Structural fat grafting: more than a permanent filler

Comparison of stromal vascular fraction cell composition between Coleman fat and extracellular matrix/stromal vascular fraction gel

As a mechanically condensed product of Coleman fat, extracellular matrix/stromal vascular fraction gel (ECM/SVF-gel) eliminates adipocytes, concentrates SVF cells, and improves fat graft retention. This study aims to compare SVF cell composition between Coleman fat and ECM/SVF-gel. Matched Coleman fat and ECM/SVF-gel of 28 healthy women were subjected to RNA-seq, followed by functional enrichment and cell-type-specific enrichment analyses, and deconvolution of SVF cell subsets, reconstructing SVF cell composition in the transcriptome level. ECM/SVF-gels had 9 upregulated and 73 downregulated differentially expressed genes (DEGs). Downregulated DEGs were mainly associated with inflammatory and immune responses, and enriched in fat macrophages. M2 macrophages, resting CD4+ memory T cells, M1 macrophages, resting mast cells, and M0 macrophages ranked in the top five most prevalent immune cells in the two groups. The proportions of the principal non-immune cells (e.g., adipose-derived stem cells, pericytes, preadipocytes, microvascular endothelial cells) had no statistical differences between the two groups. Our findings reveal ECM/SVF-gels share the same dominant immune cells beneficial to fat graft survival with Coleman fat, but exhibiting obvious losses of immune cells (especially macrophages), while non-immune cells necessary for adipose regeneration might have no significant loss in ECM/SVF-gels and their biological effects could be markedly enhanced by the ECM/SVF-gel's condensed nature.

Limited fasciectomy with versus without autologous adipose tissue grafting for treatment of Dupuytren's contracture (REMEDY): study protocol for a multicentre randomised controlled trial

BACKGROUND

Dupuytren's contracture is a hereditary disorder which causes progressive fibrosis of the palmar aponeurosis of the hand, resulting in digital flexion contractures of the affected rays. Limited fasciectomy is a standard surgical treatment for Dupuytren's, and the one with the lowest recurrence rate; however, the recurrence is still relatively high (2-39%). Adipose-derived stem cells have been shown to inhibit Dupuytren's myofibroblasts proliferation and contractility in vitro, as well as to improve scar quality and skin regeneration in different types of surgeries. Autologous adipose tissue grafting has already been investigated as an adjuvant treatment to percutaneous needle fasciotomy for Dupuytren's contracture with good results, but it was only recently associated with limited fasciectomy. The purpose of REMEDY trial is to investigate if limited fasciectomy with autologous adipose tissue grafting would decrease recurrence compared to limited fasciectomy alone.

METHODS

The REMEDY trial is a multi-centre open-label randomised controlled trial (RCT) with 1:1 allocation ratio. Participants (n = 150) will be randomised into two groups, limited fasciectomy with autologous adipose tissue grafting versus limited fasciectomy alone. The primary outcome is the recurrence of Dupuytren's contracture on any of the treated rays at 2 years postoperatively. The secondary outcomes are recurrence at 3 and 5 years, scar quality, complications, occurrence of algodystrophy (complex regional pain syndrome), patient-reported hand function, and hypodermal adipose tissue loss at 1 year postoperatively in a small subset of patients.

DISCUSSION

The REMEDY trial is one of the first studies investigating limited fasciectomy associated with autologous adipose tissue grafting for Dupuytren's contracture, and, to our knowledge, the first one investigating long-term outcomes of this treatment. It will provide insight into possible benefits of combining adipose tissue grafting with limited fasciectomy, such as lower recurrence rate and improvement of scar quality.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05067764, June 13, 2022.

Fillers impacting follicles: the emerging complication of filler-induced alopecia

Filler-induced alopecia is a transient alopecia characterized by localized hair loss and often attributed to vascular compromise following dermal filler injections in facial regions. Although an uncommon phenomenon, the rising incidence of filler-induced alopecia underscores the importance of understanding and managing this condition. We performed an extensive PubMed review of articles reporting filler-induced alopecia and summarizing the implicated filler types, injection areas, hair loss patterns, symptom onset, course progression, treatments, and prognosis. Hyaluronic acid injections were the most implicated in filler-induced alopecia cases, with calcium hydroxylapatite and autologous fat less frequently associated. No cases involved other dermal filler types. Although recovery times varied depending on the treatment, hyaluronidase (HAase) injections rapidly restored near-normal hair density within 3-4 months. Minoxidil and platelet-rich plasma play a more minor role in restoring hair growth but may be used as adjuncts with HAase to facilitate hair growth. Finally, alternative interventions like intralesional triamcinolone, warm compresses, and nitroglycerin warrant exploration, given limited robust clinical data. Our study promotes awareness of filler-induced alopecia's rising incidence and offers practical insights and evidence-based recommendations for effective management. By equipping dermatologists with this knowledge, our aim is to improve patient outcomes and reduce adverse events in filler-based procedures.

Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review

BACKGROUND

Since nanofat was first introduced by Tonnard in 2013, numerous studies have reported positive findings with its use; however, concerns exist regarding its effects and mechanisms, and the various methods used to generate nanofat also remain unclear. The authors conducted a systematic review to evaluate the efficacy of nanofat grafting alone in plastic and reconstructive surgery.

METHODS

The MEDLINE, Embase, Cochrane Central, Web of Science, and Scopus databases were searched for studies related to the use of nanofat grafting alone in plastic and reconstructive surgery. Outcomes of interest were all clinical results in humans or animals.

RESULTS

Twelve studies were included. No meta-analysis was conducted due to the clinical heterogeneity of the studies. In general, included studies had a low level of evidence. Six studies ( n = 253 patients) showed significant improvements in scar characteristics based on Patient and Observer Scar Assessment Scale, FACE-Q scale, physician assessment, patient satisfaction, and Vancouver Scar Scale scores. Four studies described the benefits of nanofat in skin rejuvenation (wrinkles, fine rhytides, pigmentation, and discoloration) through photographs, questionnaires, and indentation indices. Histologic evaluation illustrated overall increases in skin thickness, collagen, and elastic fibers. Three experimental studies showed the beneficial effects of nanofat on fat grafting, diabetic wound healing, and hair growth, with compelling histological evidence. No severe complication was reported.

CONCLUSIONS

Nanofat grafting shows potential benefits in scar and antiaging treatments, with conclusive histological evidence. Clinical studies of fat grafting, wound healing, and hair growth should be conducted, based on the results of this systematic review. Nanofat grafting could be a practical and safe procedure.

Secondary Breast Augmentation: The Six Winning Moves

BACKGROUND

Breast augmentation in 2019 was the first among the top five cosmetic surgical procedures performed worldwide, according to the International Society of Aesthetic Plastic Surgery. It is not only the most commonly performed cosmetic surgery, but also the aesthetic procedure with the highest reoperation rate.

METHODS

A retrospective observational study of 306 female patients who underwent secondary breast surgery, with a follow-up of at least 1 year after surgery, from 2010 to 2020 is presented. For patients'selection, we decided to include all patients who performed a secondary breast surgery for aesthetic reasons; only patients with history of previous radiotherapy were excluded.

RESULTS

Patients were divided into different groups according to the performed procedure (the six winning moves) and associated postoperative outcomes are shown.

CONCLUSIONS

The aim of this paper, based on authors' own experience, is to present a personalized approach to secondary breast reshaping, describing the six "winning" moves to apply, which, differently combined among each other, intend to address each specific cause of reintervention with a dedicated surgical procedure.

LEVEL OF EVIDENCE IV

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 .

Investigation of the Effect of Mobile and Immobile Regions on Fat Graft Viability: An Experimental Study in a New Model

BACKGROUND

Fat grafts are widely used in plastic, aesthetic and reconstructive surgery. Their unpredictable resorption is their main disadvantage. A review of the literature shows that there is a lack of research on the effect of mobile and immobile regions on fat graft survival in fat graft applications.

OBJECTIVE

Our aim was to investigate the relationship of fat graft survival with mobile and immobile region in a new experimental model.

METHODS

Twenty-four male Wistar albino rats were randomly divided into two groups (n=12). Fat grafts were harvested from the right inguinal region of the rat. In Group 1, the fat graft was placed in the subcutaneous pouch formed in the scalp region of the rat. In Group 2, fat grafts were placed in the pouch formed in the posterior cervical region of the rat. At the end of 6 weeks, the weights and histopathology of the fat grafts were evaluated. Histopathological examinations were performed in a blinded fashion.

RESULTS

The weights of the fat grafts were found to be higher in Group 1. At the same time, histopathological examinations showed that vascular density was higher in Group 1. There was no statistically significant difference in other histopathological examinations.

