Abdominal fat harvest technique and its uses in

maxillofacial surgery
Dennis J. Kantanen, DDS," James J. Closmann, DDS,b and Henry H. Rowshan, DDS,'
Honolulu, Hawaii
DIVISION OF ORAL AND MAXILLOFACIAL SURGERY, TRIPLER AR~IY MEDICAL CENTER

Abdominal fat harvest and augmentation to the maxillofacial region is a relatively inexpensive, safe, and
readily available procedure. The use of abdominal fat free transfer has been well documented for cosmetic, trauma,
and temporomandibular joint reconstruction. Fat is the closest we have to an ideal filler, it is readily available and
inexpensive, it is autologous and therefore lacks a host immune response, it is safe and noncarcinogenic, and it is
easily acquired with a minimally invasive procedure. Abdominal fat donor site is the most commonly used owing to
ease of access and availability of fat stores. Complications are rare and easily managed in the office. Free abdominal
fat harvest is a predictable surgical technique that allows the maxillofacial surgeon access to autologous graft material
that is ideal for multiple facial procedures. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:367-371)

Abdominal fat harvest and augmentation to the maxil- years, more widespread clinical use of autologous fat
lofacial region is a relatively inexpensive, safe, and grafts for facial soft-tissue augmentation suggests that
readily available procedure.' The use of abdominal fat this procedure is the best presently available. In many
free transfer has been well docnmented for cosmetic, ways, fat is the closest we have to an ideal filler: It is
trauma, and temporomandibular joint reconstruction. In readily available and inexpensive, it is autologous and
2009, autogenous fat is still the preferred method for therefore lacks a host immune response, it is safe and
the treatment of frontal sinus obliteration. Abdominal noncarcinogenic, and it is easily acquired with a min-
fat has been nsed since the 1890s for cosmetic proce- imally invasive procedure. Viable autogenous free ab-
dures 2 En bloc resection and removal of abdominal fat dominal fat along with the removal of mucosal lining
has been shown experimentally to contain a greater from the frontal sinus consistently prevents regrowth of
percentage of surviving adipocytes compared with can- the mucoperiosteum. The use of autogenous fat for
nnla removal. 3 Therefore, the aim of the present article frontal sinus obliteration purposes continues to be the
is to discuss the suprapubic abdominal fat harvest tech- gold standard (Fig. 1).4-6 Areas of the maxillofacial
nique to include the pertinent anatomy, complications, region that are routinely augmented during cosmetic
and uses of the technique. procedures include the malar region, lips, nasolabial
folds, and mental area. Facial reconstruction for the
ABDOMINAL FAT treatment of facial lipodystrophy due to underlying
There are a myriad of autogenous and alloplastic HIV disease has been documented (Fig. 2). 7 Free ab-
materials that can be used for maxillofacial procedures dominal fat has been used dnring the treatment of TMJ
for trauma, cosmetic, facial, and temporomandibular disorders (Fig. 3). During open joint surgery, free ab-
joint (TMJ) reconstruction. Facial rejuvenation with dominal fat has been transplanted into the joint space to
autologous fat has the advantage of replacing or aug- replace joint space after complete removal of the disc
menting tissue with like tissue. Over the past 10-15 and associated capsule. The use of autologous fat grafts
in the treatment of TMJ ankylosis has been reported in
The views and opinions expressed herein are those of the authors and the literature as early as 1913 8 •9 Autologous transplan-
do not necessarily reflect those of the Department of the Defense or tation of abdominal fat around the TMJ can minimize
the Department of the Army. occurrence of fibrosis and heterotopic bone formation,
aChief resident, Division of Oral & Maxillofacial Surgery.
bChief and Program Director, Division of Oral & Maxillofacial
leading to improved range of motion.'o Autologons
Surgery. transplantation of fat has been used as a method to
CAssistant Program Director, Division of Oral & Maxillofacial prevent heterotopic bone formation after hip replace-
Surgery. ment surgery for many years.'o The use of dermal fat
Received for publication May 5, 2009; accepted for publication Sep for correction of contour defects in the head and neck
8,2009.
1079-2104/$ - see front matter
area from trauma, congenital defects, and neoplasm has
Published by Mosby, Inc. remained a well known and time-honored choice (Fig.
doi: 10.1016/j .tri pleo.2oo9.09.037 4)7 Dennafat is used owing to the dennal layer being

367
 OOOGE
368 Kantanen et at. March 2010

Fig. 1. Frontal sinus obliteration with autologous abdominal

fat.
Fig. 3. Free abdominal fat graft used in temporomandibular
joint reconstruction. Courtesy of Michael Doherty, DDS.

