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Frozen Fat: Better Than Fresh Fat;
International Journal of Cosmetic Surgery Vol. 7, No.1, 1999

Ziya Saylan, MD - Königsallee 22, 40212 Düsseldorf, Germany
Abstract:. The harvesting of fat which is painful to the patient and costs time to the surgeon can be avoided if the gained fat is frozen. This article answers an important question in autologous fat storage. This Article proves that the frozen fat survives better than the fresh fat and brings more desired results. The Author has observed that just harvested fat cells are swollen and contain more water than normal, due to the tumescent solution injected into the fat. During the thawing, frozen fat cells release water and become more vital than after the infiltration of the tumescent so-lution. The vitality and water release can be documented histologically in this study.

Until now the opinion of the majority of surgeons was as follows: Fat grafting does not remain in the patient longer than 6 to 12 months. Dr. Sydney Coleman1 showed us the certain principles are necessary for successful fat grafting. In his several instructive courses² and presentations, he has shown that long-term and satisfactory results are possible if large amounts of fat is injected. In op-position to Coleman's techniques of Lipostructure whereby large amounts of fat (up to 70ml.) have been injected which causes long term swelling until the water from the tissue diminishes. In my practice of large Volume fat transfer, I had patients complaining about the swelling after treatment for 3 to 4 weeks. After using frozen fat which preferably stored for 8 days, I have observed satis-factory results with less swelling and bruising. After 2 to 3 days the swelling had disappeared. Lesser swelling occurs by means of crystallization of water molecules by freezing and reduction of water during the thawing period. It shows that harvested fat which is stored by means of freezing and used afterwards for lipofilling, gives better results with less swelling and no bruising.

History
The first fat transfer was performed in Germany in 1893. During the 23rd Meeting of the German Society of Surgery, Neuber3 has reported his technique of fat transfer. Neuber removed small pieces of fat from upper arm and implanted it into a depressed area of the face. In 1895 Czerny4 used lipomas in order to enlarge small breasts. His results were very satisfactory, he advocated the use of small pieces of fat transplants, which believed to survive and live longer. In 1909 an-other respected authority on this topic appeared, Lexer5 has performed large amount of fat trans-plantation's and wrote many articles about it. Lexer used large pieces of fat transplants; according to his experiences, this form of fat yielded better results.

The first physician to study the fat after the transplantation was a French physician named Tuffier6. He inserted fat into the pleural space and after 4 months he made biopsies of the fat transplant. He reported that most of the fat was absorbed and replaced by fibrous tissue. Zipper7 followed Tuffier in performing a biopsy on free transplants after mammoplasties. He observed that there is a capsule around the implanted fat as well as that of normal living fatty tissue.

In the 1930s the surgeons started using pedicle flaps and neglected the free fat transfers. The pedicle flaps conserved the blood supply to the fat, which made the outcome more predictable. In the early 1950s artificial substances such as paraffin and silicone became available. Few physi-cians continued to work with free fat transplants. A German physician, Brunnings8 placed small pieces of fat in a syringe, and injected them through a needle into the nasal dorsum in order to cor-rect postrhinoplasty deformities.

In 1950, Peer9 reported a series of experiments with autologous transplants in humans. Thirteen cases of transplanted fat were reported wherein large pieces of fat were used. Later the trans-planted fat was removed at intervals varying from 3 days to 14 months. The pathological findings included the fact that vascular invasion begins by the fourth day after transplantation, and it was noted that part of the fat cell liquefied. About 45% of the original volume was lost within a year. Peer concluded that fat cells survive transplantation, in contrast to previous theories stating that histocytes would absorb the fat.

In the modern times Pierre Fournier10 in France started to use the aspirated fat for the body-styling purposes. Liposuction led to the development of techniques, involving the grafting of fat from the body and extremities for use in other areas of the body, particularly the face and the breast. These techniques have been used successfully for a number of years, but early relative unpredictability of fat survival made many surgeons decide that fat was not a good or reliable material to be used for tissue augmentation. One interesting development that comes from fat transplantation has been the possibility of removing the collagen from the fat and reinjecting it. Dr. Fournier has also devel-oped a technique to gain collagen from the body during fat harvesting. Julius Newman11 in Phila-delphia have patented a machine that can be used with liposuction equipment to extract this por-tion of the collagen from the fat for reinjection.

About four years ago I had heard that some colleagues were freezing the fat and reinjecting it. This gave me courage to try it also. The pathologist who was examining our operation materials offered me immediately his cooperation. This study is the product of this cooperation and it shows how to store own fat of the patient by means of freezing.

Harvesting
The harvesting is done in low pressure suctioning with large diameter cannulas (3 mm) and without any centrifuging. The parts of the body chosen must be a low tension place such as gluteal region and the abdomen which enables the fat cells to survive. The fat cells gained from parts of the body where a fluctuation of volume occurs, reduce their amount of cells as the patient may fast or makes a diet. After waiting about 30 minutes in a metal strainer (open technique) the fat tissue is filled into a 5 ml syringe and marked with the name and the birthday of the patient. Afterwards it will be placed in a box made specially for this purpose and cataloged again.

Freezing
The freezing of fat at the outset has been done in a normal commercial refrigerator deep freeze. A shock freezing (immediate, quick freezing) is not desirable and is believed to destroy the fat cells. We maintain a constant temperature and safeguard against poweroutages and have a backup power supply. Any drastic increase in temperature will result in totally damaging the stored fat tis-sues randoming them useless. I have consulted with the sperm-bank of the University hospital of City Düsseldorf. They have advised me to freeze in lower temperatures so that in case of an tem-perature problem I will have six to eight hours to rerefrigiate the fat. We are freezing at a constant of minus 30 degrees Co and a build in warning system which informs me about any temperature changes. Labeling and cataloging of the frozen fat samples is critical. Cataloging and Double-check is a primary factor in my security system.

