Fat transfer for aging skin: technique for rhytids

What We Know About Facial Volume Restoration with Autogenous Fat

Facial rejuvenation involves a careful analysis of a patient's anatomic changes that are secondary to aging and then the application of several methods, tools, and technologies to reverse those changes. A central component of facial aging is the changes seen in facial soft tissue volume that occurs with atrophy and malpositioning of normal facial volume through several underlying aging processes. Although many surgical and nonsurgical interventions are available to remedy many of the sequela of aging, the restoration of volume is one of the most important goals that has to be engaged. Over the years, autogenous fat has emerged as one of the safer and reliable methods to restore the diminished volume of the aging face. The purpose of this manuscript is to relate some of the history, clinical practices, research, and current literature supporting the use of autologous fat in facial rejuvenation.

Viability of Fat Cells in Frozen Fat Tissue in Relation to Thawing Technique

Damage of frozen fat, which will be used for retransplantation, is inevitable. Reuse of frozen fat requires a thawing process. No standardized method has yet been established for thawing frozen fat.

Blood Impairs Viability of Fat Grafts and Adipose Stem Cells: Importance of Washing in Fat Processing

BACKGROUND

Fat processing plays a pivotal role in graft survival. Each component of the blood in lipoaspirate affects fat survival in different ways, but the mechanisms are not clear.

OBJECTIVES

The aim of this study was to investigate, by various experimental methods, the effect of blood on the viability of fat grafts and adipose stem cells (ASCs).

METHODS

Blood and fat samples were obtained from 6 female patients undergoing aesthetic liposuction. For the in vivo experiment, we compared fat mixed with normal saline or various ratios of blood in nude mice. The samples were explanted at 2 and 8 weeks to evaluate the gross volume retention and histologic and immunohistochemical characteristics. For in vitro experiments, ASCs were pretreated with hemoglobin at different concentrations and for different times. We then assessed the proliferation, migration, adipogenesis, and reactive oxygen species production of ASCs.

RESULTS

Blood in the graft led to a decrease in graft viability, as evaluated by general observation and histologic and immunohistochemical morphology in vivo. In vitro experiments showed inhibited proliferation, migration, and adipogenesis, and increased reactive oxygen species production in ACSs, after hemoglobin treatment, suggesting impaired ASC viability.

CONCLUSIONS

This study suggests that blood impairs the viability of fat grafts and ASCs and provides evidence that washing to remove blood is important in fat processing.

TRAF3IP3 at the trans-Golgi network regulates NKT2 maturation via the MEK/ERK signaling pathway

Thymic natural killer T (NKT)2 cells are a subset of invariant NKT cells with PLZF^hiGATA3^hiIL-4⁺. The differentiation of NKT2 cells is not fully understood. In the present study, we report an important role of TRAF3-interacting protein 3 (TRAF3IP3) in the functional maturation and expansion of committed NKT2s in thymic medulla. Mice with T-cell-specific deletion of TRAF3IP3 had decreased thymic NKT2 cells, decreased IL-4-producing peripheral iNKTs, and defects in response to α-galactosylceramide. Positive selection and high PLZF expression in CD24⁺CD44^- and CCR7⁺CD44^- immature iNKTs were not affected. Only CD44^hiNK1.1^- iNKTs in Traf3ip3^-/- mice showed reduced expression of Egr2, PLZF, and IL-17RB, decreased proliferation, and reduced IL-4 production upon stimulation. This Egr2 and IL-4 expression was augmented by MEK1/ERK activation in iNKTs, and TRAF3IP3 at the trans-Golgi network recruited MEK1 and facilitated ERK phosphorylation and nuclear translocation. LTβR-regulated bone marrow-derived nonlymphoid cells in the medullary thymic microenvironment were required for MEK/ERK activation and NKT2 maturation. These data demonstrate an important functional maturation process in NKT2 differentiation that is regulated by MEK/ERK signaling at the trans-Golgi network.

Safety and efficacy of autologous noncultured dermal cell suspension transplantation in the treatment of localized facial volume loss: A pilot study

Background

Available options for correction of facial volume loss, such as synthetic fillers, autologous fat and cultured fibroblasts, have limitations viz. temporary effect and high cost.

