Aesth Plast Surg DOI 10.1007/s00266-013-0254-6
I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Simplified Lipostructure: A Technical Note Guido Paolini • Matteo Amoroso • Benedetto Longo Michail Sorotos • Dimitrios Karypidis • Fabio Santanelli di Pompeo
•
Received: 12 June 2013 / Accepted: 7 November 2013 Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background The Coleman technique is universally recognized as the gold standard for fat transfer, but although effective, it is tedious, time consuming, and costly. This report proposes a new and more efficient method of fat grafting (simplified lipostructure). Methods This report introduces a modification of the standard Coleman transfer and injection technique, performed by connecting a 10-ml syringe to a 1-ml syringe and to a blunt infiltrating cannula through a ‘‘three-way stopcock valve.’’ The study retrospectively evaluated two groups of patients who had undergone either Coleman or simplified lipostructure, comparing surgical staff, operative time, volume of infiltrated fat, cosmetic outcome, and complications. Statistical analyses were conducted using the Wilcoxon rank sum test and Spearman’s rank-order correlation. Results The simplified lipostructure group compared with Coleman lipostructure showed a reduced operative staff (1 vs. 2 members), a reduced operative time (66 vs. 74.2 min) Electronic supplementary material The online version of this article (doi:10.1007/s00266-013-0254-6) contains supplementary material, which is available to authorized users. G. Paolini (&) M. Amoroso B. Longo M. Sorotos F. Santanelli di Pompeo Plastic Surgery Unit, Faculty of Medicine and Psychology, Sant’Andrea Hospital, ‘‘Sapienza’’ University of Rome, Via di Grottarossa 1035/1039, 00189 Rome, Italy e-mail: [email protected] D. Karypidis Plastic Surgery Unit, ‘‘Andrea Sygros’’ Hospital, School of Medicine, University of Athens, Athens, Greece D. Karypidis II Level Master on Breast Reconstruction, Faculty of Medicine and Psychology, ‘‘Sapienza’’ University of Rome, Rome, Italy
(a = 0.0035), and an increased volume of infiltrated fat (167.2 vs. 138.7 ml) (p \ 0.0001) while retaining comparable cosmetic results (7.45 vs. 7.25; visual analog scale 0–10), and only minor complications. Conclusion The three-way stopcock valve system appears to be a smart technical solution that eases syringe refilling, improves fat transplantation times, and reduces costs. The findings show this technical modification to be easy and effective. The authors therefore recommend it to all surgeons performing fat transfer. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Lipostructure Lipofilling Lipografting Fat transplant Adipose tissue Coleman technique
Introduction The term ‘‘liposculpture’’ was first coined by Fournier in 1989 to describe a process of first harvesting adipose tissue through liposuction and then regrafting it in selected areas to correct irregularities [1]. However, the use of autologous adipose tissue for the same reason had already been reported previously by several other authors [2, 3]. Coleman [4] in the 1990s developed a new, less invasive, and more effective technique for collecting and relocating adipocytes (lipostructure), preserving them from reabsorption, and popularized his method for fat harvesting and processing, naming it the ‘‘Coleman System.’’ Several authors proposed modifications of Coleman’s technique in their effort to improve graft take [2, 5–11].
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Refinements of the technique involved harvesting fat in the form of small particles, protecting it from air exposure, and reducing the pressures used during aspiration and injection that possibly caused mechanical trauma to the fragile graft during its passage through narrow parts such as the connectors and the cannula. This report presents a new and more efficient method of fat grafting that promises less fat manipulation, time savings, and cost reductions. This method is useful primarily for breast cosmetic and reconstructive purposes.