Warming up
The syringe filled with frozen fat is taken out of the deep freeze as the patient arrives at the office and by means of holding the frozen syringe for 20 minutes in the hand, the patient warms up her own fat.

During the thawing process we have found out the freezing and warming allows the fat to release water and become more condense which makes it more vital. It has been found that the thawing of the frozen sperms have resulted in tissue deteriation by means of lost of water. During the warming up procedure water collects at the bottom of the syringe when held in a vertical position. This is done by draining of this excess water.

Lipoinjection
The injection of the frozen fat does not differ from the conventional lipoinjection. The amount in-jected in one part of the face must be less than 4 cc. Low pressure filling is necessary which re-quires a thick needle (1.8 to 2.4 mm) and a small syringe (not bigger than 5 ml). The larger sy-ringes produce to much pressure as you inject and kill the fat cells.

Small pearls of fat are injected in different layers. An injection close to periosteum or to the ves-sels facilitates a better blood supply which will make it possible for the fat to survive longer. Mold-ing the fat immediately is very important to distribute the fat in different layers homogeneously and evenly to the facial contours where the blood supply is optimal.

I have found that it is best to administer the desired amount of fat in two or three separate ses-sions. By injecting the total fat desired at one time the body is unable to nourish the newly introduced fat and a large percent of fat cells injected diminish due to insuffi-cient blood supply. Resulting in uneven distribution.

I inject the first amount of fat 8 days after the harvesting, the second amount after 3 to 6 weeks and the third and final amount after 6 to 12 months.

Histology
A histological study5 of freshly harvested fat cells has shown that the cells are swollen because of the injected tumescent solution. Figure 1 shows a histological section of swollen adipose tissues. The proportions of the cells have been changed showing more fat (Swelling) than the collagen septa and the Figure 2 shows how the normal histological conditions have been restored again af-ter freezing and thawing again. Figure 2 is almost identical to a normal adipose tissue harvested without any tumescent solution.

I had a few opportunities to take out the injected fat again (mainly after penile enlargements for correction purposes) which was frozen before. The histological study of these adipose tissue has shown totally vital adipose tissues with normal amount of collagen septa and some small blood vessels (Figure 3) as an evidence of revascularisation.

Advantages of Interval Frozen Fat Injections
1. Controlled results
2. Better possibility of contouring and replacement
3. Less swelling and no bruising
4. Long lasting results
5. Easy to obtain and perform
6. Less pain for the patient

Results:
Since October 1995 we have performed frozen fat injections in 105 patients with satisfactory re-sults. 6.7% of the patients (7 cases) were males who had undergone malar and penile enlarge-ment. Patient ages range from 19 to 74 years with ages 30-39 and 40-49 accounting for 36% and 41% of total patients respectively. Between 1 and 12 ml of frozen fat tissue was injected. The graph in Figure 1 demonstrates the amount of frozen fat injected. The other 98 (93 %) female pa-tients had undergone mainly malar , lip and chin enlargements. All cases were satisfactory. 12 pa-tients (12%) didn't show up again after the first injection, they had all to come from far away. The other group of patients (93 patients) became lipoinjections approximately 2,9 times. 75 patients still have frozen fat in our freezer, this work is still not finished and will be updated next year with more accurate results. We had 2 cases of infection one at a penile lipofilling (in our opinion due to hy-genic conditions) and one case of a female patient who had diabetes (was not known by the pa-tient).

Conclusion:
This technique will assist the surgeon in sculpturing, formation and contouring of the face and body, thus obtaining the desired results for the patients without any major swelling and bruising. The frozen fat survives, if obtained and stored properly, better than using the immediate harvested fat.

References
1. Coleman, Sydney, MD; Personal Conversation; November 1996 during the 14th Annual Meet-ing of the Lipoplasty Inc. Dallas, Texas
2. Coleman, Sydney, MD; Facial Recountouring with Liposculpture, Instructive Course in Düssel-dorf - Germany, April 11th, 1997. His own remarks.
3. Neuber F.,MD; Fat Grafting, Chirurgische Kongress der Deutschen Gesellschaft für Chirurgie Verh. 22:66, 1893 (in German)
4. Czerny, M., MD; Reconstruction of the Breast with a lipoma. Chirurg. Kongress Verh. 2:216 1895 (in German)
5. Oellig Peter, MD Pathology Institute of Mülheim, Heide Str. Mülheim an der Ruhr. Germany; Personal Communication and also his Presentation during the Fat Transfer Meeting in Düssel-dorf, November 14th 1997.
6. Tuffier, E.; Treatment of pulmonary gangrene and fat embolism; Troiseme Congress Interna-tionale Chirurgi,1911, p. 780 (in French)
7. Zipper, J.; Fettransplantationen, Beitrag Klinische Chirurgie, 81; 1912.
8. Brunings; Cited by Broeckaert and Steinhaus, 1951.
9. Peer L.A. ; The neglected free fat graft. Plast. Reconstr. Surgery 18:233, 1956
10. Fournier, Pierre; Personal Conversations 1991-1996
11. Newman, Julius; Personal Conversations and demonstrations during several Workshops in Philadelphia 1992-1994

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