cannulas. The fat was processed in the standard manner using the
Coleman technique. The first round required 232 mL of fat graft for the right breast and 230 mL for the left
breast. The second round required 237.5 mL of fat graft for the right breast and 287 mL for the left breast.
The patient has a lasting result of breast augmentation with improved breast contour.

hand, Choi et  al’s fat grafting results reached steady state
sooner with larger volume breast grafts nearing stability
closer to 49 days while small volumes continued to rapidly
shrink out to 140 days.28 All of the studies that qualified
long-term retention found optimal results ranging from
51% to 68%.19,29 These discrepancies in results require clar-
ification with larger-scale prospective trials using lipofilling
techniques.  good candidate and respondent for serial fat grafting is cru-
Impact of Serial Fat Grafting
With the uncertainty of graft retention, varying use of mul-
tiple injections have been implemented.2,33-35
Serial fat grafting is often needed to correct deformities.
A prime example is fat grafting for breast augmentation or
reconstruction either with or without the use of a preexpan-
sion device (Fig. 70.1). Khouri et al report using between
1 and 10 rounds of fat grafting at a minimum of 8-week
intervals to achieve satisfactory results, noting needing more
injections in delayed reconstruction and post-radiation
patients, and higher volumes injected in later procedures.34
Kim et al used fat grafting for secondary breast reconstruc-
tion, reporting about a quarter of their patients required
reinjection due to inadequate volume.33
The ideal interval between grafting procedures remains
unclear. Lim et al found no significant difference in symme-
try outcomes when comparing patients undergoing serial fat
grafting with short versus long intervals, though this result
was obtained by comparing facial symmetry using 2D facial
analysis.2 Jiang et al used a 3D laser scanner to compare vol-
ume retention of serial grafts and found significantly higher
retention in the second graft over the first in a pilot study of
13 patients.35 While serial grafting is a frequently employed
technique, information regarding its efficacy and predict-
ability remain uncertain. Further information on who is a
cial to ensure the appropriate technique is employed. 
Role of ASCs in Fat Graft Survival
ASCs reside in the perivascular compartments of the stroma
of adipose tissue and is part of the stromal vascular frac-
tion (SVF), which contains various progenitor cells other
than ASCs including pericytes, transit amplifying cells,
and endothelial progenitor cells. Whether supplementing
the lipoaspirate with SVF or ASCs or enriching these cells
through centrifugation, all of these methods have enhanced
fat graft retention and improved clinical outcomes by pro-
viding sites of adipogenesis in zones in which the graft would
otherwise not survive as well as improving vascular support
via endothelial cell proliferation.4,36,37 Very strong pre-
clinical and clinical evidence supports the benefit of ASC-
enriched fat grafting. In a landmark study, Yoshimura et al
introduced cell-assisted lipotransfer (CAL) or SVF-enriched
fat grafting, and reported a very high graft retention in 40
patients undergoing breast augmentation with CAL.37 Kølle

et al conducted a triple-blinded randomized controlled trial
of 10 patients receiving ASC-enriched or nonenriched fat
grafting and showed improved graft retention, enhanced
formation of connective tissue and reduced fat graft necro-
sis in ASC-enriched fat graft.2 Tanikawa et al conducted a
randomized controlled trial of 14 patients with craniofacial
microsomia and ASC-enriched graft significantly improved
volume retention at 6 months.38 Koh et  al found similar
results in hemifacial atrophy secondary to Parry–Romberg
disease though with ASCs that were derived by culture
expansion.39 The benefits of ASC-enriched fat graft are
increasingly highlighted in the literature. However, before
stem cell therapies can become mainstream, a higher level
of scrutiny and regulation needs to take place to protect the
safety of our patients.  relationship of the major vessels to the port sites and glu-
Complications and Emerging Safety
Concerns
Liposuction and fat grafting are usually well tolerated and
very safe. Complications are very infrequent and most com-
monly minor in nature. Liposuction can lead to ecchymosis,
edema, pain, and mild oozing, which normally are self-
resolving. As mentioned above, inappropriate liposuction
technique may lead to contour irregularities due to excessive
and/or heterogenous aspiration. These can be prevented by
careful and frequent reassessment of the harvested area. Fat
grafting may also lead to minor complications like under-
correction, overcorrection, visible irregularities, graft resorp-
tion, migration of injected fat. More serious complications
can infrequently occur, like infection or injury of underlying
structures (e.g., muscle, nerve, glands) during the harvesting
and grafting processes. Lastly, the most dreaded complica-
tion is embolization after intravascular injections which can
lead to blindness (injections to the face), respiratory com-
promise or death (injection in the buttocks).