CONCLUSION

The mobile and immobile areas may have different effects on the survival of transplanted fat grafts. Sliding movement between muscle and skin in the mobile zone puts stress on the fat graft. In our study, the mobile site was shown to have a negative effect on the vascularity of the fat graft. It was observed that the vascular density was higher in the fat graft placed in the immobilised area. Further studies on the increase in vascularity can be carried out using the new experimental model we have created.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Enhancing high-quality fat survival: A novel strategy using cell-free fat extract

High-quality fat (HQF) improves the survival rate of fat and volumetric filling compared to traditional Coleman fat. However, this HQF strategy inevitably leads to a significant amount of unused fat being wasted. "CEFFE" (cell-free fat extract) is an acellular aqueous-phase liquid, rich in bioactive proteins. The remaining fat from preparing HQF can be further processed into CEFFE to promote the survival of HQF. HQF was obtained and the remaining fat was processed into CEFFE, then HQF was transplanted subcutaneously in nude mice. Animal studies showed that CEFFE significantly improved the survival rate of HQF. Histological analysis revealed that CEFFE improved the survival rate of HQF, by enhancing cell proliferation activity, reducing apoptosis, increasing angiogenesis, and improving the inflammatory state. Under simulated anaerobic conditions, CEFFE also improved the viability of HQF. In vitro, studies demonstrated that CEFFE enhanced the survival rate of HQF through multiple mechanisms. Transcriptomic analysis and qPCR showed that CEFFE increased the expression of angiogenesis-related genes in ADSCs while enhancing their proliferation-related gene expression and suppressing the expression of three differentiation-related genes. Moreover, functional experiments demonstrated that CEFFE-induced ADSCs exhibited stronger proliferation and adipogenic differentiation abilities. Tube formation and migration assays revealed that CEFFE promoted tube formation and migration of HUVECs, indicating its inherent pro-angiogenic properties. CEFFE facilitated the development of M0 to M2 macrophages, suggesting its role in improving the inflammatory state. This innovative clinical strategy optimizes HQF transplantation strategy, minimizing fat wastage and enhancing the efficiency of fat utilization.

[Forehead burns]

Severe burns on the forehead are rare; well-conducted initial surgical treatment also limits the occurrence of sequelae. Therefore, indications for repairing the forehead arise from complex burns often extending to adjacent units. Repair techniques depend on the location and size of the lesions, associated nearby damage, and the patient's ability to withstand the burden of treatment. Management at the acute stage determines the sequelae; excision-grafting is the standard treatment, but it yields good results only if the fundamental principles of repair are respected: intervention within the 10th and 15th days post-burn, graft harvesting from the cephalic extremity or the upper part of the thorax and arms, and respect for the frontal unit. Sequelae management follows the same imperatives and typically requires skin expansion: front expansion for skin flaps if enough frontal skin is still available, upper thorax expansion for full thickness skin grafts if the frontal scar is too extensive. However, the excellent results obtained should not conceal the significant constraints associated with skin expansion.

Effectiveness of Autologous Fat Grafting in the Treatment of Scars: A Systematic Review and Meta-Analysis

BACKGROUND

Autologous fat transfer (AFT) has been proposed as a possible treatment for scar tissue and its associated symptoms. Its effectiveness's evidence is yet unidentified though. The aim of this meta-analysis is to evaluate the currently available evidence on the efficacy and safety of autologous fat transfer in treating post-burn and post-traumatic scars using a validated scar measurement tool.

METHODS

This study performed a systematic literature review in November 2023 using the following electronic databases: MEDLINE, SCOPUS, Directory of Open Access Journals (DOAJ), PUBMED, and Google Scholar. The following key terms were included: (Fat grafting OR Autologous fat transfer) AND (body scars OR body burns OR body wounds) AND (Efficacy OR Safety OR satisfaction). We evaluated articles according to predefined quality criteria. The following data were included during the extraction period: patient demographics, indications for AFT, the number of AFT sessions, follow-up periods, and changes in the Patient and Observer Scar Assessment Scale (POSAS) scores, which contain both the patient and observer components.

RESULTS

This study included 1326 patients and 23 published articles. A total of 14 prospective studies, 7 retrospective studies, and 2 Randomized clinical trials studies were evaluated. These 23 articles came from diverse global locations; the earliest was published in 1992, and the most recently published in 2022.

CONCLUSION

Our findings demonstrated significant enhancements in scar characteristics from both patient and observer perspectives. Overall, AFT holds promise as a valuable treatment option for scar-related conditions as it enhances scar quality ,contributing to improved patient outcomes and satisfaction.

LEVEL OF EVIDENCE III

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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Camouflage of Postburn Scarring Alopecia Using Nanofat Grafting and Follicular Unit Hair Transplantation

BACKGROUND

Postburn scarring alopecia on hair-bearing aesthetic subunits causes cosmetic disfiguring and psychological problems. Follicular unit extraction (FUE) hair transplantation is an effective technique for camouflaging postburn scarring alopecia. However, poorly vascularized and fibrotic scar tissue limits the viability of grafts. The mechanical and vascular characteristics of scar tissue can be improved by nanofat grafting. This study aimed to present the results of postburn scarring alopecia treatment using nanofat-assisted FUE hair transplantation.

METHODS

Eighteen patients who had postburn scarring alopecia in and around the beard were enrolled. Patients underwent single-session nanofat grafting and FUE hair transplantation at 6-month intervals. Twelve months after hair transplantation, the survival rate of transplanted follicular graft, scar improvement, and patient satisfaction were assessed by counting each transplanted follicle individually, using the Patient and Observer Scar Assessment Scale, and using a 5-point Likert satisfaction scale, respectively.

RESULTS

Nanofat grafting and hair transplantation were successfully performed without complication. All scars significantly improved in mature characteristics ( P < 0.00001 for patients; P < 0.00001 for observers). The survival and density rates of transplanted follicular units ranged from 77.4% to 87.9% (mean, 83.2% ± 2.5%) and 10.7% to 19.6% (mean, 15.2% ± 2.46%), respectively. All patients reported significantly satisfying cosmetic results ( P < 0.00001).

CONCLUSIONS

Scarring alopecia is an inevitable and challenging late complication of deep burned hair-bearing units. Combining nanofat injection and FUE hair transplantation is among the most innovative and effective treatments for postburn scarring alopecia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Preconditioning Strategies for Improving the Outcome of Fat Grafting

Autologous fat grafting is a common procedure in plastic, reconstructive, and aesthetic surgery. However, it is frequently associated with an unpredictable resorption rate of the graft depending on the engraftment kinetics. This, in turn, is determined by the interaction of the grafted adipose tissue with the tissue at the recipient site. Accordingly, preconditioning strategies have been developed following the principle of exposing these tissues in the pretransplantation phase to stimuli inducing endogenous protective and regenerative cellular adaptations, such as the upregulation of stress-response genes or the release of cytokines and growth factors. As summarized in the present review, these stimuli include hypoxia, dietary restriction, local mechanical stress, heat, and exposure to fractional carbon dioxide laser. Preclinical studies show that they promote cell viability, adipogenesis, and angiogenesis, while reducing inflammation, fibrosis, and cyst formation, resulting in a higher survival rate and quality of fat grafts in different experimental settings. Hence, preconditioning represents a promising approach to improve the outcome of fat grafting in future clinical practice. For this purpose, it is necessary to establish standardized preconditioning protocols for specific clinical applications that are efficient, safe, and easy to implement into routine procedures.

Comparison of Stored and Fresh Injectable Acellular Adipose Matrix in Soft Tissue Reconstruction in a Murine Model

BACKGROUND

We previously showed comparable volume effects of injections of acellular adipose matrix (AAM), an adipose tissue-derived extracellular matrix, and conventional fat grafting in a murine model. Thus, AAM could be a novel allogenic injectable product. However, its retention rate poses a concern, as repeated AAM injections may be required in some cases. This study investigated the biological properties and therapeutic value of stored AAM and compared them with those of fresh AAM, in a murine model.

METHODS

AAM was manufactured from fresh human abdominoplasty fat. Fresh and stored injectable AAM was prepared within 24 h and 3 months after generation, respectively. Either fresh or stored injectable AAM was injected into the scalp of athymic nude mice (0.2 mL/sample, n = 6 per group). After 8 weeks, graft retention was assessed through weight measurement, and histological analysis was performed, including immunofluorescence staining for CD31 and perilipin.

