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other proteases, which play a role in not only inhibiting skin fibrosis but also remodeling the extracellular
matrix [19,40] . Finally, AFT can effectively improve the contour irregularities that result from the cutaneous
involvement of different subtypes of scleroderma by providing structural support and volume
restoration [19,41] .

FAT GRAFTING TECHNIQUE
Fat is harvested from the abdomen and/or thighs using a 3.0-mm liposuction cannula under hand-held
suction. The lipoaspirate is carefully transferred to 10 cc syringes and processed by centrifugation at 3000
[42]
rpm (1228 x g) for 3 min, according to the Coleman method . Centrifugation produces concentrated
lipoaspirates and allows for efficient decantation of oil and debris. The fat is then transferred to 3 cc syringes
for injection. For fat transfer to the face, small incisions are made along the lateral commissures using an
11-blade. Multiple tunnels are created and small volumes of fat (0.1-0.2 mL) are injected with each pass only
at the withdrawal of the cannula. Over 30 patients with a diagnosis of scleroderma have been treated at the
University of Michigan between March 2015 and March 2023 . Patients received 1-4 rounds of fat grafting
[7]
based on the severity of their disease at presentation and were evaluated at 1, 3, 6, and 12 weeks
[7]
postoperatively .
FAT GRAFTING FOR THE TREATMENT OF SCLERODERMA
Systemic scleroderma
Face
Orofacial manifestations of scleroderma are disabling and contribute to significant functional and aesthetic
[43]
concerns for patients . Facial involvement presents as hardened or atrophic skin, loss of mimic folds, deep
wrinkles in the upper and lower face, and hair loss [19,44,45] . Microstomia is a common oral manifestation of
systemic scleroderma due to perioral tissue sclerosis [46,47] . AFT to the face improves oral opening, reduces
facial skin sclerosis, and improves oral incompetence [48,49] . The procedure is safe and has minimal
complications postoperatively [48,49] . Figure 1 demonstrates a 52-year-old patient with improved lip contour
and volume after facial fat grafting.

Fat transfer to the face in scleroderma patients should ideally be performed at a subdermal level to correct
contour abnormalities and improve skin fibrosis. Both macrofat and microfat have been shown to improve
the contour irregularities observed in patients with scleroderma. However, microfat, which is lipoaspirate
isolated with a smaller cannula port size or macrofat further processed with filters, yields smaller fat grafts
[50]
compared to traditional liposuction and provides many advantages over macrofat . The utilization of
microfat has the advantage of improving superficial contour abnormalities as the parcel size of microfat is
small. This micronized fat allows for the injection of fat grafts in a more superficial plane to reduce skin
fibrosis without the contour irregularities associated with fat necrosis or oil cysts from the injection of
macrofat [51,52] . Various techniques have been described in the literature to generate microfat [51,53] . In our
practice, the Coleman technique is utilized to process and harvest macrofat, which is subsequently passed
through two Luer-Lok syringes connected to a three-way stopcock for a total of 10 times to generate
microfat. The microfat is subsequently injected using a 25-gauge cannula to the desired region of the face
and hands. Subcutaneous perioral microfat injection in systemic sclerosis patients has been shown to
[52]
improve facial animation, skin sclerosis, and oral opening . Other studies have shown that microfat
provides symptomatic improvement of xerostomia, as assessed by the xerostomia inventory index . While
[54]
the results of microfat alone have been shown to be promising, additional studies have investigated the
addition of platelet-rich plasma (PRP) to fat grafts . Systemic sclerosis patients treated with AFT and PRP
[43]
demonstrated significant improvements in oral opening and lip thickness with aesthetically pleasing
outcomes. It has also been reported that the addition of PRP to fat graft improves skin elasticity and