history

The history of fat grafting is fascinating and goes back to the 17th century. Since then many attempts have been made to transplant fat. Since a couple of decades the technique has been re-introduced and refined.

For the first report of fat allotransplantation we have to go back to the seventeenth century. On the 5th of July 1601, the Archduke Albert began the siege of Ostend – described as ‘the long carnival of death – with 20,000 men and 50 siege guns. After each encounter the Dutch surgeons brought in great bags filled with human fat, which was then esteemed the sovereignest remedy in the world for wounds and diseases.

close microscopic view of fat cells used for lipofilling

Van der Meulen described the first use of fat in human autotransplantation in 1889 (3). The procedure consisted of grafting a free omentum and fat autograft between the liver and diaphragm.

The first use of free fat autografts in humans was by the German surgeon Gustav Adolf Neuber in 1893, in which several small grafts were used to fill a soft-depression in the face in a 20-year-old man. Neuber mentioned he had less success when he tried to use larger grafts, saying “grafts larger than an almond would not give good results”.

Other pioneers in fat grafting were Lexer (1909) and Ellenbogen (1986) who used fat pearls to treat tissue deficiencies in the face. The first reported use of fat in breast reconstruction was a case by Czerny in 1895. Other names include Lexer (1931), May (1941) en Schorcher (1957). Schorcher believed that the fat shrinked to one-fourth the original size by 6 to 9 months. Surgeons have used free fat autotransplants for many purposes. There is a wide and varied application of free fat autotransplantation in surgery and it illustrates that free fat autografts have provided a useful material for small amounts of soft-tissue augmentation under ideal conditions. Lexer believed that careful preparation of the implantation bed and immediate transfer would give optimal results. Brunings in 1911 used a syringe to inject small cubes of adipose tissue under the skin. He became dissatisfied with the results due to progressive absorption of the graft.

Wertheimer and Shapiro (1948) reported that fat develops from very primitive adipose cells and the structure of the cells is like that of the fibroblasts of connective tissue. Peer (1956) stressed that survival of fat grafts was dependent on early neovascular anastomoses (new blood vessels), and stated that 50% of the adipose cells in free fat grafts survive.

microscopic close-up of a fat cell or adipocyte

The literature concerning the study of microscopic events that occur within the free fat autografts has spanned 80 years. It has represented some consistent observations and provided a great knowledge and understanding of the behavior of adipose tissue as an organ. Other physicians and researchers have studied the behavior of free fat grafts. They observed how vessels in the graft connected up (anastomosed) with vessels at the grafted area. This process occurred at day 4 after transplantation. Another observation was that apparently only the periphery of fat grafts survived while the center of the graft degenerated (Neuhof, 1941).

Watson observed that the fat graft survived on oxygen and carbon dioxide diffusion in a state of anaerobic metabolism, but oxygen diffusion is limited to a 1 mm depth into the graft prior to revascularization, which occurs in 2 to 4 days. Surgeons also observed that when a patient is given a lipid-rich diet after implantation, there is also a decrease in the loss of bulk from fat grafts. Wasserman (1926) described the “preadipocyte”.

microscopic images of the vascularisation of fat cells in lipofilling plastic surgery

Hausberger (1954) stated that is was the “preadipocyte”, or mesenchymal adipose cell precursor, that is destined to become a mature adipose cell. He worked with immature fat in a rat model. During the 1960s and 1970s, there was a relative disinterest in fat transplantation and physicians and researchers started to focus more on the behavior of fat tissue in obesity. Many investigators deduced that adults have a fixed complement of adipocytes and that new adipose cells are not formed in adult adipose tissue. In 1971, Smith was the first to describe fibroblast-like or spindle-shaped cells grown in tissue cultures. Van (1976) studied adipocyte precursors in tissue culture and concluded that adipose tissue is probably much more dynamic than previously thought. Together with Roncari in 1978, he developed a culture system to study the complete morphologic maturation of adipocytes in culture.  In 1974, a gynecologist, Dr. Fischer, invented the liposuction technique. Later in 1978, French physicians Illouz and Fournier further developed the procedure and introduced it in the clinic. By 1980, liposuction was becoming extremely popular in the United States. Dr Klein (1985), a California dermatologist, invented the revolutionizing tumescent technique for liposuction. His “Tumescent Technique” allowed patients to have liposuction performed totally by local anesthesia using much smaller cannulas. Patients could now have liposuction surgery without the fear of excessive bleeding and undesirable skin depressions.