Aim

To assess the use of a novel technique, autologous non-cultured dermal cell suspension transplantation, for correction of localized facial volume loss due to inflammatory pathologies.

Methods

It was a pilot study conducted in the Dermatology Outpatient Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Autologous non-cultured dermal cell suspension was transplanted in a total of 10 patients, out of which 5 had predominantly dermal loss and the rest had predominantly lipoatrophy. The donor tissue from the gluteal region was digested into a single cell suspension using collagenase-1 and injected into the recipient area. The outcome was assessed subjectively by patients and investigators and objectively using ultrasonography. Cell count, viability testing and measurement of mesenchymal stem cells were also done.

Results

On assessment of patients, the median improvement in the predominantly dermal atrophy group at 3 and 6 months was 70% (range: 10-90%) and 80% (range: 0-90%), respectively, and in the predominantly lipoatrophy group, 0% (range: 0-40) and 0% (range: 0-50), respectively. Mean thickness of dermis + subcutis at the baseline was 1.835 mm (range: 0.89-6.04 mm), which increased to 2.912 mm (range: 0.88-7.07 mm, P = 0.03) at 6 months.

Limitations

Our pilot study has some limitations such as small sample size and heterogeneity of the recruited patients.

Conclusions

Autologous non-cultured dermal cell suspension transplantation appears to be safe and effective in localized facial dermal defects because of inflammatory pathologies, but not effective in deeper defects.

Autologous Fat Transfer for Facial Rejuvenation: A Systematic Review on Technique, Efficacy, and Satisfaction

Background

Parallel to the steady decline in surgical aesthetic procedures to the face, dermal fillers seem to have gained a more prominent place in facial rejuvenation over the last couple of years. As a dermal, facial filler, autologous fat transfer (AFT) seems to have real potential because of the biocompatibility of adipose tissue besides being a procedure with few and primarily minor complications. This systematic review aims to evaluate the available evidence regarding the safety and effectiveness of AFT for facial rejuvenation.

Method

A systematic review after the Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analysis (PRISMA) statement was conducted. MEDLINE, Embase, and Cochrane Library were searched up to December 2016, with no language restrictions imposed. Case series, cohort studies, and randomized controlled trials (RCTs) reporting on relevant outcomes were included.

Results

Eighteen clinical articles were included, reporting on 3,073 patients in total over a mean follow-up period of 13.9 months. Meta-analysis showed an overall complication rate of 6% (95% CI 3.0-14.0), with hematoma/ecchymosis (5%), fat necrosis/oil cysts (2%), and irregular fat distribution and scars (both 2%) being among the most reported. No major complications were reported, and the overall patient satisfaction rate was 81%.

Conclusion

Although the evidence in this systematic review is still limited and plagued by heterogeneity between studies, AFT seems to be a promising method in facial rejuvenation with fewer complications than other fillers and high patient satisfaction rates. Further large-cohort, preferably multicenter, RCTs should substantiate these results through quantifiable volumetric assessment tools and validated patient questionnaires, while adhering to predetermined nomenclature in terms of complications.

Comparison of the viability of cryopreserved fat tissue in accordance with the thawing temperature

Background

Adipose tissue damage of cryopreserved fat after autologous fat transfer is inevitable in several processes of re-transplantation. This study aims to compare and analyze the survivability of adipocytes after thawing fat cryopreserved at -20℃ by using thawing methods used in clinics.

Methods

The survival rates of adipocytes in the following thawing groups were measured: natural thawing at 25℃ for 15 minutes; natural thawing at 25℃ for 5 minutes, followed by rapid thawing at 37℃ in a water bath for 5 minutes; and rapid thawing at 37℃ for 10 minutes in a water bath. The survival rates of adipocytes were assessed by measuring the volume of the fat layer in the top layers separated after centrifugation, counting the number of live adipocytes after staining with trypan blue, and measuring the activity of mitochondria in the adipocytes.

Results

In the group with rapid thawing for 10 minutes in a water bath, it was observed that the cell count of live adipocytes and the activity of the adipocyte mitochondria were significantly higher than in the other two groups (P<0.05). The volume of the fat layer separated by centrifugation was also measured to be higher, which was, however, not statistically significant.

