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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 5  |  Page : 21-27

Augmentation of the calf region with autologous fat and platelet-rich plasma-enhanced fat transplants: A comparative study


Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Ege University, İzmir, Turkey

Date of Submission17-Jun-2020
Date of Acceptance23-Aug-2020
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Ahmet Bicer
Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Ege University, 35100 Bornova, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_67_20

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  Abstract 


Background: Contour and volume deficiencies in the calf region, either unilateral or bilateral, may raise an esthetic concern in affected individuals. There are numerous methods described for volume augmentation or contour reshaping in this region including implant placement, autogenous tissue transfer, liposuction, and/or fat injections. The authors present their series of patients to whom they performed fat injections with or without platelet-rich plasma (PRP) enrichment for addressing this problem. Methods: Fifty-two patients who had undergone calf lipostructuring procedure(s) in our clinic were included in this retrospective study. The procedure was repeated with a fixed value of fat volume per leg until a satisfactory limit for both the patient and the senior author could be achieved. Regarding the analysis of outcome, the number of sessions needed to be repeated was recorded for each patient. Results: 125 cc of fat was injected per session per leg. Ten patients were treated with PRP enriched fat transplants while 42 were treated with fat only. The mean number of sessions was 2.76 (min. 2, max. 6). For the group treated with PRP-enriched fat grafts a mean 2.00 number of sessions had to be carried out while the mean was 2.95 for the patients in the fat-only group. The mean number of sessions to achieve our goal was significantly lower in the PRP-enriched fat injected group (P < 0.001). Conclusion: Addition of PRP significantly reduces the need of repeated operations to achieve the best possible outcome in lipostructuring around the calf region. Level of Evidence: Retrospective comparative study, level III.

Keywords: Aesthetic calf augmentation, body contouring, fat graft, platelet-rich plasma


How to cite this article:
Bilkay U, Bicer A, Ozek ZC, Gurler T. Augmentation of the calf region with autologous fat and platelet-rich plasma-enhanced fat transplants: A comparative study. Turk J Plast Surg 2021;29, Suppl S1:21-7

How to cite this URL:
Bilkay U, Bicer A, Ozek ZC, Gurler T. Augmentation of the calf region with autologous fat and platelet-rich plasma-enhanced fat transplants: A comparative study. Turk J Plast Surg [serial online] 2021 [cited 2022 Dec 7];29, Suppl S1:21-7. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/21/311433




  Introduction Top


Although not considered a common site for esthetic concern; asymmetries, hypoplasias, atrophies, or irregularities in the leg may urge certain patients to seek surgical solutions.[1],[2] With increasing body of knowledge and public awareness of what plastic surgeons can possibly achieve, the number of patients steadily increases.

There are numerous methods described in the literature for calf augmentation including injectable fillers and placement of various forms of implants subcutaneously, subfascially, intermuscularly, or even supraperiosteally.[3],[4],[5],[6],[7],[8],[9] The utilization of autologous fat tissue alone[1],[2],[10] or in combination with implants[11] for this matter was also mentioned, albeit not as commonly.

The concept of utilization of fatty tissue for soft augmentation is well established.[12] As early as 1895, a Bohemian oncological surgeon, Vincenz Czerny is often credited for first documented breast augmentation, for which he employed a benign lipoma at the back of a patient in an effort to reconstruct an acquired deformity resulting from a partial mastectomy defect.[13] Infiltration, rather than placement of crude lipoid tissue was mentioned by Hollander in 1912 in his report in which infiltrated fat was used for correction of facial lipoatrophy, and by Miller in 1926 where lipoid tissue was infiltrated through cannulas for correction of various deformities around face and neck.[12]

Not later than the introduction of lipoaspiration techniques to the armamentarium of plastic surgery, utilization of the aspirate for defective areas elsewhere in the body had been proposed.[14] Bearing that perspective, the term lipostructuring should be considered to better define these procedures rather than simple lipoaspiration or liposuction. Early reports of fat grafting were not free from ups and downs notwithstanding. An initial excitement with great results postoperatively, followed by a disappointment, partly because absorption of infiltrated fat over weeks to months, encountered with late follow-up. This, again, was replaced by satisfaction as their experience with acquiring, handling, and administration of fat accumulated.[12],[15] Although the number of high quality, evidence-based knowledge in fat grafting as a whole is somehow lacking, current literature yields results that are far more predictable and consistent compared to earlier counterparts.[16]

Virtually, every type of soft-tissue deficiency is reported to be treated with fat injections; either acquired or inherent. Age-related facial atrophy, as well as congenital facial hypoplasia, cicatricial depressions and contractures, contour deformities, volume losses and insufficiencies, and iatrogenic deformities are merely a portion of the vast clinical areas which fat grafting can be employed. Acquired or inherent deformities in or about the calf region is no exception.