Fig. 2. Free abdominal dennafat graft for treatment of HIV-

associated lipodystrophy syndrome. From Rowshan et a1. 7

the vasoinductive layer for the underlying adipose graft

Fig. 4. Free abdominal derrnafat used during superficial pa-
and is nsually placed facing against the subadjacent
rotidectomy to prevent Frey syndrome and to fill the cosmetic
subcutaneous layer for optimal blood supply.
defect. Courtesy of Henry H. Rowshan, DDS.

TECHNIQUE OF AUTOGENOUS FREE

ABDOMINAL FAT HARVEST
Extensive comparative studies between different do-
nor sites and fat graft success have yet to be conducted. I. Superficial skin.
The abdominal donor site is the most common owing to 2. Subcutaneous fat.
ease of access and availability of fat stores. General 3. Superficial fascia.
anatomic knowledge of the anterior abdominal wall is 4. Deep fascia.
critical for abdominal fat harvest (Fig. 5). The anterior S. Rectus abdominis muscle.
abdominal wall in the suprapubic area consists of 7 6. Subserous fascia.
layers: 7. Peritoneum.
OOOOE
Volume 109, Number 3 Kantanen et ai. 369

Fig. 5. Anatomy of anterior abdominal wall in umbilicus

region.

The subcutaneous fat layer can be accessed rather

easily immediately below the superficial skin and sub-
cutaneous tissue, which normally measures 5-10 mm
deep. Depending on the size of the patient, a sufficient
layer of subcutaneous fat can be obtained without dif-
Fig. 6. 3-5 cm transverse midline incision approximately 2-3
ficulty. Below the subcutaneous fat, the superficial and
cm below the umbilicus.
deep fascias are encountered. The superficial fascia
overlies the entire anterior abdominal wall just below
the abdominal fat. The deep fascia surrounds the ab-
dominal rectus muscles. The deep fascia of the abdom-
inal wall is different than that found around muscles of
the extremities. It is of the loose connective tissue
variety. It is necessary in the abdominal wall because it
offers more flexibility for a variety of functions of the
abdomen. At certain points, this fascia may become
aponeurotic and serve as attachments for muscle and
bone, as for the linea alba. The rectus abdominis muscle
is a paired muscle running vertically on each side of the
anterior abdominal wall. The muscle is a key postural
muscle, responsible for flexing the lumbar spine. Sub-
serous fascia, also known at extraperitoneal fascia, is a
layer of loose connective tissue that serves as a glue to
hold the peritoneum to the deep fascia of the abdominal
wall or to the outer lining of the gastrointestinal tract. It
may receive different names depending on its location
(i.e., transversalis fascia when it is below that muscle,
psoas fascia when it is next to that muscle, iliac fascia,
etc.) Lastly, before entering the abdominal cavity, the Fig. 7. Two Kocher clamps aiding in fat harvest.
peritoneum, a thin I-ceIl-thick membrane that lines the
abdominal cavity and in certain places reflects inward
to form a double layer of peritoneum. Double layers of
peritoneum are called mesenteries, omenta, falciform incision through skin and subcutaneous tissue to expose
ligaments, lienorenal ligament, etc. the abdominal fat pad. Electrocautery is then used to
The following surgical technique is currently used at control and obtain surgical site hemostasis. Two Kocher
the our institution for fat harvest. The free abdominal clamps are placed on the superficial subcutaneous fat to
fat graft harvest begins by first outlining a 3-5 cm apply tension to aid in the fat harvest (Fig. 7). Care is
transverse midline incision line approximately 2-3 cm taken to limit the dissection to superficial of the ab-
below the umbilicus (Fig. 6). One-percent lidocaine dominal muscular fascia. During the harvesting, the
with I: 100,000 epinephrine is injected into the pro- overlying skin is undermined to maximize the abdom-
posed surgical site. A #10 blade is used to make an inal fat harvest and minimize the length of the skin
 OOOOE
370 Kantanen et ai. March 20JO

Fig. 9. Final closure of abdominal fat harvest site.