Conclusions

It was shown that the survival rate of adipocytes was higher when the frozen fat tissue was thawed rapidly at 37℃. It can thus be concluded that if fats thawed with this method are re-transplanted, the survival rate of cryopreserved fats in transplantation will be improved, and thus, the effect of autologous fat transfer will increase.

Periocular autologous fat transfer

Autologous fat transfer is a useful adjunct to augment facial soft tissue deflation in the periocular region. With meticulous technique, small aliquot placement, and reinjection at appropriate intervals, fat makes an excellent adjunct to the management of the aging face, and compliments other facial rejuvenation techniques. Appropriate counseling, realistic expectations, and meticulous technique make fat transfer an effective method of soft tissue augmentation.

Current practice in autologous fat transplantation: suggested clinical guidelines based on a review of recent literature

After more than a century of use, fat grafting is firmly entrenched in the skill set of plastic surgeons. While macrofat grafting is relatively predictable and reliable, microfat grafting by injection is still in the stages of technical evolution. Review of the current literature suggests that revascularization may take up to 21 days to reach the center of a microfat graft. We recommend harvesting by excision (or gentle aspiration), processing by short and gentle centrifuge to separate the layers, and reinjection of the lower layer via a fine cannula (for example, 17 gauge for the face) and a 1-mL syringe with multiple passes, injecting only a tiny amount with each pass as the needle is withdrawn, to obtain the most reliable clinical outcome.

An Experimental Model for Improving Fat Graft Viability and Purity

BACKGROUND

Autologous fat is an excellent soft-tissue filler, given its abundance, ease of harvest, and natural appearance. However, graft longevity is unpredictable and is reported in the literature to be between 3 months and 8 years.

METHODS

A genetically identical, age- and sex-matched mouse experiment was used to develop a model. Inguinal fat pads were subjected to different harvest and preparatory techniques. Primary endpoints-viability and purity-were assessed with the trypan blue viability assay and component counting with a hemocytometer.

RESULTS

Viability and purity were highest after excisional harvest versus blunt or needle harvest, presumably secondary to differences in cellular trauma. Saline wash or centrifugation after harvest produced modest but statistically significant improvements in viability and purity. However, if grafts harvested in any fashion were treated with an initial collagenase digestion followed by an idealized centrifugation regimen and a single wash step, viability and purity were consistently 96 percent and 93 percent, respectively.

CONCLUSIONS

Using an in vitro murine model, the authors have systematically developed a clinically practical model for creating a pure single-cell suspension of viable adipocytes that is reproducible, regardless of tissue harvest method.

Autologous Cultured Fibroblast Injection for Facial Contour Deformities: A Prospective, Placebo-Controlled, Phase III Clinical Trial

BACKGROUND

Previous data indicate that injections of autologous fibroblasts increase collagen formation, accompanied by a concomitant increase in thickness and density of dermal collagen.

OBJECTIVE

The purpose of this study was to determine efficacy and side effects of autologous living fibroblast injections versus placebo in a randomized Phase III trial for the treatment of various facial contour defects.

METHODS

This was a double-blind, randomized comparison of injectable living autologous fibroblast cells and placebo for the treatment of facial contour defects (N=215). Live fibroblasts (20 million/mL) or placebo (the transport medium without living cells) were given as three doses administered at 1- to 2-week intervals. Efficacy evaluations were performed 1, 2, 4, 6, 9, and 12 months after the first injection.

RESULTS

Living fibroblasts produced statistically significantly greater improvements in dermal deformities and acne scars than did placebo. The difference between live fibroblast injections and placebo achieved statistical significance at 6 months (p<.0001). At 9- and 12-month follow-up, live fibroblast-treated patients continued to demonstrate benefit from treatment with response rates of 75.0 and 81.6%, respectively. No serious treatment-related adverse events were reported.

CONCLUSIONS

Our results indicate that autologous fibroblast injections can safely and effectively produce improvements in rhytids, acne scars, and other dermal defects continuing for at least 12 months after injection.

Fat injections for facial rejuvenation: 17 years experience in 1720 patients

BACKGROUND

Autologous adipose tissue has been proved to be an excellent filling material. Fat injections can correct cosmetic defects that are caused by loss of subcutaneous tissue, such as atrophy of the face due to significant weight loss, wrinkles and facial involution due to ageing.