RESULTS

Retention rate was significantly reduced in the stored compared to the fresh injectable AAM group. Nevertheless, histological analysis revealed comparable inflammatory cell presence, with minimal capsule formation, in both groups. Adipogenesis occurred in both groups, with no significant difference in the blood vessel area (%) between groups.

CONCLUSIONS

Although the volume effects of stored AAM for soft tissue reconstruction were limited compared to those of fresh injectable AAM, stored AAM had similar capacity for adipogenesis and angiogenesis. This promising allogeneic injectable holds the potential to serve as an effective "off-the-shelf" alternative for repeated use within a 3-month storage period.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://link.springer.com/journal/00266 .

Fat or fillers: The dilemma in eyelid surgery

The aging of the periocular region has always aroused great interest. A fresh, young, and attractive sight determined an ever-greater attention to surgical and non-surgical techniques to obtain this result. In particular, the change in the concept of a young look, considered then "full", led to the increasing use of surgical (fat grafting) or medical (hyaluronic acid) filling techniques. Eyelid rejuvenation became increasingly popular in the field of cosmetic treatments, with a focus on achieving a youthful and refreshed appearance. Among the various techniques available, the choice between using fat grafting or fillers presented a clinical dilemma. In particular, what surgery considered of fundamental importance was a long-lasting result over time. On the other hand, aesthetic medicine considered it fundamental not to have to resort to invasive treatments. But what was the reality? Was there one path better than the other, and above all, was there a better path for patients? The minireview aims to explore the physiopathology, diagnosis, treatment options, prognosis, and future studies regarding this dilemma. We analyzed the literature produced in the last 20 years comparing the two techniques. Current literature reveals advancements in biomaterials, stem cell research and tissue engineering held promise for further enhancing the field of eyelid rejuvenation. The choice between fat grafting and fillers in eyelid cosmetic treatments presented a clinical dilemma. Understanding physiopathology, accurately diagnosing eyelid aging, exploring treatment options, assessing prognosis, and conducting future studies were essential for providing optimal care to patients seeking eyelid rejuvenation.

M2 Macrophage Polarization and Tissue Remodeling in Autologous Fat Grafting for Diabetic Skin Defects

Autologous adipose tissue was recognized as a promising therapeutic option for soft tissue defects owing to its regenerative potential and ability to facilitate tissue reconstruction. However, the mechanisms by which autologous fat grafting (AFG) promotes healing remain unclear, hindering its potential applications. This study aimed to investigate the distribution and phenotypic transition of infiltrating macrophages in transplanted adipose tissue, as well as their correlation with diabetic skin defect remodeling. Streptozotocin-induced diabetic rats with full-thickness dorsal skin defects were included in this study. The transplanted adipose tissue at the skin defects was collected and analyzed using flow cytometry to determine macrophage proportion and phenotype. The healing of skin defects was evaluated, and treatment was continued until day 14 as the designated endpoint of healing, followed by histopathologic examinations. Immunostaining with CD31 and lymphatic vessel endothelial receptor-1 was performed on wound tissues to analyze angiogenesis and lymphangiogenesis, respectively. Western blot and quantitative polymerase chain reaction analyses were used to assess the expression of the representative genes involved in the healing process. The results showed early polarization of M2 macrophages in the transplanted adipose tissue, concomitant with the upregulation of growth factors and downregulation of inflammatory factors. In vivo experiments revealed that AFG significantly promoted macrophage infiltration and M2 transformation in diabetic skin defects compared to the control groups, thereby promoting tissue extracellular matrix remodeling and lymphatic and vascular regeneration. However, the beneficial effects of AFG were inhibited by macrophage depletion. This study further demonstrated the potential of AFG for treating diabetic skin defects.

Pain-relieving Effects of Autologous Fat Grafting in Breast Cancer Surgery: A Scoping Review

Background

Chronic pain is relatively common after breast cancer surgery, including breast reconstruction. Autologous fat grafting (AFG) has gained attention as a novel method for breast reconstruction, and recent clinical studies have also shown effects of AFG on alleviation of chronic pain after breast cancer surgery. Our objective was to conduct a scoping review of studies that have examined these effects with clearly defined clinical outcomes.

Methods

A literature search was conducted using three databases: PubMed, MEDLINE, and Google Scholar, following PRISMA guidelines and the Arkesy and O'Malley framework. The search focused on clinical studies of the effects of AFG on chronic pain after breast cancer surgery. All studies reporting functional outcomes, return to work, and secondary surgery in a repeat operation were identified.

Results

Of the 148 studies identified in the search, 11 studies with a total of 684 patients were included in the review. The average volume of fat grafted was approximately 128 mL over an average of 1.6 sessions. The most common time point for assessment was 1 year post-AFG. In all studies with an evidence level of 3 or lower, AFG showed positive results in alleviating pain after breast cancer surgery. However, one of the three randomized controlled trials did not show clinically significant effects.

Conclusions

Most of the studies examined in this review suggested pain-relieving effects of AFG. However, there was one randomized controlled trial in which these effects were not confirmed, indicating a need for further accumulation of cases and performance of new, well-designed randomized controlled trials.

Combining High-Density Fat and Condensed Low-Density Fat Injections for Precise Facial Rejuvenation

BACKGROUND

Facial aging involves ptosis, adipose atrophy, and skeletal resorption. Depletion of adipose tissue primarily affects the deep facial fat compartment, leading to facial depression or ptosis, accompanied by atrophy of the superficial compartment. Restoring volume in the deep fat compartment is crucial for facial rejuvenation, while enhancing its supportive properties is also important. The superficial fat compartment contains small-sized adipocytes, and autologous fat grafting is a popular approach. However, variability in fat retention, homogeneity, and processing methods can impact outcomes, necessitating careful selection of a suitable fat processing material for precise facial fat grafting.

METHOD

A retrospective study was conducted on 50 patients who underwent facial augmentation using combined transplantation of high-density fat (HDF) and condensed low-density fat (CLDF) and 25 patients who underwent conventional Coleman fat grafting. Coleman fat was harvested by standard technique and the adipose tissue was divided into HDF and CLDF fractions through centrifugation. Subsequently, the low-density fat fraction was subjected to a process involving physical disruption followed by additional centrifugation to obtain CLDF. The CLDF fraction was consequently injected into the pre-SMAS subcutaneous layer of the superficial fat compartments. Patient satisfaction was evaluated using a typical Likert scale. Photographs were taken and imageological examinations were performed before and after treatment.

RESULT

The CLDF+HDF grafting group demonstrated a significantly shorter duration of swelling (6.0 ± 1.2 to 12.6 ± 3.3 days) and higher level of patient satisfaction when compared to the Coleman fat group. No serious complications were observed among all the patients who received the injections.

CONCLUSION

The use of this new treatment approach allows for precise fat transplantation in facial regions. The use of high-concentration fat filling for deep facial layers and CLDF filling for superficial layers is a safe and effective treatment plan for facial rejuvenation.

LEVEL OF EVIDENCE IV

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 .

Effect of Injectable Acellular Adipose Matrix on Soft Tissue Reconstruction in a Murine Model

BACKGROUND

The extracellular matrix isolated from adipose tissue, known as acellular adipose matrix (AAM), represents a novel biomaterial. AAM functions as a scaffold that not only supports stem cell proliferation and differentiation but also induces adipogenesis and angiogenesis. This study aims to investigate the volumetric effects and microenvironmental changes associated with injectable AAM in comparison to conventional fat grafting.

METHODS

AAM was manufactured from fresh human abdominoplasty fat using a mechanically modified method and then transformed into an injectable form. Lipoaspirate was harvested employing the Coleman technique. A weight and volume study was conducted on athymic nude mice by injecting either injectable AAM or lipoaspirate into the scalp (n=6 per group). After eight weeks, graft retention was assessed through weight measurement and volumetric analysis using micro-computed tomography (micro-CT) scanning. Histological analysis was performed using immunofluorescence staining for perilipin and CD31.

RESULTS

Injectable AAM exhibited similar weight and volume effects in murine models. Histological analysis revealed comparable inflammatory cell presence with minimal capsule formation when compared to conventional fat grafts. Adipogenesis occurred in both AAM-injected and conventional fat graft models, with no significant difference in the blood vessel area (%) between the two.