Fig. 8. En bloc fat harvest.

incision. A 3-5 mm layer of fat on the skin side is

maintained to decrease the likelihood of an uncosmetic
result and wound dehiscence. With adequate tension on
the fat graft, the fat is then widely undermined super-
ficial to the rectus abdominis muscle fascia to a similar
extent as the overlying skin dissection. The desired
amount of graft is harvested from the midline region
(Fig. 8). To allow for shrinkage and errors in frontal
sinus volume estimation, the fat harvest should be
-30% more than the estimated amount needed to fill
the dead space of the frontal sinus or whereever it is to
be used. Before closure, meticulous hemostatis is
achieved with electrocautery and the need for a drain is
not indicated. The dissection should not violate the
abdominal muscular fascia and should remain solely in
the underlying fat layers. The wound is closed by
advancing the superior and inferior fat flaps toward the
surgical incision and sutured with 3-0 vicryl popoffs in Fig. 10. Fat wrapped in gauze sponge.
an interrupted fashion. The subcutaneous tissue is
closed with 4-0 monocryl in a subcuticular closure
fashion (Fig. 9). To minintize the incidence of hema-
toma and seroma formation, a pressure dressing of autologous fat can be placed into the prepared area.
Kerlix (Hamilton Medical Products, Mill Valley, CAl Patients are maintained on appropriate antibiotics, typ-
fluffed gauze and elastic tape is applied and maintained ically cephalexin, 500 mg 4 times a day for 7 days, as
for a period of 3 days before removal. The harvested well as analgesics after surgery.
autogenous free abdominal fat is wrapped in a moist
saline gauze sponge (Fig. 10). Metabolic analysis has COMPLICATIONS
shown improved cell viability in fat tissue specimens Although fat transfer is generally regarded to be a
undergoing ntinimal manipulation. II Once the maxillo- safe procedure, there are reports of associated morbid-
facial graft site is accessed and prepared, the en bloc ity. Possible complications of abdominal fat graft har-
OOOOE
Volume 109, Number 3 Kantanen et ai. 371