OBJECTIVE

To evaluate the safety and long-term results of facial rejuvenation by autologous fat injections using the fine-needle technique to inject fat and frozen fat for repeating the implantation procedure.

METHOD

Patients were evaluated clinically and photographically. Extraction, processing and implantation of fat were performed using an anaerobic technique. The fat was harvested by tumescent liposuction, using syringes and small diameter blunt-tip cannulas (2-3 mm). After washing the collected fat in normal saline it was centrifuged, transferred to small syringes (1-2.5 mL diameter) and then injected subcutaneously using fine needles of 21-23 G. Hypercorrection was avoided, so one or two repetitions of the fat injections were usually necessary, at intervals of at least 1 month, in order to achieve the desired cosmetic result. Using frozen fat simplified repeat fat implantation.

RESULTS

The clinical long-term follow-up of 1720 patients up to 17 years is presented. Absorption of the injected fat was estimated at 40-60%. The absorption rate varied a lot in each case. Long-term follow-up proved that final correction after two or more repetitions of frozen fat injections, persisted for many years, the longest proved to be more than 12 years.

CONCLUSIONS

The advantages of the fine-needle technique for fat grafting were very important: more accurate and refined work, less painful injections, no scars at needle puncture points, early treatment of small defects, and the facility to treat multiple sites, even the entire face, in one session. There were no major complications. Oedema and sometimes echymoses at the donor site for 6-10 days and slight bruising at the injected areas for 3-5 days are the disadvantages of the procedure.

Facial autologous soft-tissue contouring by adjunction of tissue cocktail injection (micrograft and minigraft mixture of dermis, fascia, and fat)

Facial aging is both a physiologic and anatomic process characterized by changes in the skin and supporting tissues. The aging process produces an outer envelope that gradually expands while its contents gradually involute and the underlying structure weakens. This process results in an excess of skin that tends to create folds, grooves, and deepening furrows. Contour augmentation and filling depressions with autologous tissue or heterogeneous materials are widely used in face rejuvenation as an adjunctive procedure. There is unanimous agreement on the advantages of autogenous tissue grafts over alloplastic materials and heterogeneous transplants. It is also well known that the revascularization of a small graft (fat, dermis, and/or composite graft) is better than a large graft. For this reason, fat injections consisting of small particles have recently become popular. According to different authors, a graft take may vary from 30 to 50 percent. Nevertheless, it has been thoroughly documented that a graft consisting of dermis or fascia is superior to a fat graft in both the graft take rate and quality of the tissue. Strips of dermal graft have been used successfully for several years to fill lip contour and nasolabial folds. However, the main disadvantage of this technique is that utilization is restricted only to certain areas where there is a need for a small incision. To overcome this obstacle, the author developed a simple technique to obtain an injectable mass from a mixture of dermis, muscle strips, fat tissue, and fascia to use in body contouring (especially in the facial region) in large areas. The author describes the use of the technique in 450 patients. Follow-up in these patients from 6 months to 10 years showed that the application of the "tissue cocktail" procedure in select patients improved the author's results and created a marked increase in the number of satisfied patients with no complaints. The take and durability of this kind of graft were superior to the author's results using fat grafts. The tissue cocktail graft remained stable for several years, as effectively seen in the chin region. The sole complication from the procedure was some bruising, which was resolved in several days. No single infection or inclusion cyst was observed in this series.

Successful correction of depressed scars of the forehead secondary to trauma and morphea en coup de sabre by en bloc autologous dermal fat graft

BACKGROUND

Atrophic scars of the forehead can result from various pathologic processes including morphea en coup de sabre as well as trauma. A variety of surgical techniques can be used to correct these atrophic scars.

OBJECTIVE

Soft tissue augmentation for correction of atrophic scars of the forehead using en bloc autologous dermal fat graft.

METHODS

Use of en bloc autologous dermal fat graft harvested from the hip and inserted into a pocket created under the atrophic scar in two patients with depressed scars of the forehead.

RESULTS

Overcorrection of the scars with en bloc autologous dermal fat grafts resulted in the treated areas becoming level with the adjacent skin within 3 months. Follow-up for a period of 12 months showed a perfectly level and stable graft with no further resorption.

CONCLUSION

En bloc autologous dermal fat grafting appears to be a safe technique that provides excellent cosmetic results for the correction of small to medium depressed scars of the forehead.