CONCLUSIONS

In summary, injectable AAM demonstrates effectiveness comparable to conventional fat grafting concerning volume effects and tissue regeneration in soft tissue reconstruction. This promising allogeneic injectable holds the potential to serve as a safe and effective "Off-the-Shelf" alternative in both aesthetic and reconstructive clinical practices.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Utility of Fat Grafting in Chronic Wounds

Introduction  The history of wounds dates back to the evolution of mankind. Throughout the centuries, management modalities of wounds have undergone drastic changes. With the advent of technology, we have multiple options for wound care, but none of them can be called the gold standard of wound care. Autologous fat grafting (AFG) is one of the most routinely performed procedures in aesthetic surgery. Fat grafting has shown beneficial effects in the healing of wounds. The regenerative potential of autologous fat is contributed by the adipose-derived stem cells present within the stromal vascular fraction, which are capable of differentiating into multiple cell types. This study aims to analyze the usefulness of AFG in cutaneous wound healing. Materials and Methods  This prospective, study was conducted in our institute between April 2021 and May 2023. Eighteen patients with nonhealing wounds were included in the study. For assessing wound healing all the patients were first managed with conventional dressing for 2 weeks before surgery. After routine preoperative workup, the procedure was performed under local anesthesia in most cases. Fat was harvested from the lower abdomen and after emulsification, was injected into the edge and floor of the ulcer. The dressing was changed on the third postoperative day and the outcome was assessed. Results  Eighteen patients (M:F ratio 8:1), with a mean age of 35.61 ± 12. 64 years (range 10-65 years), were included in this study. The most common etiology was trauma (44%), others being postop infection (17%), veno-lymphatic ulcer (17%), burns (11%), insect bite (5%), and trophic ulcer (5%). Majority of the wounds (95%) healed without the need for any extra intervention. The mean period taken for complete wound healing was 5.05 weeks. Conclusion  Complete wound healing was achieved in majority of the patients without any complications. We recommend the usage of AFG for nonhealing wounds, as the procedure is relatively simple and can be performed after basic training. Larger-scale randomized controlled trials should be conducted to prove their efficacy in the management of complicated wounds.

Adipose-Derived Stromal Cell-Based Therapies for Radiation-Induced Fibrosis

Significance: Half of all cancer patients receive radiation therapy as a component of their treatment regimen, and the most common resulting complication is radiation-induced fibrosis (RIF) of the skin and soft tissue. This thickening of the dermis paired with decreased vascularity results in functional limitations and esthetic concerns and poses unique challenges when considering surgical exploration or reconstruction. Existing therapeutic options for RIF of the skin are limited both in scope and efficacy. Cell-based therapies have emerged as a promising means of utilizing regenerative cell populations to improve both functional and esthetic outcomes, and even as prophylaxis for RIF. Recent Advances: As one of the leading areas of cell-based therapy research, adipose-derived stromal cells (ADSCs) demonstrate significant therapeutic potential in the treatment of RIF. The introduction of the ADSC-augmented fat graft has shown clinical utility. Recent research dedicated to characterizing specific ADSC subpopulations points toward further granularity in understanding of the mechanisms driving the well-established clinical outcomes seen with fat grafting therapy. Critical Issues: Various animal models of RIF demonstrated improved clinical outcomes following treatment with cell-based therapies, but the cellular and molecular basis underlying these effects remains poorly understood. Future Directions: Recent literature has focused on improving the efficacy of cell-based therapies, most notably through (1) augmentation of fat grafts with platelet-rich plasma and (2) the modification of expressed RNA through epitranscriptomics. For the latter, new and promising gene targets continue to be identified which have the potential to reverse the effects of fibrosis by increasing angiogenesis, decreasing inflammation, and promoting adipogenesis.

Endoscopic mastectomy followed by immediate breast reconstruction with fat grafting for breast cancer

BACKGROUND

Although endoscopic mastectomy has been associated with good tolerance and enhanced patient satisfaction, limitations such as the implant or flap size for reconstruction with small incisions remain unresolved. Fat grafting (FG) can expand tissue volume with pinhole skin incisions. Herein, we evaluated the safety and efficacy of endoscopic mastectomy followed by immediate FG.

METHODS

Patients who underwent endoscopic mastectomy with immediate FG reconstruction from 2015 to 2021 were retrospectively evaluated to establish surgical outcomes and prognosis.

RESULTS

Twenty-three patients with clinical stage 0 or I breast cancer underwent unilateral endoscopic mastectomy with immediate FG. The median age was 45 years (41-55), and the median body mass index was 19.3 kg/m2 (15.8-26.6). Endoscopically performed procedures included skin-sparing mastectomies in 18 patients (78%) and nipple-sparing mastectomies in five patients (22%). The median procedure duration was 295 min (242-346). The median specimen weight was 133 g (71-334), and the median grafted fat volume was 200 mL (136-320). No patient required reoperation or additional procedures for complications. One patient experienced recurrence at a median follow-up of 56.1 months and underwent resection; the patient was alive without recurrence 54 months post-resection.

CONCLUSION

To the best of our knowledge, this is the first report of endoscopic mastectomy with immediate FG for reconstruction. When compared with other immediate autologous reconstructions, our strategy could minimize the skin incision and procedure duration, as well as limit complications. Further prospective investigations are needed to evaluate oncological safety, surgical outcomes, and patient satisfaction.

Composite Microparticles of Fat Graft and GFR Matrigel Improved Volume Retention by Promoting Cell Migration and Vessel Regeneration

BACKGROUND

The retention volume of autologous fat grafts decreases after transplantation due to limited nutrition infiltration and insufficient blood supply. Structural fat grafts and the 3M (multipoint, multitunnel, and multilayer) injection technique have been considered to improve the survival of grafts; however, it is difficult for surgeons to practice in the clinic because grafts tend to gather into a cluster, especially in large volume fat grafting. Therefore, we hypothesize that prefabricated microparticle fat grafts (PFMG) may improve the retention rate.

METHODS

The C57BL/6 mouse fat particles were embedded in growth factor-reduced (GFR)-Matrigel to detect cell migration by immunofluorescence staining in vitro. PFMG was prepared by mixing mouse fat particles and GFR Matrigel in a 1:1 volume ratio and injected subcutaneously into C57BL/6 mice. Fat particles mixed with PBS in equal volume served as control group. The grafts were harvested at 1, 4, 8, and 12 weeks after sacrifice. The retention rate of grafts at each time point was measured, and the structural alterations were detected by SEM. Fat necrosis and blood vessel density were evaluated by histological analysis.

RESULTS

CD34+ cells are migrated from the PFMG and formed a tree-like tubular network in the in vitro study. The retention rate was higher in the PFMG group than in the control group at week 12 (38% vs. 30%, p < 0.05). After transplantation, the dissociated structure of fat particles was maintained in PFMG by SEM analysis. Histological analysis of PFMG confirmed less fat necrosis and more blood vessel density in the PFMG group at the early stage than in the control group. The GFR Matrigel was displaced by adipose tissue with time.

CONCLUSIONS

In this study, we developed a novel fat grafting method, PFMG that dispersed fat grafts and maintained the structure after transplantation. High volume retention volume of PFMG was achieved by promoting cell migration and vessel regeneration.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

3D Lipogluing: Preliminary Results of a Novel Technique for Direct Three-dimensional Fat Grafting in Breast Reconstruction Surgery

Lipofilling has emerged as an effective technique in breast reconstruction for enhancing aesthetic outcomes and addressing residual deformities. Traditionally, fat grafting has been performed as a secondary step in implant-based breast reconstruction during the replacement of the expander with a breast implant or as a revisional procedure. Our study investigates the technical feasibility and presents preliminary results of a new promising technique for delivering fat grafting in a three-dimensional (3D) shape, directly during mastectomy with immediate breast reconstruction or in delayed breast reconstructive procedures. Our new 3D lipogluing technique involves securing the fat tissue in a 3D manner using fibrin glue. This method enhances the coverage of soft tissues and provides improved volume and shape supplementation. In selected cases between December 2015 and September 2023, we treated 24 patients using the 3D lipogluing technique and five patients using 3D lipocubing (without use of fibrin glue).The patient cohort consisted of different indications for breast reconstructions: direct-to-implant, expander-based breast reconstruction, and "conservative" surgery. Preliminary findings suggest the technique is a safe and effective approach that can enhance the soft-tissue envelope of reconstructed breasts by acting as an autologous scaffold, owing to its regenerative properties. This technique not only improves the overall aesthetic outcome but also has the potential to reduce implant-related complications. Furthermore, ongoing studies are investigating methods to optimize the results and explore the potential application of 3D lipogluing and 3D lipocubing in breast-conserving oncoplastic surgery, cosmetic breast surgery, and other areas of plastic reconstructive and aesthetic surgery.