Materials and Methods From January 2012 to April 2013, we applied our modified technique to more than 200 reconstructive and aesthetic lipostructure cases. In our fat-grafting technique, the fat transfer is combined with the infiltration phase. This is accomplished by using a different type of connector, the three-way stopcock instead of the usual ByronTM connector used to pass fat from 10 to 1-ml syringes. To investigate the usefulness of our method, we compared it with the technique used previously (Coleman System). We included only postmastectomy breast reconstruction cases so as to evaluate a homogeneous sample of patients and reduce the number of confounding variables. We performed a retrospective review of our prospective breast reconstructive surgery database and selected two groups of patients who had undergone lipostructure for primary or secondary breast reconstruction at our institution. Only cases with at least 100 ml of infiltrated fat per breast during each session were selected. Patients who had undergone lipostructure for different purposes with associated procedures or had a follow-up period shorter than 6 months were excluded from the study. The ‘‘standard’’ group was composed of 111 cases and 94 patients (two patients underwent five sessions, three patients underwent three sessions, and three patients underwent two sessions each) treated with the ‘‘Coleman technique’’ (lipostructure) between January 2010 and December 2011. The mean age of the patients was 50 years (range 31–74 years). Lipostructure was used as primary breast reconstruction in 11 cases (6 skin-sparing mastectomy [SSM] reconstructions and 5 quadrantectomies [QUARTs]). Additionally, lipostructure was used to improve the result of purely autologous reconstruction in 50 cases (49 deep inferior epigastric perforator flaps [DIEPs] and 1 thoracodorsal artery perforator flap [TAP]) and of implant-based reconstruction in 50 cases (30 latissimus dorsi flaps [LD], 14 expander-implant reconstructions, and 6 Wise-pattern mastectomy reconstructions). The ‘‘modified’’ group consisted of 104 cases and 92 patients (82 patients with one session, 8 patients with two
123
sessions each, plus 2 patients with three sessions each) (82 ? 16 ? 6 = 104 sessions or cases) treated with the three-way stopcock technique (simplified lipostructure) between January and December 2012. The mean patient age was 51 years (range 32–67 years). Simplified lipostructure was used as primary breast reconstruction in 22 cases (16 SSM reconstructions and 6 QUARTs), to improve the result of purely autologous reconstruction in 34 cases (33 DIEPs and 1 TAP), and for implant-based reconstruction in 48 cases (28 LDs, 11 expander-implant reconstructions, and 9 Wise-pattern mastectomy reconstructions). The three-way stopcock connector is a device routinely used by nurses and anaesthesiologists to deliver different fluids from one-vein access only simultaneously. It is a sterile device very easy to handle, readily available, and affordable in each hospital facility. The three-way stopcock connector has two way-in exits and one way-out exit, allowing the simultaneous connection of the 10 and 1-ml syringes with the blunt infiltration cannula (Fig. 1). In one step, it allows the clinician to switch the fat from the 10-ml syringe to the 1-ml syringe by pressing the 10-ml plunger and retrieving the 1-ml one, and to start the injection by simply rotating the valve and pressing the 1-ml plunger. When the 1-ml syringe is emptied, the valve is turned back 90, and the syringe is filled again without removal of the infiltrating cannula from the host bed and without changing the 1-ml syringe (Supplemental Digital Content, Video 1). Patient charts, surgical records, and clinical pictures were reviewed and analyzed. The data evaluated were the number of surgeons participating, the operative time, the volume of infiltrated fat, and the registered complications. Because the aim of lipostructure was to improve breast shape, breast volume, and skin irregularities, the cosmetic result of the procedure was considered as in indirect measurement of fat graft take. The cosmetic outcome of lipostructure was judged by a separate team of blinded plastic surgeons (three independent observers), who evaluated the pre- and postoperative clinical pictures 6 months or more after surgery using a visual analog scale (VAS) based on a score of 0–10. A score of 0–5 was considered to be poor, whereas a score of 6 was regarded as fair, and a score of 7–10 to be considered as good to excellent. No ultrasound scanning investigation was conducted. Statistical Analysis VAS scores consist of Likert-type scale data, so nonparametric analysis using the Wilcoxon rank sum test (a.k.a. Mann–Whitney test) for the two independent sets of scores (one set of scores from the standard and one set from the modified group) was appropriate. The Spearman rank-order correlation coefficient (Spearman’s q) was used to calculate the correlation between paired variables (e.g., the
Aesth Plast Surg Fig. 1 a The three-way stopcock connector system (the valve is connected to a 10-ml syringe, a 1-ml syringe, and a blunt-tip infiltrating cannula). b The 10-ml syringe with centrifuged fat is connected to the system. The valve is in the open position at 0. c The valve is rotated 90 clockwise, and 1 ml of fat is transferred to the 1-ml syringe. d The valve is rotated 180 clockwise, and the system is ready for transfer of fat from the 1-ml syringe to the recipient site through the blunttip cannula
Table 1 Statistical analyses of the results in the standard and modified lipografting groups
Infiltrated/harvested fat (%)
Standard group Coleman technique
Modified group Stopcock technique
Statistical significance (a B 0.05; p B 0.05)
69
68
a = 0.002*
Average infiltrated fat (ml)
138.7
167.2
p \ 0.0001*
Average operative time (min)
74.2
66
a = 0.0035*
Volume of grafted fat (ml/min)
1.84
2.5
a \ 0.0001*
Overall infiltration/volume grafted fat per min (correlation, Spearman’s q)
0.39
–
p = 0.0014*
–
0.66
p \ 0.0001*
Cosmetic outcome (VAS score 1–10)
7.25
7.45
a = 0.076-NS
NS not significant * Statistically significant
correlation between the total amount of grafted fat and the volume of grafted fat per minute). Statistical significance was considered to be indicated by a values of 0.05 or lower and p values of 0.05 or lower.