Although lipostructuring of the calf region is a practice not unheard of, large series with reliable long-term follow-up is lacking. Our series hopefully would fulfill some of the shortcomings of previous studies. We also present long-term results with platelet rich plasma (PRP) treated fat grafts, which is a rather new concept, for calf region which is not precedented in the current literature as far as we know.


  Methods Top


Patients

Fifty-two patients (age min. 27, max. 47, med. 38) who had undergone calf lipostructuring procedure (s) in our clinic between 2009 and 2012 and were found to have completed with their fat injection sessions were included in this retrospective study. All the patients were female. Forty-six patients were treated bilaterally.

The recorded preoperative patient data were accessed. The preoperative evaluations were made anteroposteriorly and laterally while standing. A topographical anatomy was outlined with projection of proposed deficiency via a marker pen prior to surgery. This method was followed each time as multiple sessions needed to achieve a satisfactory result.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or National Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Surgical technique

Fat harvest and preparation

Following intravenous antibiotic prophylaxis with 1 g of cephazoline, under general anesthesia the patients were positioned supine, the donor sites, and legs were prepared and draped accordingly. Either flank, lower or upper abdomen was selected for harvest.

The fat grafts were harvested manually (Coleman technique).[17] The donor site was infiltrated with 1:1 wetting solution prepared with 1:200,000 epinephrine in lactated Ringer. Local anesthetics were not added to the solution. 250–300 cc of fat was obtained for each leg per session.

The fat grafts were left to sediment. Following sedimentation for 30–45 min 125 cc of fat fraction was obtained [Figure 1].
Figure 1: Obtained fat grafts are left for sedimentation for 30–45 min

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Platelet-rich plasma harvest and preparation

The decision whether to employ PRP enrichment was made independently regarding the patient characteristics or etiology.

PRP was obtained from the patient's own peripheral blood employing the cascade system.[18] A rather miniscule amount of blood (20 cc) was driven from one of the peripheral veins of the patient, which then transferred into 3.8% (w/v) sodium citrate solution for preservation and anticoagulation. The fluid was then centrifuged at a rate of 1100 g for 10 min. Calcium chloride was made ready for inducing platelet degranulation but not added until the pure fat component became ready through sedimentation.

Transfer of fat

The sedimented and purified fat fraction, and if used, activated PRP mixed with the pure fat fraction, was transferred into 10 cc Luer-Lok syringes. Five mm incisions were made by a No 11 blade as portals of injection. The fat injections were carried out entirely suprafascially in each of the cases. No fasciotomy was performed.

Postoperative care

A lightly compressive bandage was applied for 5 days' postoperatively. An overnight stay planned for each patient to handle any probable postoperative complications. Oral antibiotics (cefalosporines) and nonsteroidal anti-inflammatory drug were begun the next day on which all of the patients were discharged.

The number of sessions carried out, complications and if present, their management was recorded.

Instrumentation

A spoon tip Luer Hub 3.0 mm × 20 cm Tulip® (4360 Morena Blvd. Suite 100, San Diego, CA 92117, USA) cannula was used for fat harvest. A Tulip tipTM 1.6 mm x 9 cm Tulip® cannula connected to a 10 cc Luer-Lok syringe was used to deliver the obtained and sedimented graft.

Slow centrifugation with cell fraction separation of peripheral blood to obtain PRP was carried out using Cascade-Fibrinet® (Cascade Medical Enterprises, Plymouth, Devonshire, UK) system.

Outcome analysis

The procedure (either chosen to be with or without PRP) was repeated with a fixed value of fat volume per leg until a satisfactory limit for both the patient and the senior author could be achieved. Regarding the analysis of outcome, the number of sessions needed to be repeated was recorded for each patient.

Statistics

The statistical analysis was carried out by SPSS v. 18.0 ™ (PASW Statistics, v 18.0, IBM corporation, Armonk, NY, USA). The homogeneity of variances in the groups was tested by a Levene's test. An independent-samples t-test was performed to compare means for both the groups (with or without PRP). The P value was set to 0.001.