Enhancing Fat Transplantation Efficiency in a Mouse Model through Pretreatment of Adipose-Derived Stem Cells with RIP3 Inhibitors

BACKGROUND

Autologous fat transplantation, widely used in cosmetic and reparative surgery for volumetric enhancements, faces challenges with its inconsistent long-term survival rates. The technique's efficacy, crucial for its development, is hindered by unpredictable outcomes. Enriching fat grafts with adipose-derived stem cells (ADSCs) shows promise in improving survival efficiency.

OBJECTIVES

This study aimed to explore the potential of receptor-interacting protein kinase 3 (RIP3) kinase inhibitors as a pretreatment for ADSCs in enhancing autologous fat graft retention over a long term.

METHODS

ADSCs were isolated, cultured under normal or oxygen-glucose deprivation conditions, and mixed with particulate fat grafts to form distinct experimental groups in female nude mice. Fat graft mass and volume, along with underlying mechanisms, were evaluated using quantitative reverse transcription polymerase chain reaction (RT-qPCR), immunohistochemistry, and Western blot analysis.

RESULTS

The experimental group, pretreated with RIP3 kinase inhibitors, had higher graft mass and volume, greater adipocyte integrity, and increased peroxisome proliferator-activated receptor gamma (PPARγ) mRNA levels than control groups. Furthermore, the experimental group demonstrated lower expression of necroptosis pathway proteins in the short term and an ameliorated inflammatory response as indicated by interleukin-1 beta (IL-1β), interleukin-10 (IL-10) mRNA levels, and histological analyses. Notably, enhanced neovascularization was evident in the experimental group.

CONCLUSIONS

These findings suggest that RIP3 kinase inhibitor pretreatment of ADSCs can improve fat graft survival, promote adipocyte integrity, potentially decrease inflammation, and enhance neovascularization.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Personalized Research on the Aging Face-A Narrative History

Throughout history, people have struggled to find out the secret of youth. The aim of the manuscript is to review the main achievements regarding the exploration of the aging face phenomenon. It should be very important to know the evolution in this field due to the increase in life expectancy among the population. Our purpose is for the current study to serve as a starting point towards exploring novel research avenues in molecular biology and the confocal immunofluorescence of cervicofacial soft tissues, employing cutting-edge techniques. All changes in the shape of the facial skeleton, soft tissue, retaining ligaments, fat compartments, and the skin envelope contribute to facial aging to varying degrees.

Variable Energy and Ultrasound-based Liposculpture of the Arms: Multicenter and Multidevice Study

Incorporation of new technologies to assist the liposuction procedure is becoming increasingly common. These technologies allow for a softer technique, balanced shaping, elimination of excess adipose tissue, and skin tightening. Some of these technologies include ultrasound (US; US-assisted liposculpture, VASER-assisted liposuction), power suction (power-assisted liposuction), radiofrequency (RF; RF-assisted lipolysis), and laser (laser-assisted liposuction). In addition, some of these devices have been shown to reduce the incidence of hematomas/inflammation and shorten recovery time. We report our experience in high-definition liposculpture of the arms in addition to new technologies to improve skin retraction, comparing their results in terms of complications, satisfaction score, and aesthetic outcomes. We included patients with mild-to-moderate arm dermatochalasis (Duncan classification) fat deposits in the upper extremities who were considered candidates for third-generation US-assisted liposculpture, power-assisted liposuction, RF-assisted lipolysis/skin tightening, and laser-assisted liposuction. A total of 683 consecutive patients met the inclusion criteria for the study. Most of them were women (n = 605, 88%). Fat grafting was performed in 80 patients (11.7%). A significant portion of the patients were secondary cases (n = 223, 33%). Age ranged from 18 to 70 years (median = 38 years). BMI ranged from 17.8 to 34.8 kg/m2 (mean = 24.3 kg/m2). RF-assisted and laser-assisted high-definition liposculpture of the arms are both effective and reproducible techniques for patients who seek an athletic and slim arm contour. A low rate of complications and high satisfaction index support our findings.

Use of brown adipose tissue transplantation and engineering as a thermogenic therapy in obesity and metabolic disease

The induction of thermogenesis in brown adipose tissue is emerging as an attractive therapy for obesity and metabolic syndrome. However, the long-term efficacy and safety of clinical pharmaceutical agents have yet to be fully characterized. The transplantation of brown adipose tissue represents an alternative approach that might have a therapeutic effect by inducing a long-term increase in energy expenditure. However, limited tissue resources hinder the development of transplantation. Stem cell-based therapy and brown adipose tissue engineering, in addition to transplantation, represent alternative approaches that might resolve this problem. In this article, we discuss recent advances in understanding the mechanisms and applications of brown adipose tissue transplantation in the treatment of obesity and related metabolic disorders. Specifically, the induction of brown adipocytes and the fabrication of engineered brown adipose tissue as novel transplantation resources have long-term effects on ameliorating metabolic defects in rodent models. Additionally, we explore future prospects regarding the development of three-dimensional engineered brown adipose tissue and the associated challenges.

Safety and Efficacy Study of the Application of Redensified Cross-Linked Hyaluronic Acid for Filling Gluteal Volume and Cellulite Depressions

PURPOSE

To test the efficacy and safety of cross-linked hyaluronic acid application for filling buttocks and cellulite depressions and its permanence over time.

METHODS

For a period of a year, 25 patients were applied redensified cross-linked hyaluronic acid in the gluteal area. These patients were all 23-45-year-old women with little fat to be removed. The product used is composed of hyaluronic acid with high cross-linking and redensification which allows it to maintain shape and durability over time. All patients underwent tumescent anesthesia with neuroleptic sedation in the operating room. The procedure was regarded as minimal (container, sterile gloves, and surgical field). The amount applied for gluteal augmentation varied from 50 to 100 ml per application area and according to the patient's needs. For the filling of cellulite depressions, the application was up to 3 cc per depression and up to a total of 40 ml. The maximum volume used per patient in the buttocks did not exceed 200 ml, and it did not exceed 40 ml in cellulite depressions.

RESULTS

A group of patients was treated in the upper and middle third of the buttocks in superficial and deep subcutaneous layers and in cellulite depressions. Very good results have been obtained without any major complications.

CONCLUSIONS

The use of redensified cross-linked hyaluronic acid of non-animal origin is therefore an option for gluteal augmentation and cellulite depressions. Although the product degrades over time, after 12 months, 44% of treated patients rated their results as highly or very much improved, 36% as improved, 16% rated the improvement as poor, and one patient (4%) was dissatisfied.

LEVEL OF EVIDENCE IV

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 .

Single-Step Full-Face Surgical Treatment of the Facial Profile

The present study was performed to describe how much affordable, feasible, and straightforward is the approach the authors called "single-stage full-face surgical profileplasty," tailored to greatly improve the surgery of the facial profiling setting and achieve complete profile correction at the same time. From January 2010 to May 2019, 113 patients (95 females and 18 males; aged 19 - 63 years) were surgically treated for full-face profile amelioration. Profile correction was performed by using a combination of five procedures out of other various previously experienced: forehead fat grafting, rhinoplasty, lip fat grafting, genioplasty, and submental liposuction. All patients were assessed at 1, 3, 6, and 12 months following surgery for assessing the surgical profile treatment (SPT) outcome and any possible side effects of the combined treatment. Facial profile stability at 1 year was taken as the completion point of this treatment. Arnett et al's "Soft Tissue Cephalometric Analysis" (1999) was used to clinically evaluate the soft tissues before and after the SPT. Patients' satisfaction was measured with the Client Satisfaction Questionnaire-8" at 3 and 12 months after surgery. Statistics were used for Arnett et al's evaluation. Almost all the values were consistent and reached the normal ranges indicated by Arnett et al (p < 0.001), confirming that the desired results of the surgical profileplasty have been achieved. Single-stage full-face surgical profile treatment helps in correcting faults of the global facial deformity, in every single treated area, providing an overall improvement in facial aesthetics and harmony. Obtaining the simultaneous correction in the whole face has also the advantage of avoiding multiple surgical procedures, reducing postoperative discomfort, and the overall risks for the patient due to multiple surgical and anesthetic procedures.

Histological Comparison of Nanofat and Lipoconcentrate: Enhanced Effects of Lipoconcentrate on Adipogenesis and Angiogenesis

BACKGROUND

Nanofat and lipoconcentrate contain adipose-derived stem cells and growth factors, and have wide clinical applications in the regenerative field. This study aimed to investigate the microenvironmental changes associated with nanofat and lipoconcentrate.

METHODS

Conventional fat, nanofat, or lipoconcentrate (0.2 mL each, n = 5 per group) were injected subcutaneously into the dorsal flanks of athymic nude mice. The graft weights were measured at postoperative week 4; the grafts and their overlying skin were used for histological analyses.