Results The surgical team was composed mainly of one senior surgeon and one resident in the standard group and of one senior surgeon only in the modified group. The percentage of the infiltrated fat (of the total harvested amount) was 69 % in the standard group versus 68 % in the modified group, and these results were statistically significant (a = 0.002, Mann–Whitney test). The average infiltration of fat to the breast was 138.7 ml (range 100–286 ml) in the
standard group compared with 167.2 ml (range 100–250 ml) in the modified group, and this difference was highly significant (p \ 0.0001). The average operative time was 74.2 min (range 35–200 min) in the standard group compared with 66 min (range 40–200 min) in the modified group, and this difference also was statistically significant (a = 0.0035) (Table 1). Additionally, the average volume of grafted fat per minute rate efficiency was 2.5 ml/min in the modified group versus 1.84 ml/min in the standard group, and this difference was highly significant (a \ 0.0001). In the modified group, the overall infiltrated amount of grafted fat was positively correlated with the volume of fat infiltration per minute (q = 0.66; p \ 0.0001). The aforementioned correlation was lower but still positive (q = 0.39; p = 0.0014) in the standard group.
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The cosmetic outcome of the procedures investigated with the VAS score (1–10) was 7.25 (range 6–9) in the standard group and 7.45 (range 6–9) in the modified group. No major complications such as skin or flap necrosis or implant infection were observed in either group. Minor complications such as ecchymoses were common among both groups. Hematoma in the donor area was observed in three standard group patients and two modified group patients undergoing low-molecular-weight heparin for deep venous thrombosis prophylaxis. One case of breast inflammation was observed at the 2-month follow-up assessment in the modified group, which healed spontaneously with medical treatment. Regarding the cosmetic outcome evaluation in both groups using the Wilcoxon rank sum test, no significant difference was shown between the medians of the two groups (a = 0.076) (Table 1).
Discussion Currently, fat transfer in general has become an exceptionally advantageous method for plastic and aesthetic surgeons and is spreading worldwide. The concept is simple and effective, but the Coleman technique and some of the procedures proposed by others can be very tedious and costly because of the need for an assistant, several syringes, and a quite long operative time. From this perspective, the use of the three-way stopcock valve provides a smart technical solution that enables easy syringe refilling, improves fat transplantation times, and promises reduced costs. This system is easy to implement and user friendly. It allows for 10 ml of fat to be transferred using 1-ml cannulas according to micro structural fat-grafting principles. It allows fast and precise positioning of the fat particles into the recipient area by a single operator with minimal fat trauma and air exposure. By connecting the 10-ml syringe through the three-way stopcock valve to the 1-ml syringe and to the blunt infiltrating cannula, we create a closed system that allows the transfer of 10 ml fat of fat in microparticles to the recipient bed in one step. The same 10-ml syringes used for aspiration and fat centrifugation are used in each session for fat infiltration. The fact that the 10-ml syringe remains in the field during grafting has not proved to be inconvenient because of the ability to rotate it around the axis of the 1-ml syringe accordingly and avoid contact with the field. This technique also has not proved to be uncomfortable in recipient areas other than the breast. The three-way stopcock valve system provides a faster and more compact system of fat infiltration than the Coleman technique due to the customization of the 10-ml syringes and their use as a fat depot. The 1-ml infiltration syringe is ready for use, offering a larger volume ([1/3 ml)
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for injection per ‘‘turn’’ [4]. In our hands, the syringe can deliver almost 2.5 ml of fat per minute compared with the 1.84 ml of the Coleman method, saving almost 20 min in a 150-ml procedure (60 vs. 80 min). Furthermore, this system allows the surgeon to work alone without the help of an extra assistant to fill up the syringes. Therefore, although a real-cost analysis of the two methods has not been undertaken, the three-way stopcock valve system promises to reduce theatre, personnel, and equipment costs significantly. Regarding the percentage of fat graft take and the incidence of complications, in our hands, the modified method showed results comparable with those of the Coleman technique because the technique of fat dispersion in the hosting bed rests the same, and the harvesting procedure is identical. The weak positive correlation between overall grafted volume and grafted volume per minute in the standard group shows that with the Coleman method, the efficiency in terms of how much fat is grafted per minute remains rather constant in both the small and larger amounts of grafted fat. Conversely, in the modified group, the same correlation was much stronger (almost