  Results Top


Ninety-eight legs of 52 patients were followed up over a mean 42.3 months (min. 24, max. 66 months) [Table 1].
Table 1: Header: Descriptive analysis of the results of the patients

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All patients were repeatedly treated with a fixed 125 cc fat injection per session per leg. Ten patients were treated with PRP enriched fat transplants while 42 were treated with fat only.

All patients were treated until a satisfactory result could be achieved and the photographs are obtained after 12 months of follow-up [Figure 2], [Figure 3], [Figure 4]. Mean number of sessions was 2.76 (min. 2, max. 6). For the group treated with PRP-enriched fat grafts, a mean 2.00 number of sessions had to be carried out while a mean 2.95 number of sessions needed to achieve the proposed outcome for the patients in the fat-only group.
Figure 2: (a) Preoperative anterior view of a patient within the fat injection-only group. (b) Postoperative anterior view of the patient

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Figure 3: (a) Preoperative anterior view of a patient within the platelet-rich plasma enriched fat injection group. (b) Postoperative anterior view of the patient

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Figure 4: (a) Preoperative posterior view of the patient in Figure 2. (b) Postoperative posterior view of the patient

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In the study group, a mean 250 cc PRP-enriched fat injection per leg was found to be adequate for a satisfactory outcome, whereas it is found to take a mean 368.75 cc (min. 250 cc, max. 750 cc) of fat to obtain a satisfactory outcome.

The variances between the groups were found to be homogeneic (P > 0.10) while the mean number of sessions to achieve our goal was significantly lower in the PRP-enriched fat injected group (P < 0.001).

Complications

One minor complication was encountered. A localized soft-tissue infection was observed unilaterally in a patient with bilateral constitutional leg slenderness following her third fat-only session. The infection was controlled with oral antibiotics (sulbactam-ampicillin, p. o., 1 g, 2 × 1) and lead subacetate solution (Eau de Goulard) soaked dressings changed overnight. Healing was uneventful, a small patch of hyperpigmentation notwithstanding.


  Discussion Top


The rationale

The reasons behind the patients' desire for an improved contour in the calf region may be varied. Congenital or acquired deficiencies or discrepancies with the other leg would be a rather obvious indication for augmentation.[10],[19],[20] However, in perfectly healthy controls a desire for a gentle curve medially, laterally, or posteriorly may be sought to improve esthetic appeal.[1],[21],[22]

Overall appearance of the calf region is dictated by its contents. Length and width of tibia and fibula, as well as their relation to each other and successive joints are among the rather fixed components of calves which are not easy to alter either nonsurgically or surgically. The muscular compartments of the calves are amenable to alteration through exercise to an extent in healthy individuals, not as easy as other parts of body though.[1],[31] This may be the rationale behind bodybuilders seeking calf augmentation procedures more commonly than other segments of their extremities. The overlying fascia serves as an envelope smoothing the bulge of the muscles. Finally, the skin and subcutaneous tissue gives the final contour of the calf region. The abundance and distribution of soft-tissue varies with age, sex, and constitutional features of the individual.[23] Although the volume of any compartment can be altered surgically, the technique chosen often determine the plane, thus the compartment. Subcutaneous, subfascial, or intramuscular planes are the principle planes of intervention.[7],[8]

Basic science

As basic science is increasingly contributing to the viability and longevity of grafted fat cells, the future seems to hold better results with a higher degree of prediction, lessened operative time and less number of operations needed to achieve the best possible outcome.[24] In the presence of growth factors, graft survival is significantly increased.[25] Creating a high concentration of growth factor environment for the graft can be achieved either directly or indirectly. The administration of certain growth factors such as vascular endothelial growth factor,[26] insulin-like growth factor[27] or basic fibroblast growth factor[27] to the recipient site is the direct approach, whereas treating the graft with stromal vascular fraction,[28] tissue cocktails[29] or PRP[30] is the indirect approach and are among some, if not many methods to increase cell viability in fat grafts.