RESULTS

Weights of the lipoconcentrate grafts were significantly greater than those of the conventional fat (p < 0.05) and nanofat (p < 0.01) grafts. There was no significant difference in inflammation, oil cysts, and fibrosis between the conventional fat and nanofat groups. Histological examination of the lipoconcentrate grafts showed less macrophage infiltration and the formation of fibrosis and oil cysts. Additionally, adipogenesis and angiogenesis were induced more in the lipoconcentrate grafts than in the nanofat grafts (p < 0.01). Lipoconcentrate and nanofat improved dermal thickness (p < 0.001 and p < 0.01, respectively, versus the baseline).

CONCLUSION

Lipoconcentrate grafts had greater volume and shape retention than conventional fat and nanofat grafts. They had better histological structure and acted as scaffolds for adipogenesis and angiogenesis. Both products showed regenerative effects on dermal thickness; however, only lipoconcentrate grafts had the required volume and regenerative effects, allowing it to serve as a novel adipose-free grafting method for facial rejuvenation and contouring.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hybrid Breast Augmentation: Double Benefit or Double Risk? A Comparative Study of 932 Cases

BACKGROUND

The authors propose a hybrid breast augmentation (HBA) method combining implants and fat grafting and explore the outcome and safety through a retrospective, single-center, propensity score-matched, comparative study.

METHODS

Outcome, satisfaction, and complications were compared between the HBA group (302 cases) and the implant-based breast augmentation (IBA) group (353 cases), and between the HBA group and the autologous fat grafting (AFG) group (277 cases).

RESULTS

The mean follow-up period was 31.7 months. After propensity score matching (PSM), 270 cases were matched between the HBA and IBA groups, and 156 cases were matched between the HBA and AFG groups. Compared with the IBA group, HBA achieved higher scores of implant visibility/palpability and upper pole contour with the specialists' evaluations (before and after PSM; P < 0.05). Regarding patient satisfaction, the scores of softness (before and after PSM), smoothness of the upper pole (before PSM), and overall satisfaction (after PSM) of the HBA group were better ( P < 0.05). Implant-related complications occurred at a similar rate. Compared with the AFG group, HBA achieved higher scores of shape (before and after PSM) and symmetry (after PSM) with evaluations by specialists ( P < 0.05). The scores of shape, symmetry, and overall satisfaction in the HBA group were better (before and after PSM; P < 0.05). The HBA group showed a lower incidence of palpable cysts, fat necrosis, oil cysts, and fat calcification (before PSM; P < 0.05).

CONCLUSION

When the three techniques were compared objectively, HBA presented better indices of aesthetic outcomes, satisfaction, and acceptable complications rates when compared with IBA and AFG.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

3D-Bioprinted GelMA Scaffold with ASCs and HUVECs for Engineering Vascularized Adipose Tissue

The purpose of tissue engineering is to reconstruct parts of injured tissues and to resolve the shortage of organ donations. However, the main concern is the limited size of engineered tissue due to insufficient oxygen and nutrition distribution in large three-dimensional (3D) tissue constructs. To provide better support for cells inside the scaffolds, the vascularization of blood vessels within the scaffold could be a solution. This study compared the effects of different culturing systems using human adipose tissue-derived stem/stromal cells (ASCs), human umbilical vein endothelial cells (HUVECs), and coculture of ASCs and HUVECs in 3D-bioprinted gelatin methacrylate (GelMA) hydrogel constructs. The in vitro results showed that the number of live cells was highest in the coculture of ASCs and HUVECs in the GelMA hydrogel after culturing for 21 days. Additionally, the tubular structure was the most abundant in the GelMA hydrogel, containing both ASCs and HUVECs. In the in vivo test, blood vessels were present in both the HUVECs and the coculture of ASCs and HUVECs hydrogels implanted in mice. However, the blood vessel density was the highest in the HUVEC and ASC coculture groups. These findings indicate that the 3D-bioprinted GelMA hydrogel coculture system could be a promising biomaterial for large tissue engineering applications.

Quantitative Assessment of Periocular Autologous Fat Transfer Survival Using 3D Stereophotogrammetric Imaging

PURPOSE

To assess periocular autologous fat transfer (AFT) survival by assessment of volume change with sequential 3D VECTRA imaging.

OBJECTIVE

Little is known about the patterns of graft survival of AFT in the periorbital region, especially in cases involving prior radiotherapy or trauma. The aim of this pilot study was to characterize fat survival following AFT in patients with a broad range of clinical indications, with and without a history of prior radiotherapy, for both periocular and orbital AFT, and in a subgroup of patients with an anophthalmic socket.

METHOD

A single-institution, prospective cohort study involving 18 applications of AFT for volume augmentation in the periocular and orbital area. All patients had sequential 3D VECTRA photographs following a validated standardized protocol. Patient demographics, including gender, age, ethnicity, underlying diagnosis, and volume of fat injected, were also collected.

RESULTS

In total 13 patients were enrolled, 9 female (69.2%) and 4 male (31.0%). Mean age at the time of surgery was 47.8 years. Patients had volume deficiency secondary to a variety of causes; the most common cause was postenucleation socket syndrome following trauma in 6 patients (46.2%). The mean fat survival volume at the 1-month postoperative point was 70% and 55% by 6 months. AFT conducted with a multiport cannula for fat harvesting use had an initial higher rate of fat reabsorption with ANOVA p = 0.002, however, this was not observed at the later follow-up periods. There was no statistically significant difference in fat survival between abdominal or thigh donor fat sites. There was no statistically significant difference in residual injected volume at the early follow-up period between patients who had prior radiotherapy and those who did not p = 0.8496.

CONCLUSION

AFT is an effective treatment for periorbital volume compromise with an acceptable survival rate in all categories of patients. Complex etiologies such as radiotherapy-related orbital and midface dysgenesis should not be a contraindication for AFT, with no difference in outcomes.

Titanium plates salvage in irradiated facial areas with the lipomodeling technique

Major defects of the facial structures cause severe functional and aesthetic impairment. For composite defects with bone loss, the use of a titanium plate bridging the bony defect, associated or not to a soft tissue pedicled flap is to be considered in complex cases, or for patients with high comorbidities. The principal limit of this technique is the risk of plate exposure, especially for patients who had adjuvant radiation therapy. We present two clinical cases of patients who had a facial reconstruction using a titanium plate associated with a locoregional soft tissue flap, and who presented a near-exposed plate a few years after the first surgery and adjuvant radiation therapy. In order to prevent plate exposure, we performed several lipomodeling sessions between skin and plate. Our results are very encouraging, with no plate exposure and thickening of the soft tissues which cover the plate at 10-years follow-up. The knowledge of the possibility to use fat grafting transfer could therefore lead to a strong return to the use of titanium plates in facial reconstruction.

Fractional CO 2 Laser Combined With Autologous Nanofat Injection Versus Fractional CO 2 Laser Combined With Platelet-Rich Plasma in the Treatment of Atrophic Acne Scars: A Split-Face Comparative Study With Optical Skin Imaging

BACKGROUND

Atrophic acne scarring is a common problem. If left untreated, its implications can impair the quality of life. Various treatments, with differing degrees of success, are used to alleviate atrophic scars.

OBJECTIVE

To assess the efficacy of nanofat versus platelet-rich plasma (PRP) as an adjuvant therapy to fractional CO 2 laser (FCL) for atrophic acne scars.

METHODS

This study included 35 patients with atrophic acne scars who received 3 sessions of FCL at 1-month intervals on both sides of the face, followed by intradermal PRP injection on the left side. A single session of nanofat was injected into the right side of the face 2 weeks before the laser sessions. The evaluation was conducted 3 months after the final treatment session.

RESULTS

After treatment, the right side of the face showed a significant reduction in Goodman scores and the indentation index of the Antera camera. The left side showed a significant difference in Goodman scores, yet the Antera camera showed a nonsignificant improvement. Nonetheless, the difference between the 2 sides was statistically insignificant.

CONCLUSION

Atrophic acne scars improved with both modalities. As a result, cotreatment with these techniques may synergistically affect atrophic acne scars in efficacy and safety.

Stromal Vascular Fraction Gel (SVF-Gel) Combined with Nanofat for Tear Trough Deformity

BACKGROUND

Tear trough deformity makes patients appear tired. Patients with less severe tear trough deformity prefer a less invasive method to correct the deformity. The infraorbital area is a multilayered tissue, and the aging of various components leads to tear trough deformity. To this end, we utilized the different characteristics of different fat derivatives to correct tear trough deformity.