Gluteal fat grafting (GFG) for gluteal augmentation has
become one of the fastest growing fields in cosmetic sur-
gery, with its popularity growing dramatically in the USA
over the past seven years, from 7382 procedures in 2011 to
23,115 procedures in 2017 (American Society for Aesthetic
Plastic Surgeons statistics). This trend can be explained by
an increased understanding of the female form, a growing
role of the female buttocks as a secondary sexual character-
istic in popular culture, and an evolving ethnic variation
in the USA. Fat grafting is a technically challenging pro-
cedure and complication rates may increase if performed
by inexperienced physicians. Along with this rise in num-
ber of GFG procedures, serious safety issues are evolving,
with severe morbidity and mortality events publicized in
the media. Although GFG has been performed across the
globe for decades without safety concerns raised, the more
recent expansion in case volume broadens the range of
surgeons performing this procedure. Moreover, clinicians
not trained in plastic surgery are performing GFG. It is
estimated that as many as 25% more of these procedures
CHAPTER 70  Liposuction and Liposculpture 1113
are performed by practitioners other than plastic surgeons,
facial plastic surgeons or dermatologists, resulting in a
total of approximately 23,774 procedures performed in
2017 in the USA.40 GFG can lead to serious complica-
tions, including death, which was found by the Aesthetic
Surgery Education and Research Foundation (ASERF)
Task Force to be between 1:2351 and 1:6241, many times
higher than other plastic surgery procedures.40 Autopsy
findings indicate that the key technical problem is fat
grafting material being introduced into major blood ves-
sels (including the iliac veins) following tearing of the ves-
sels with the cannulas. These fat parcels then travel around
the body leading to fat embolism syndrome or pulmonary
fat emboli. For this reason, understanding the location and
teal muscles is imperative. The superior and inferior gluteal
veins drain into the internal iliac vein and can be 4 mm
or more in diameter as they cross the glutei maximus and
medius towards the iliac wing. Larger diameter veins (6
mm or more) may also be present near the sciatic notch,
which divide into smaller perforators at the level of the
gluteal muscle fascia to supply the subcutaneous tissue and
skin.40 Given the life-threatening association with GFG,
the Multi-Society Gluteal Fat Grafting Task Force was
created under the direction of Dan Mills, J. Peter Rubin
and Renato Saltz, and found that all examined autopsies
of deceased GFG patients shared common findings: (1)
fat in the gluteal muscles; (2) fat beneath the muscles; (3)
damage to the superior or inferior gluteal vein; (4) massive
fat emboli in the heart and/or lungs. No post mortem has
yet shown a cause of death with fat only in the subcuta-
neous space; this means that surgeons have injected more
deeply than they had intended. The mechanism of death
is presumed to be high pressure extravascular grafted fat
entering the circulation via tears in the large gluteal veins
with subsequent embolization to the heart and lungs. The
Task Force proposed several recommendations to mini-
mize morbidity and mortality, which are summarized in
Table 70.1, but significant caution should be taken when
performing this procedure to ensure patient safety.41 
Conclusion
Liposuction and liposculpture has revolutionized how chal-
lenging contour irregularities and facial rejuvenation are
tackled. Fat is an ideal filler given its biocompatibility, ease
of harvest, and regenerative properties. A wide spectrum
of studies explored the various facets of fat grafting from
harvesting to injection technique. However, the surgeon
should be mindful of the current literature to optimize adi-
pocyte survival and graft retention, and should be aware of
the emerging safety concerns. Many unanswered questions
still remain, mostly due to the lack of coherence in surgical
methodology, making interpretation of outcomes very chal-
lenging. Fat grafting is a common procedure performed by
most surgeons and thus a methodical approach is needed to
ensure patient safety and excellent outcomes.
1114 PA RT V I I I     Esthetic Surgery
TABLE   Multi-Society Gluteal Fat Grafting Task Force
70.1  Recommendations on Gluteal Fat Grafting41
1. Stay as far away from the gluteal veins and sciatic
nerve as possible. Fat should only be grafted
into the superficial planes, with the subcutane-
ous space considered safest. If the esthetic
goal requires more fat than can be placed in the
subcutaneous layer the surgeon should consider
staging the procedure rather than injecting deep
2. Concentrate on the position of the cannula tip
throughout every stroke to assure there is no
unintended deeper pass, particularly in the
medial half of the buttock overlying the critical
structures
3. Use access incisions that best allow a superficial
trajectory for each part of the buttock; avoid
deep angulation of the cannula; and palpate
externally with the nondominant hand to assure
the cannula tip remains superficial
4. Use instrumentation that offers control of the can-
nula; avoid bendable cannulas and mobile Luer
connections. Vibrating injection cannulas may
provide additional tactile feedback
5. Injection should only be done while the cannula is
in motion in order to avoid high pressure bolus
injections
6. The risk of death should be discussed with every
prospective [GFG] patient
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