Approach

Basically, two groups of approach can be found in the current literature to address the problem; prosthetic or autogenic approach. Silicone implants are being used since introduced in 1979 by Carlsen and Glicenstein.[4] The utilization of autogenous tissue for calf augmentation can be traced back to 1972 when Crocenzi reported the case with dermal fat graft placement for calf augmentation.[31] Calf augmentation with myocutaneous-free flap (TRAM) can be found in the current literature as case reports which stand tall as a vascular transplant alternative.[32],[33] The augmentation of the calf volume with injected fat was reported by Matsudo and Toledo in 1988.[34]

The authors of this article chose the utilization of autologous fat, with or without PRP enrichment, to address the volume deficiencies in the calf region. Autogenous fat transplantation offers some advantages as being safe, biocompatible, immuncompatible, abundant, accessible, and inexpensive.[17] A natural overall appearance is easier to achieve. In majority of cases, the donor site morbidity is negligible; in fact, the technique inherently allows lipostructuring of a potentially problematic area (belly, flank, and buttock regions) for the patient.[20] A major advantage may be the avoidance of potentially problems and complications with foreign material use.[1]

Calf augmentation with mainly silicone implants is a popular method among plastic surgeons on grounds that it yields immediate results following a rather straightforward operation.[35] A short incision made along the popliteal creases often gives adequate access to the planes chosen to be dissected by the surgeon. This incision may also be used for placement of an endoscope for further access.[7],[11] Long segments of fascia can also be addressed through these ports.[11] Uniform deficiencies of volume can be enhanced by standardized fusiform implants with an asymmetric base.[21] On the other hand, asymmetric deficiencies or defects can either be addressed by custom made implants, or combination of fat injections and standard implants.[8],[35] Anticipated advantages of this technique over lipostructuring are; first of all this technique is far more efficient in volume enhancement, and with careful planning, the anticipated result can be established in one setting.[23]

However, the disadvantages of implant augmentation are not lacking.[1] Pain on ambulation, capsular contracture, implant failure, skin erosions, hyperpigmentation, hypertrophic scarring, infections, seroma, extrusion, rippling, displacement, warping, nerve damage, atrophy of underlying muscle or bone and compartment syndrome are among the complications can be encountered.[8],[9],[11],[21],[23],[35],[36],[37],[38] Although the more drastic ones are rare, pain, seroma and capsular contracture are not. Additional points to be considered may be unnatural appearance, palpability, and failure to choose the right implant for the right patient. Those tackles may indeed be more frequent than reported in the literature as many of us in practice deal with these unfortunate patients treated by inexperienced surgeons. This technique appears to be far more demanding and dependent on personal experience and finesse than repeated fat injections.

Large volume fat injections are not shy of complications and disadvantages for their own sake either.[10] The injected fat is a graft-dependent vascularly on the recipient site and some extent of resorption is inevitable, thus long-term results are not predictable.[20],[23] Although augmentation in a single-stage operation had been proposed, multiple operations are needed to achieve the best possible outcome.[20],[23] Volume expansions, especially single-stage augmentations are invariably associated with discomfort, swelling, and mild pain.[10] The fraction of injected graft that cannot be nourished by recipient bed ends up with resorption, while failure to maintain the longevity of fat cells results in oily cysts and fibrosis.[12] Resorption is the main cause of nonpredictability, need for repeating the sessions and need for a slight overcorrection.[39] Contour irregularities and palpable masses are mainly caused by devitalized fat. Other causes are rather rare. The common complications that would compel utilization of certain precautions include mild infection (mainly staphylococcal), seroma, and mild hematoma.[39] Serious infections and a hematoma urging the need for surgical drainage are rare. The most devastating complications, though theoretical would be caused by inadvertent administration of fat into the blood vessels. Arterioarterial embolism would endanger limb circulation, while venous emboli may result in pulmonary embolism or stroke (in the setting of patent foramen ovale).[40]

Risk control

Although rare, some potential complications regarding fat injections are dreadful. Dealing with possible problems starts with donor site preparation. The donor site should be infiltrated with a wetting solution which includes a certain amount of epinephrine to induce vasoconstriction, thus decrease the probability of vascular damage.[41]

Whole process can be carried out under local anesthesia but if that is the case, this dictates adding local anesthetics to the wetting solution.[41] Some authors suggest that this interfere with the survival of adipocyte derived stem cells and their differentiation into mature adipocytes, thus decrease the overall efficacy.[42] The cases presented in this article were operated under general anesthesia; not only for patient comfort but also for avoiding the use of possibly lipotoxic local anesthetics.