METHODS

Thirty-two patients with Barton Grade I/II tear trough deformity were enrolled in this study between September 2020 and March 2021. We injected Stromal Vascular Fraction Gel (SVF-Gel) into the suborbicularis oculi fat layer and Nanofat into the subcutaneous. After 12 months of follow-up, we evaluated the changes using standardized clinical photogrammetric techniques, volume, global aesthetic improvement scale, and patient self-evaluation.

RESULTS

There were no major complications in any of the 32 patients. The measured data points demonstrated improvements in all aesthetic parameters. The width of the tear trough and the distance from the pupil to the tear trough improved. The Global Aesthetic Improvement Scale (GAIS) showed a high score (2.45±0.64 points), with patient self-assessment showing satisfactory results.

CONCLUSION

SVF-Gel combined with Nanofat injection can effectively correct tear trough deformities.

LEVEL OF EVIDENCE IV

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 .

The Evolving Function of Vasculature and Pro-angiogenic Therapy in Fat Grafting

Autologous fat grating is a widely-accepted method to correct soft tissue deficiency. Although fat transplantation shows excellent biocompatibility and simple applicability, the relatively low retention rate caused by fat necrosis is still a challenge. The vasculature is integral after fat grafting, serving multiple crucial functions. Rapid and effective angiogenesis within grafts is essential for supplying oxygen necessary for adipocytes' survival. It facilitates the influx of inflammatory cells to remove necrotic adipocytes and aids in the delivery of regenerative cells for adipose tissue regeneration in fat grafts. The vasculature also provides a niche for interaction between adipose progenitor cells and vascular progenitor cells, enhancing angiogenesis and adipogenesis in grafts. Various methods, such as enriching grafts with diverse pro-angiogenic cells or utilizing cell-free approaches, have been employed to enhance angiogenesis. Beige and dedifferentiated adipocytes in grafts could increase vessel density. This review aims to outline the function of vasculature in fat grafting and discuss different cell or cell-free approaches that can enhance angiogenesis following fat grafting.

Evidence-based management of cutaneous scarring in dermatology part 2: atrophic acne scarring

Atrophic acne scars are the most common type of acne scars and are classified into three main types: icepick, boxcar, and rolling scars. Various procedures and techniques for atrophic acne scarring are discussed in detail, with stronger evidence-based support for lasers (non-fractional, fractional, ablative, and non-ablative), platelet-rich plasma as adjunctive treatment, chemical peels (glycolic acid, trichloroacetic acid, and Jessner's solution), dermal fillers such as hyaluronic acid, and microneedling, and lesser quality evidence for microdermabrasion, subcision, and lipoaspirate grafting. Further research is needed to optimize treatment protocols, assess the efficacy of monotherapies, and establish standardized guidelines for clinicians. This paper will provide a comprehensive review of the evidence-based management of atrophic acne scars, including currently commonly utilized therapies as well as more innovative treatment options.

Parry-Romberg Syndrome: Successful Result in a Single Procedure Combining Silicone Implant and Structural Fat Grafting for Severe Facial Deformity

Background

Parry-Romberg syndrome (PRS) is an enigmatic and acquired degenerative condition. It is characterized by a gradual and progressive facial hemiatrophy, after which facial deformities appear unexpectedly in a stable state. The degree of disfigurement depends on tissue involvement, illness onset, and duration. Nowadays, non-invasive treatments with lower morbidity, such as structured fat grafting (SFG) are preferred over traditional operations such as free flaps and bone grafts. However, for severe cases of PRS, multiple sessions of SFG are required.

Case study

Despite the therapeutic failure that a 20-year-old lady had suffered after five previous conventional surgical procedures, the outcome was successful after only one surgical therapy employing a particular combination of SFG and malar silicone elastomers implant (SI).

Conclusion

The author highlights the interest in a combination of non-invasive procedures using SFG and malar augmentation with SI to repair large volume loss while improving symmetry and skin texture. Otherwise, the role of adipose-derived stem cells in fat survival is crucial and should be the focus of future studies and the key to technological advancement.

Outcomes of Autologous Fat Graft Injection(s) in Treating Sequelae of Digital Trauma: A Case Series

Background: Sequelae of digital trauma, such as painful scars adherent to tendons and bones, pain of neural origin, cold intolerance, skin and pulp atrophy, occur frequently. Autologous fat graft injections is an interesting option to treat these sequelae. The aim of this study is to describe the outcomes of autologous fat graft injections to treat sequelae of digital trauma. Methods: This retrospective study included all adult patients with digital trauma who underwent an autologous fat grafting procedure at our hospital between 2015 and 2019. The procedure was done at least 6 months after the initial trauma. Outcomes were assessed at least 9 months after the injection and included 2-point epicritic discrimination by Weber test (2-PD) and pulp circumference of the affected finger compared with the contralateral finger, a satisfaction questionnaire concerning the improvement of symptoms, aesthetic aspects and pain related to the operation, evaluation of pain by visual analogue scale, quality of life by SF-36 score and quick disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score. We also assessed whether the patients had reintegrated a previously excluded finger. Results: The study included 14 patients. All patients received one session except for one patient who received two sessions. The average 2-PD of the injured finger was 7 mm compared to 3.57 mm for the contralateral finger. There was no difference in pulp circumference between the treated and contralateral fingers. The mean satisfaction score for symptom improvement and aesthetic improvement was 3.36/5, and the mean score for procedure-related pain was 2.36/5. The mean VAS of the patients was 2.91/10, the mean SF-36 was 60.42/100 and the mean QuickDASH was 40.09/100. Five of the nine patients who had a previously excluded finger were able to reintegrate it. Conclusions: Autologous fat transfer seems to offer some benefit in patients with adherent scars and pulp atrophy. It has little effect on neuropathic pain. Level of Evidence: Level IV (Therapeutic).

Facial Fat Graft Injection Reduces Asymmetry and Improves Forehead Contour in Early Infancy Apert Syndrome Patients

BACKGROUND

The objective of this study is to report the outcomes of a modified comprehensive Apert syndrome surgical protocol in which fat injection was performed during early infancy concurrent with postposterior vault distraction osteogenesis (PVDO) distractor removal.

METHODS

A retrospective study was performed on 40 consecutive young patients with Apert syndrome who underwent PVDO and subsequent distractor removal between 2012 and 2022. Of these 40 patients, 12 patients underwent facial fat injection concurrent with distractor removal to treat residual supraorbital bar recession as part of a modified comprehensive Apert syndrome surgical protocol. Preoperative and postoperative severity of recession and irregularity was graded from 1 to 3, with 1 being less severe and 3 being the most severe. Recession severity was correlated with the number and type of suture fusion. The complication rate was stratified via a Clavien-Dindo scale.

RESULTS

The average patient age was 14.3±5 months, with 5 males (41.6%) and 7 females (48.3%). The average hospital stay was 1.08 days. The average volume of free fat graft injection was 8.29±5 mL. According to the Likert scale, forehead morphology improved in 91.67% of the patients. Complete resolution of supraorbital bar recession was achieved in seven patients (58.33%), all of whom presenting a single suture synostosis. One patient with a cloverleaf skull presented a type IIIB complication.

CONCLUSIONS

Facial fat grafting markedly reduces forehead asymmetry and improves forehead contour in Apert syndrome patients following PVDO. Total resolution of forehead recession directly correlated with a single suture fusion.

Facial Hypertrophy as a Complication of Weight Gain in Autologous Fat Graft Patients: Considerations and Recommendations

Fat grafting can restore facial volume for reconstructive and cosmetic indications. Common practice often involves extracting lipoaspirate from the most abundant anatomic location. However, grafted fat retains the phenotypic characteristics of its original location and can undergo exaggerated hypertrophy with patient weight fluctuations. The aim of this study was to systematically assess the literature to summarize the reported effects of postoperative weight gain on facial hypertrophy in patients after facial fat grafting and to determine potentially avoidable factors. A search through PubMed/MEDLINE was conducted on October 4, 2022, to identify relevant articles with appropriate search terms. No lower date limit was applied and all eligible nonanimal clinical articles in English were included for review. Reports were summarized and presented as descriptive statistics. The search generated 714 articles. After abstract and full-text review of the initial set of articles, 6 were included in our analysis. All articles described poor cosmetic outcomes resulting from nonanatomic hypertrophy of the grafted fat. None of the articles reported a thorough methodology for selecting the donor site to minimize fat hypertrophy with potential future weight fluctuations. Grafted facial fat is susceptible to exaggerated hypertrophy as a result of changes in patient weight. Specifically, harvesting lipoaspirate from maximally abundant areas of the body may increase this risk. Individualizing the area of fat donation may attenuate unwanted fat growth and further contribute to increased patient quality of life.