double), showing that the larger the amount of the total infiltrated fat, the higher the efficiency (volume per minute) of fat infiltration per minute. This result is supported by the significantly shorter overall intraoperative times in the modified group and by the highly significant difference between the means of the volume per minute in each group (with the modified group having a much higher rate) (Table 1). Consequently, when large amounts of fat are required, the improved rate of fat infiltration increases and makes the stopcock method clearly superior. When smaller amounts of fat are needed, the stopcock method retains its advantageous volume per minute rate and still comprises an improved alternative in terms of time efficacy. Compared with more recent methods, our technique retains the efficacy of the original Coleman System while reducing operative times and costs. The LipiVage system (Genesis Biosystems Inc, Lewisville, TX) [6] is primarily an efficient fat-harvesting system. However, use of a separate compatible transfer system is required in lipofilling procedures. Consequently, although it may save time by eliminating the need for centrifugation, LipiVage system (Genesis Biosystems Inc, Lewisville, TX) requires additional patented parts, a longer time to connect, and a higher cost to obtain. The Ellik evacuator (BARD, Covington, GA) [7] requires a power-assisted suction machine and additional system parts, increasing the cost for the harvesting phase alone and offering no alternative to the method of infiltration. Nguyen et al. [9] in their animal study used a smaller syringe than that used in the Coleman technique. Although their modification showed promising results in infiltration of
Aesth Plast Surg
more superficial layers, its efficiency was not tested clinically, and it is fundamentally similar to the Coleman System. Similarly, the double-folded needle technique by Pignatti et al. [10] presents a method for draining serum from the aspirate, and the water-assisted fat-harvesting methods such as BEAULITM (Park-Klinik Birkenwerder, Birkenwerder, Germany) [11] may be efficient in harvesting small fat particles in large quantities but require additional compatible parts for fat infiltration, and their cost is high.
•
We find this technical modification to be easy and effective and therefore recommend it to all surgeons performing fat transfer.
Conflict of interest interest.
The authors declare they have no conflict of
References Conclusions In our opinion, the three-way stopcock system has several advantages: •
•
•
•
It is faster than other techniques because it does not require replacing the emptied 1-ml syringe with a filled one by disconnecting it from the cannula through which every milliliter of fat is injected (10-fold faster for a 10-ml injection). It is a safer system because it reduces fat manipulation and air exposure, avoiding open-air 1-ml syringe refilling and connection. It is a cheaper system because an extra assistant is not required (cost of 40 euro/h1) to fill up the 1-ml syringes and pass them to the surgeon. It requires only one 1-ml syringe (cost, 30 cents each) instead of multiple syringes. It uses the three-way stopcock valve (cost, 0.156 euro) instead of the ByronTM connector (cost, 38 euro), and it allows faster fat delivery, reducing the operative time by one-fourth in our experience and consequently reducing theatre costs (cost, 560 euro 9 1 h). A saving of about 220 euro for a 1-h procedure may be expected. It allows easier planning and assessment for the amount of fat transferred to each region because it consistently delivers 10 ml of fat per use.
1. Fournier PF (1996) Liposculpture: my technique. ArnetteBlackwell, Paris 2. Flynn TC, Coleman WP, Field LM, Klein JA, Hanke CW (2000) History of liposuction. Dermatol Surg 26:515–520 3. Illouz YG (1996) History and current concepts of lipoplasty. Clin Plast Surg 23:721–730 4. Coleman SR (1995) Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 19:421–425 5. Butterwick KJ, Nootheti PK, Hsu JW, Goldman MP (2007) Autologous fat transfer: an in-depth look at varying concepts and techniques. Facial Plast Surg Clin North Am 15:99–111 6. Ferguson RE, Cui X, Fink BF, Vasconez HC, Pu LL (2008) The viability of autologous fat grafts harvested with the LipiVage system: a comparative study. Ann Plast Surg 60:594–597 7. McArdle C, Feehily A, Allison KP (2013) The Ellik evacuator: a modified technique for autologous fat collection during fat harvest. J Plast Reconstr Aesthet Surg 66:737–738 ¨ ber die Wiederanheilung vollsta¨ndig vom 8. Neuber G (1893) U Ko¨rper getrennter, die ganze Fettschicht enthaltender Hautstu¨cke, in Zbl f. Chirurgie 30:16 9. Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G (2012) Development of micro-injection as an innovative autologous fat graft technique: the use of adipose tissue as dermal filler. J Plast Reconstr Aesthet Surg 65:1692–1699 10. Pignatti M, Bruti M, Rigotti G (2001) Saving one step in lipostructure: M-AGO (magic needle). Plast Reconstr Surg 108:1833–1834 11. Ueberreiter K, von Finckenstein JG, Cromme F, Herold C, Tanzella U, Vogt PM (2010) BEULI, a new and easy method for large-volume fat grafts. Handchir Mikrochir Plast Chir 42:379–385
1
Single-surgeon average cost per hour according to the Italian National Health Service.