vest include seroma, infection, hematoma, ileus, and REFERENCES

inadvertent peritoneal perforation. The most common 1. Butterwick 10. Nootheti PK. Hsu rw, Goldman MP. Autologous
fat transfer: an in-depth look at varying concepts and techniques.
complication, although still rare, is a seroma formation Facial Plast Surg Clin Nonh Am 2007;15:99.
at the abdominal fat harvest site. Wolford et al. 12 re- 2. Kaufman MR. MiUer TA, Huang C, Roostaien J, Wasson KL.
ported a 6.9% incidence of seroma fonnation requiring Ashley RK. et al. Autologous fat transfer for facial recontouring:
aspiration. Postsurgical abdominal seromas are typi- is there science behind the art? Plast Reconstr Surg 2007;119:
2287-%.
cally evacuated with percutaneous drainage and aspi-
3. Guymon B, Majzoub RK. Facial augmentation with core fat graft:
ration under local anesthesia. Infection rates are con- a preliminary report. Plast Reconstr Sw-g 2007; 120:295-302.
sistent with any other surgical procedure, with an 4. Bergara AR, Itoiz AD. Present state of the surgical treatment of
incidence of around 3%. J2 Abdominal subcutaneous chronic frontal sinusitis. Arch Dto1aryngol 1955;61:616-28.
5. Bergara AR, Itoiz AG. Experimental study of the behavior of
hematoma formation is a rare occurrence during ab-
adipose tissue within the frontal sinus of dog. Argent Rev 010-
dominal fat harvest, with a reported incidence between rhinolaryngoI1951;12:184-92.
0% and 3.2%, owing to the small surgical field, short 6. Montgomery WW. The fate of adipose implants in a bony cavity.
surgical time, and ease to obtain hemostatis. J3 With Laryngoscope 1964;74:816-27.
7. Rowsban HH. Hart K. Arnold JP, Thompson SH, Baur O. Keith
careful attention to hemostasis, drain placement into the
K, Skidmore P. Treatment of human immunodeficiency viros-
harvest site is rarely needed. Adequate placement of associated facial lipodystrophy syndrome wilh dermafat graft
fluffed gauze and elastic dressing minimizes the inci- transfer to the nasolabial fold areas: a case report and review of
dence of hematoma formation. Postsurgical ileus and the literature. J Oral MaxiUofac Surg 2008;66:1932-8.
8. Blair VP. Operative trealment of ankylosis of the mandible.
inadvertent peritoneal perforation are possible sequelae
Trans South Surg Assoc 1913;28:435.
during abdominal fat harvest. An ileus occurs from 9. Murphy JB. Arthroplasty for intra-articular bony and fibrous
hypomotility of the gastrointestinal tract in the absence ankylosis of the temporomandibular articulation. JAMA 1914;
of a mechanical bowel obstruction. Frequently, an ileus 62,1783.
10. Wolford LM. Karras Sc. Autologous fat transplantation around
occurs after intraperitoneal operations, but it may also
temporomandibular joint total joint prostheses: preliminary treat-
occur after retroperitoneal and extra-abdominal sur- ment outcomes. J Oral Maxillofac Surg 1997;55:245-52.
gery. No documented cases of postsurgical ileus or 11. Smith P, Adams WP, Lipschitz AH, Chau B. Sorokin E, Rohrich
peritoneal perforation after abdominal fat harvest could RJ, et al. Autologous human fat grafting: effect of harvesting and
preparation techniques on adipocyte graft survival. Plast Recon~
be found in the literature.
str Surg 2006; 117: 1836-44.
Kaufman et al.\" found that fat transfered into sub- 12. Wolford LM, Morales-Ryan CA, Morales PG, Cassano OS.
cutaneous tissue demonstrated 30% survival after 6 Autologous fat grafts placed around temporomandibular joint
months. Keerl et al. \5 studied fat implanted into the total joint prostheses to prevent heterotopic bone fonnatioo. Proc
frontal sinus of 11 patients for obliteration of the frontal Baylor Univ Moo Cent 2008;21:248.
13. Sanna M, Taibah A, Russo A, Falcioni M, Agarwal M. Periop-
sinus cavity. Postoperative magnetic resonance imag- erative complications in acoustic neuroma (vestibular schwan~
ing evaluation showed viable fat in 6 of the II patients noma) surgery. Olol Neuroto1 2004;25:379-86.
4-24 months after surgery. In the remaining 5 patients, 14. Kaufman MR, Bradley JP, Dickioson B, HeUer JB, Wasson K.
the fat demonstrated necrosis and had been replaced by O'Hara C. et at. Autologous fat transfer national consensus
survey: trends in techniques for harvest, preparation, and appli-
granulation tissue and connective tissue. cation. and perception of short- and long-term results. Plast
Reconstr Surg 2007;119:323-31.
15. Keerl R, Weber R, Kable G, Drat W, Constantinidis J. Saba A.
CONCLUSION Magnetic resonance imaging after frontal sinus surgery with fat
Free abdominal fat harvest is a predictable surgical obliteration. J Laryngol 0101 1995; 109: IlIS·19.
technique that allows the maxillofacial surgeon access
Reprint requests:
to autologous graft material which is ideal for multiple
facial procedures. Minimal morbidity and ideal graft Dr. Dennis J. Kantanen
Tripier Army Medical Center
material will enable abdominal fat to continue to be the
1 Jarrett White Road
gold standard upon which all filler materials are com- Honolulu. Hawaii 96859-5000
pared. dkaOlanen@hotmail.com