Atraumatic harvesting, processing, and delivery of fat is the mainstay of dealing with the aforementioned problems. Although techniques employing automated devices for fat grafting have been praised as superior concerning graft survival,[43] Coleman's technique[17] is widely accepted as a routine among practitioners in the field. The authors of this article are no exception. Following the infiltration of wetting solution inducing the classical peau d'orange appearance on the skin surface and waiting until skin blush is achieved. Bearing in mind that this is not a case of assisted lipectomy, the cannula should be advanced and retracted with long and gentle strokes meanwhile a minimum of negative back pressure is being delivered by the connected syringe. A Luer-Lok plug is placed to seal the syringe to prevent leakage and limit the exposure time of the harvest.

Transforming the harvested crude material into pure fat needs some sort of processing.[44] Although three techniques are in use, centrifugation, washing, and sedimentation, they have shown equivalent results. This evidence notwithstanding, we prefer to use sedimentation as this is the least traumatic method. In this method harvested tissue is left to sediment up to 45 min before injection.

The technique concerning the injection of fat should be as atraumatic as possible. As safety comes first, the cannula should be blunt tipped as round or spoon shaped. Sharp cannula should never be used while injecting fat or any other filler except to break up tissue and form subcutaneous tunnels before injection.[45] The injection should be made into multiple imaginary planes in a radial fashion.[15] Although better graft take had been reported with external tissue expansion and injection of the fat into the muscle, the authors of this article employed neither. We feel that increasing the pressure in the muscular compartments may cause problems as pain or worse as motor weakness and compartment syndrome. Furthermore, the injection should be with low pressure and evenly distributed along the radial planes to increase the graft take.[17]

Fat graft survival depends on the aforementioned donor and recipient characteristics, as well as the degree of technical refinement. Gentile et al. in their comparative study with large volume injections to defective breasts demonstrated that the injected fat retained 39% of its volume after 1 year of treatment.[46] However, apart from the viability of transferred adipocytes, another component was found to contribute. This component present in the fat grafts is named as stromal vascular fraction (SVF) and includes many types of mesenchymal cells. Smooth muscle cells, endothelial cells, preadipocytes, mast cells, blood cells, and multipotent so-called adipose-derived stem cells (ASCs) are among many of the cell types in that fraction.[47] Regenerative effects of the fat grafts are contributed to those stem cells as they are multipotent cells able to differentiate into a wide variety of cell types under proper signaling.[48] Various growth factors act as signaling molecules for multipotent cells, increasing their survival, multiplication, and differentiation.[28] The ASCs and preadipocytes are readily available in the fat grafts for maturation into adult adipocytes.In an effort to stimulate this process, several methods have been coined. Some of those methods are delivery of various growth factors in the transplantation area, administration of tissue cocktails,[39] enhanced stromal vascular fraction (eSVF),[47] PRP,[49] and platelet-rich fibrin (PRF).[50] They are shown to be effective in durability of fat grafts in the long run. Gentile et al. found that 63% of the initial volume can be retained in one year postoperatively if the injected fat is enhanced with eSVF, and 69% with PRP.[47] The authors of this article preferred PRP enrichment as it is more accessible, available, and inexpensive.

Patient evaluation

Measuring the circumference and height of the calves and a quantifiable assessment of the deficiency may be mandatory before commencing an implant augmentation but with fat injections the authors felt liberal in marking the topographical projection of the desired areas of augmentation while the patient is standing upright.

Review of the literature revealed that many authors assessed their results by scores given either by the patients or peers in a temporal cross-section.[2],[20],[21],[35] Regarding the final outcome, the authors of this article employed a rather different method; the cross-section was drawn right after finalization of the procedures and number of repetitions of fat grafting sessions was recorded. In our opinion, this approach would lend us with a proper deduction of the overall efficacy of the method.

Powers of the study

Studies with long-term results of calf augmentation with autologous fat transplantation are rare in the current literature. The case series was carried out with a sufficient number of subjects, which is another rarity in the current literature. Last but not the least, important power of this study is that it combines fat grafting with PRP which is an emerging entity with several uses being introduced into the current body of knowledge.

Shortcomings of the study

The method of patient evaluation before and after the operations is insufficient to say the least. A better estimation of the benefits of PRP enriched fat grafting can only be made with objective measurements. Quantifiable assessments give us the opportunity to measure our scientific observations and lend us ways to better communicate in the scientific environment.


  Conclusion Top


Fat transplantation is an effective method for soft-tissue augmentation in the leg region. The addition of PRP significantly reduces the need of repeated operations to achieve the best possible outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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[Pubmed] | [DOI]



 

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