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I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Simplified Lipostructure: A Technical Note Guido Paolini • Matteo Amoroso • Benedetto Longo Michail Sorotos • Dimitrios Karypidis • Fabio Santanelli di Pompeo
•
Received: 12 June 2013 / Accepted: 7 November 2013 Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background The Coleman technique is universally recognized as the gold standard for fat transfer, but although effective, it is tedious, time consuming, and costly. This report proposes a new and more efficient method of fat grafting (simplified lipostructure). Methods This report introduces a modification of the standard Coleman transfer and injection technique, performed by connecting a 10-ml syringe to a 1-ml syringe and to a blunt infiltrating cannula through a ‘‘three-way stopcock valve.’’ The study retrospectively evaluated two groups of patients who had undergone either Coleman or simplified lipostructure, comparing surgical staff, operative time, volume of infiltrated fat, cosmetic outcome, and complications. Statistical analyses were conducted using the Wilcoxon rank sum test and Spearman’s rank-order correlation. Results The simplified lipostructure group compared with Coleman lipostructure showed a reduced operative staff (1 vs. 2 members), a reduced operative time (66 vs. 74.2 min) Electronic supplementary material The online version of this article (doi:10.1007/s00266-013-0254-6) contains supplementary material, which is available to authorized users. G. Paolini (&) M. Amoroso B. Longo M. Sorotos F. Santanelli di Pompeo Plastic Surgery Unit, Faculty of Medicine and Psychology, Sant’Andrea Hospital, ‘‘Sapienza’’ University of Rome, Via di Grottarossa 1035/1039, 00189 Rome, Italy e-mail: [email protected] D. Karypidis Plastic Surgery Unit, ‘‘Andrea Sygros’’ Hospital, School of Medicine, University of Athens, Athens, Greece D. Karypidis II Level Master on Breast Reconstruction, Faculty of Medicine and Psychology, ‘‘Sapienza’’ University of Rome, Rome, Italy
(a = 0.0035), and an increased volume of infiltrated fat (167.2 vs. 138.7 ml) (p \ 0.0001) while retaining comparable cosmetic results (7.45 vs. 7.25; visual analog scale 0–10), and only minor complications. Conclusion The three-way stopcock valve system appears to be a smart technical solution that eases syringe refilling, improves fat transplantation times, and reduces costs. The findings show this technical modification to be easy and effective. The authors therefore recommend it to all surgeons performing fat transfer. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Lipostructure Lipofilling Lipografting Fat transplant Adipose tissue Coleman technique
Introduction The term ‘‘liposculpture’’ was first coined by Fournier in 1989 to describe a process of first harvesting adipose tissue through liposuction and then regrafting it in selected areas to correct irregularities [1]. However, the use of autologous adipose tissue for the same reason had already been reported previously by several other authors [2, 3]. Coleman [4] in the 1990s developed a new, less invasive, and more effective technique for collecting and relocating adipocytes (lipostructure), preserving them from reabsorption, and popularized his method for fat harvesting and processing, naming it the ‘‘Coleman System.’’ Several authors proposed modifications of Coleman’s technique in their effort to improve graft take [2, 5–11].
123
Aesth Plast Surg
Refinements of the technique involved harvesting fat in the form of small particles, protecting it from air exposure, and reducing the pressures used during aspiration and injection that possibly caused mechanical trauma to the fragile graft during its passage through narrow parts such as the connectors and the cannula. This report presents a new and more efficient method of fat grafting that promises less fat manipulation, time savings, and cost reductions. This method is useful primarily for breast cosmetic and reconstructive purposes.
Materials and Methods From January 2012 to April 2013, we applied our modified technique to more than 200 reconstructive and aesthetic lipostructure cases. In our fat-grafting technique, the fat transfer is combined with the infiltration phase. This is accomplished by using a different type of connector, the three-way stopcock instead of the usual ByronTM connector used to pass fat from 10 to 1-ml syringes. To investigate the usefulness of our method, we compared it with the technique used previously (Coleman System). We included only postmastectomy breast reconstruction cases so as to evaluate a homogeneous sample of patients and reduce the number of confounding variables. We performed a retrospective review of our prospective breast reconstructive surgery database and selected two groups of patients who had undergone lipostructure for primary or secondary breast reconstruction at our institution. Only cases with at least 100 ml of infiltrated fat per breast during each session were selected. Patients who had undergone lipostructure for different purposes with associated procedures or had a follow-up period shorter than 6 months were excluded from the study. The ‘‘standard’’ group was composed of 111 cases and 94 patients (two patients underwent five sessions, three patients underwent three sessions, and three patients underwent two sessions each) treated with the ‘‘Coleman technique’’ (lipostructure) between January 2010 and December 2011. The mean age of the patients was 50 years (range 31–74 years). Lipostructure was used as primary breast reconstruction in 11 cases (6 skin-sparing mastectomy [SSM] reconstructions and 5 quadrantectomies [QUARTs]). Additionally, lipostructure was used to improve the result of purely autologous reconstruction in 50 cases (49 deep inferior epigastric perforator flaps [DIEPs] and 1 thoracodorsal artery perforator flap [TAP]) and of implant-based reconstruction in 50 cases (30 latissimus dorsi flaps [LD], 14 expander-implant reconstructions, and 6 Wise-pattern mastectomy reconstructions). The ‘‘modified’’ group consisted of 104 cases and 92 patients (82 patients with one session, 8 patients with two
123
sessions each, plus 2 patients with three sessions each) (82 ? 16 ? 6 = 104 sessions or cases) treated with the three-way stopcock technique (simplified lipostructure) between January and December 2012. The mean patient age was 51 years (range 32–67 years). Simplified lipostructure was used as primary breast reconstruction in 22 cases (16 SSM reconstructions and 6 QUARTs), to improve the result of purely autologous reconstruction in 34 cases (33 DIEPs and 1 TAP), and for implant-based reconstruction in 48 cases (28 LDs, 11 expander-implant reconstructions, and 9 Wise-pattern mastectomy reconstructions). The three-way stopcock connector is a device routinely used by nurses and anaesthesiologists to deliver different fluids from one-vein access only simultaneously. It is a sterile device very easy to handle, readily available, and affordable in each hospital facility. The three-way stopcock connector has two way-in exits and one way-out exit, allowing the simultaneous connection of the 10 and 1-ml syringes with the blunt infiltration cannula (Fig. 1). In one step, it allows the clinician to switch the fat from the 10-ml syringe to the 1-ml syringe by pressing the 10-ml plunger and retrieving the 1-ml one, and to start the injection by simply rotating the valve and pressing the 1-ml plunger. When the 1-ml syringe is emptied, the valve is turned back 90, and the syringe is filled again without removal of the infiltrating cannula from the host bed and without changing the 1-ml syringe (Supplemental Digital Content, Video 1). Patient charts, surgical records, and clinical pictures were reviewed and analyzed. The data evaluated were the number of surgeons participating, the operative time, the volume of infiltrated fat, and the registered complications. Because the aim of lipostructure was to improve breast shape, breast volume, and skin irregularities, the cosmetic result of the procedure was considered as in indirect measurement of fat graft take. The cosmetic outcome of lipostructure was judged by a separate team of blinded plastic surgeons (three independent observers), who evaluated the pre- and postoperative clinical pictures 6 months or more after surgery using a visual analog scale (VAS) based on a score of 0–10. A score of 0–5 was considered to be poor, whereas a score of 6 was regarded as fair, and a score of 7–10 to be considered as good to excellent. No ultrasound scanning investigation was conducted. Statistical Analysis VAS scores consist of Likert-type scale data, so nonparametric analysis using the Wilcoxon rank sum test (a.k.a. Mann–Whitney test) for the two independent sets of scores (one set of scores from the standard and one set from the modified group) was appropriate. The Spearman rank-order correlation coefficient (Spearman’s q) was used to calculate the correlation between paired variables (e.g., the
Aesth Plast Surg Fig. 1 a The three-way stopcock connector system (the valve is connected to a 10-ml syringe, a 1-ml syringe, and a blunt-tip infiltrating cannula). b The 10-ml syringe with centrifuged fat is connected to the system. The valve is in the open position at 0. c The valve is rotated 90 clockwise, and 1 ml of fat is transferred to the 1-ml syringe. d The valve is rotated 180 clockwise, and the system is ready for transfer of fat from the 1-ml syringe to the recipient site through the blunttip cannula
Table 1 Statistical analyses of the results in the standard and modified lipografting groups
Infiltrated/harvested fat (%)
Standard group Coleman technique
Modified group Stopcock technique
Statistical significance (a B 0.05; p B 0.05)
69
68
a = 0.002*
Average infiltrated fat (ml)
138.7
167.2
p \ 0.0001*
Average operative time (min)
74.2
66
a = 0.0035*
Volume of grafted fat (ml/min)
1.84
2.5
a \ 0.0001*
Overall infiltration/volume grafted fat per min (correlation, Spearman’s q)
0.39
–
p = 0.0014*
–
0.66
p \ 0.0001*
Cosmetic outcome (VAS score 1–10)
7.25
7.45
a = 0.076-NS
NS not significant * Statistically significant
correlation between the total amount of grafted fat and the volume of grafted fat per minute). Statistical significance was considered to be indicated by a values of 0.05 or lower and p values of 0.05 or lower.
Results The surgical team was composed mainly of one senior surgeon and one resident in the standard group and of one senior surgeon only in the modified group. The percentage of the infiltrated fat (of the total harvested amount) was 69 % in the standard group versus 68 % in the modified group, and these results were statistically significant (a = 0.002, Mann–Whitney test). The average infiltration of fat to the breast was 138.7 ml (range 100–286 ml) in the
standard group compared with 167.2 ml (range 100–250 ml) in the modified group, and this difference was highly significant (p \ 0.0001). The average operative time was 74.2 min (range 35–200 min) in the standard group compared with 66 min (range 40–200 min) in the modified group, and this difference also was statistically significant (a = 0.0035) (Table 1). Additionally, the average volume of grafted fat per minute rate efficiency was 2.5 ml/min in the modified group versus 1.84 ml/min in the standard group, and this difference was highly significant (a \ 0.0001). In the modified group, the overall infiltrated amount of grafted fat was positively correlated with the volume of fat infiltration per minute (q = 0.66; p \ 0.0001). The aforementioned correlation was lower but still positive (q = 0.39; p = 0.0014) in the standard group.
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The cosmetic outcome of the procedures investigated with the VAS score (1–10) was 7.25 (range 6–9) in the standard group and 7.45 (range 6–9) in the modified group. No major complications such as skin or flap necrosis or implant infection were observed in either group. Minor complications such as ecchymoses were common among both groups. Hematoma in the donor area was observed in three standard group patients and two modified group patients undergoing low-molecular-weight heparin for deep venous thrombosis prophylaxis. One case of breast inflammation was observed at the 2-month follow-up assessment in the modified group, which healed spontaneously with medical treatment. Regarding the cosmetic outcome evaluation in both groups using the Wilcoxon rank sum test, no significant difference was shown between the medians of the two groups (a = 0.076) (Table 1).
Discussion Currently, fat transfer in general has become an exceptionally advantageous method for plastic and aesthetic surgeons and is spreading worldwide. The concept is simple and effective, but the Coleman technique and some of the procedures proposed by others can be very tedious and costly because of the need for an assistant, several syringes, and a quite long operative time. From this perspective, the use of the three-way stopcock valve provides a smart technical solution that enables easy syringe refilling, improves fat transplantation times, and promises reduced costs. This system is easy to implement and user friendly. It allows for 10 ml of fat to be transferred using 1-ml cannulas according to micro structural fat-grafting principles. It allows fast and precise positioning of the fat particles into the recipient area by a single operator with minimal fat trauma and air exposure. By connecting the 10-ml syringe through the three-way stopcock valve to the 1-ml syringe and to the blunt infiltrating cannula, we create a closed system that allows the transfer of 10 ml fat of fat in microparticles to the recipient bed in one step. The same 10-ml syringes used for aspiration and fat centrifugation are used in each session for fat infiltration. The fact that the 10-ml syringe remains in the field during grafting has not proved to be inconvenient because of the ability to rotate it around the axis of the 1-ml syringe accordingly and avoid contact with the field. This technique also has not proved to be uncomfortable in recipient areas other than the breast. The three-way stopcock valve system provides a faster and more compact system of fat infiltration than the Coleman technique due to the customization of the 10-ml syringes and their use as a fat depot. The 1-ml infiltration syringe is ready for use, offering a larger volume ([1/3 ml)
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for injection per ‘‘turn’’ [4]. In our hands, the syringe can deliver almost 2.5 ml of fat per minute compared with the 1.84 ml of the Coleman method, saving almost 20 min in a 150-ml procedure (60 vs. 80 min). Furthermore, this system allows the surgeon to work alone without the help of an extra assistant to fill up the syringes. Therefore, although a real-cost analysis of the two methods has not been undertaken, the three-way stopcock valve system promises to reduce theatre, personnel, and equipment costs significantly. Regarding the percentage of fat graft take and the incidence of complications, in our hands, the modified method showed results comparable with those of the Coleman technique because the technique of fat dispersion in the hosting bed rests the same, and the harvesting procedure is identical. The weak positive correlation between overall grafted volume and grafted volume per minute in the standard group shows that with the Coleman method, the efficiency in terms of how much fat is grafted per minute remains rather constant in both the small and larger amounts of grafted fat. Conversely, in the modified group, the same correlation was much stronger (almost double), showing that the larger the amount of the total infiltrated fat, the higher the efficiency (volume per minute) of fat infiltration per minute. This result is supported by the significantly shorter overall intraoperative times in the modified group and by the highly significant difference between the means of the volume per minute in each group (with the modified group having a much higher rate) (Table 1). Consequently, when large amounts of fat are required, the improved rate of fat infiltration increases and makes the stopcock method clearly superior. When smaller amounts of fat are needed, the stopcock method retains its advantageous volume per minute rate and still comprises an improved alternative in terms of time efficacy. Compared with more recent methods, our technique retains the efficacy of the original Coleman System while reducing operative times and costs. The LipiVage system (Genesis Biosystems Inc, Lewisville, TX) [6] is primarily an efficient fat-harvesting system. However, use of a separate compatible transfer system is required in lipofilling procedures. Consequently, although it may save time by eliminating the need for centrifugation, LipiVage system (Genesis Biosystems Inc, Lewisville, TX) requires additional patented parts, a longer time to connect, and a higher cost to obtain. The Ellik evacuator (BARD, Covington, GA) [7] requires a power-assisted suction machine and additional system parts, increasing the cost for the harvesting phase alone and offering no alternative to the method of infiltration. Nguyen et al. [9] in their animal study used a smaller syringe than that used in the Coleman technique. Although their modification showed promising results in infiltration of
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more superficial layers, its efficiency was not tested clinically, and it is fundamentally similar to the Coleman System. Similarly, the double-folded needle technique by Pignatti et al. [10] presents a method for draining serum from the aspirate, and the water-assisted fat-harvesting methods such as BEAULITM (Park-Klinik Birkenwerder, Birkenwerder, Germany) [11] may be efficient in harvesting small fat particles in large quantities but require additional compatible parts for fat infiltration, and their cost is high.
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We find this technical modification to be easy and effective and therefore recommend it to all surgeons performing fat transfer.
Conflict of interest interest.
The authors declare they have no conflict of
References Conclusions In our opinion, the three-way stopcock system has several advantages: •
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It is faster than other techniques because it does not require replacing the emptied 1-ml syringe with a filled one by disconnecting it from the cannula through which every milliliter of fat is injected (10-fold faster for a 10-ml injection). It is a safer system because it reduces fat manipulation and air exposure, avoiding open-air 1-ml syringe refilling and connection. It is a cheaper system because an extra assistant is not required (cost of 40 euro/h1) to fill up the 1-ml syringes and pass them to the surgeon. It requires only one 1-ml syringe (cost, 30 cents each) instead of multiple syringes. It uses the three-way stopcock valve (cost, 0.156 euro) instead of the ByronTM connector (cost, 38 euro), and it allows faster fat delivery, reducing the operative time by one-fourth in our experience and consequently reducing theatre costs (cost, 560 euro 9 1 h). A saving of about 220 euro for a 1-h procedure may be expected. It allows easier planning and assessment for the amount of fat transferred to each region because it consistently delivers 10 ml of fat per use.
1. Fournier PF (1996) Liposculpture: my technique. ArnetteBlackwell, Paris 2. Flynn TC, Coleman WP, Field LM, Klein JA, Hanke CW (2000) History of liposuction. Dermatol Surg 26:515–520 3. Illouz YG (1996) History and current concepts of lipoplasty. Clin Plast Surg 23:721–730 4. Coleman SR (1995) Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 19:421–425 5. Butterwick KJ, Nootheti PK, Hsu JW, Goldman MP (2007) Autologous fat transfer: an in-depth look at varying concepts and techniques. Facial Plast Surg Clin North Am 15:99–111 6. Ferguson RE, Cui X, Fink BF, Vasconez HC, Pu LL (2008) The viability of autologous fat grafts harvested with the LipiVage system: a comparative study. Ann Plast Surg 60:594–597 7. McArdle C, Feehily A, Allison KP (2013) The Ellik evacuator: a modified technique for autologous fat collection during fat harvest. J Plast Reconstr Aesthet Surg 66:737–738 ¨ ber die Wiederanheilung vollsta¨ndig vom 8. Neuber G (1893) U Ko¨rper getrennter, die ganze Fettschicht enthaltender Hautstu¨cke, in Zbl f. Chirurgie 30:16 9. Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G (2012) Development of micro-injection as an innovative autologous fat graft technique: the use of adipose tissue as dermal filler. J Plast Reconstr Aesthet Surg 65:1692–1699 10. Pignatti M, Bruti M, Rigotti G (2001) Saving one step in lipostructure: M-AGO (magic needle). Plast Reconstr Surg 108:1833–1834 11. Ueberreiter K, von Finckenstein JG, Cromme F, Herold C, Tanzella U, Vogt PM (2010) BEULI, a new and easy method for large-volume fat grafts. Handchir Mikrochir Plast Chir 42:379–385
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Single-surgeon average cost per hour according to the Italian National Health Service.
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