LEVEL OF EVIDENCE: 4

Evaluation of Kinesio Taping for Edema, Ecchymosis, and Pain After Liposuction: A Prospective Pilot Study

BACKGROUND

Liposuction is a safe, simple, and effective method of body contouring. Pain, ecchymosis, and edema are often local complications at the removal site, especially in the first weeks after surgery. Several studies have shown that kinesiology (kinesio) taping improves blood and lymphatic flow, removing congestions of lymphatic fluid and alleviating hemorrhage. However, there are limited data on the effect of kinesio taping in mitigating local complications at fat grafting donor sites.

OBJECTIVES

The aim of this pilot study was to evaluate the impact of kinesio taping in reducing postoperative edema, pain, and ecchymosis in the liposuction area.

METHODS

Over a period of 18 months (January 2021-June 2022), 52 patients underwent liposuction of both flanks with subsequent breast fat grafting. Immediately after the surgery, kinesio taping was used on the right abdomen flank in all patients. Degree of edema as well as ecchymosis and pain were quantified at 7, 14, and 21 days after surgery.

RESULTS

There were statistically significant differences in the taping area for ecchymosis at 7 days after surgery, edema at 14 and 21 days after surgery, and in pain, rated on a visual analog scale, at 7, 14 and 21 days after surgery.

CONCLUSIONS

Kinesio taping, as used in this study, is beneficial in the reduction of edema and pain and the resolution of ecchymosis after liposuction.

LEVEL OF EVIDENCE: 3

Injectable Pectin-Alginate Hydrogels for Improving Vascularization and Adipogenesis of Human Fat Graft

Autologous fat grafting (AFG) is the most prevailing tool for soft tissue regeneration in clinics, although efficiency is limited to unpredictable volume resorption due to poor vascularization and eventual necrosis. This study sought to improve the AFG efficiency using a hydrogel as a carrier for human fat graft (F) with and without platelet-rich plasma (PRP). PRP is clinically well known for the local release of several endogenous growth factors and has been in clinical use already. A human-fat-graft-encapsulated pectin-alginate hydrogel (FG) was developed and characterized. PRP was added to F to develop a human fat graft with PRP (FP). FP was admixed with a pectin-alginate hydrogel to develop FGP. FG and FGP showed the smooth injectable, elastic, and shear-thinning properties. FG and FGP groups showed enhanced cell viability and proliferation compared to the control F in vitro. We also investigated the in vivo angiogenesis and neo-adipogenesis ability of F, FG, FGP, and FP in nude mice after subcutaneous injection. After 2 and 4 weeks, an MRI of the mice was conducted, followed by graft explantation. The explanted grafts were also assessed histologically and with immunohistochemistry (IHC) studies. MRI and histology results revealed better vascularity of the FG and FGP system compared to fat graft alone. Further, the IHC studies, CD 31, and perilipin staining also revealed better vasculature and adipogenesis of FG and FGP systems. These results indicate the enhanced angiogenesis and adipogenesis of FG and FGP. Thus, developed pectin-alginate hydrogel-based fat graft systems FG and FGP replenish the native microenvironment by mediating angiogenesis and adipogenesis, thereby maximizing the clinical outcomes of autologous fat grafting.

Aesthetic Gynaecology: What Women Want?

The demand for aesthetic gynecology is growing among patients and medical professionals. It is becoming a field of increasing interest. In obstetrics and gynecology, there are currently few superspecialization or fellowship training programs that teach this subject; nevertheless, improvements have been made in aesthetic and plastic surgery training that foresee the need to add specialized training in this sector. In the US and the UK, numerous reputable certification and preceptorship programs are now where many surgeons start their careers. To give physicians interested in surgical and non-surgical therapies certification training, new programs were introduced globally in 2016-2017. We provide an overview of both surgical and non-surgical "aesthetic gynecology" treatments, as well as the opinions of the top gynecologic associations on this new field of study.

Investigating the Efficacy of Modified Lipoaspirate Grafting to Improve the Appearance of Atrophic Acne Scars: A Pilot Study

BACKGROUND

Processed lipoaspirate grafting describes several techniques theorized to leverage the inflammatory and regenerative capacities of mechanically processed adipocytes to rejuvenate and correct skin pathology. Although lipoaspirate grafting is typically leveraged to fill visible defects such as depressed scars and dermal lines, additional fat processing allows grafts to stimulate mechanisms of wound healing, including the promotion of fibroblast activation, neovascularization, and neocollagenesis.

OBJECTIVES

This study intends to assess the efficacy and tolerability of processed lipoaspirate grafting monotherapy to improve the clinical appearance of atrophic acne scars.

METHODS

Patients underwent a single autologous processed lipoaspirate grafting procedure at the site of atrophic acne scars. Objective and subjective scar analysis was performed at 3 and 6 months posttreatment. Scars were assessed with standard photography, topographic analysis, and noninvasive skin measurements. In addition, microbiopsies were obtained before and after treatment to assess histological or genetic changes. Clinical improvement was assessed with patient and clinician Global Aesthetic Improvement Scales (GAIS) and blinded photographic evaluation.

RESULTS

Ten patients between ages 18 and 60 completed the study. Clinical evaluation demonstrated that fat grafting improved the appearance of atrophic acne scars. Clinician GAIS and patient GAIS scores showed clinical improvement at both 3- and 6-month follow-up compared with baseline (P < .05). Blinded clinician GAIS scores also showed statistically significant improvement when clinicians compared clinical photographs taken at 6-month follow-up to baseline (P < .0001). The attenuation coefficient increased at 6-month follow-up, suggesting collagen remodeling and reorganization over the study period. Patients experienced anticipated posttreatment symptoms including transient erythema and edema; however, no unexpected adverse events were reported.

CONCLUSIONS

Micronized lipoaspirate injection is a viable and effective option to improve the appearance of facial acne scarring. Favorable improvements in atrophic acne scarring were captured by objective analysis of skin ultrastructure as well as improvement in subjective assessments of scarring.

LEVEL OF EVIDENCE: 4

Closed-chamber Suction-assisted Fat Harvest: An Innovative Technique in Resource-limited Settings

Autologous fat grafting is one of the most commonly performed procedures, not only for cosmetic reasons, but in a variety of reconstructive procedures like correction of contour deformities and treatment of scars. The Coleman technique has been traditionally described as one of the efficient methods of fat harvest, where 10 mL syringes connected with a liposuction cannula are used for the manual harvest of fat; although it is a widely used technique, it becomes time-consuming and tiring when a large amount of fat has to be harvested. To overcome this issue, we have devised a simple, cost-effective, quicker method in resource-limited settings by using a 500-mL normal saline bottle as a closed chamber, which is in turn connected to a suction tube. The liposuction cannula is connected to a tube that is inserted into this closed chamber, where fat is aspirated and collected. Using this technique, a large amount of fat can be easily harvested in less time and with less effort, without damaging the adipocytes.

Nanofat in Plastic Reconstructive, Regenerative, and Aesthetic Surgery: A Review of Advancements in Face-Focused Applications

Nanofat is a relatively novel technique in fat grafting that has gained significant interest in the fields of regenerative medicine, aesthetic and translational research. It involves the extraction of autologous fat from a patient, which is then transformed into "nanofat", consisting of small fat particles with a diameter of less than 0.1 mm and containing high concentrations of stem cells and growth factors. This article focuses on the use of nanofat in facial rejuvenation and its potential for lipomodelling. Fat tissue is a "stem cell depot" and nanofat contains many stem cells that can differentiate into various cell types. The Lipogem technology, developed in 2013, enables the isolation of nanofat with an intact perivascular structure, utilizing the high concentration of mesenchymal stromal cells near the pericytes of the adipose vascular system. Nowadays nanofat is used primarily for cosmetic purposes particularly in rejuvenating and improving the appearance of the skin, especially the face. Indeed, it has wide applicability; it can be used to treat fine lines, wrinkles, acne scars, sun-damaged skin, scar repair, and as an alopecia treatment. However, further studies are needed to assess the long-term efficacy and safety of this technique. In conclusion, nanofat is a safe and minimally invasive option for tissue regeneration with considerable therapeutic potential. This study reviews the application and effects of nanofat in regenerative medicine and facial cosmetic surgery.

The Current State of Fat Grafting in the Hand: A Systematic Review for Hand Diseases

Autologous fat grafting (AFG) has traditionally been used for facial rejuvenation and soft tissue augmentation, but in recent years, its use has expanded to treat diseases of the hand. Autologous fat grafting is ideal for use in the hand because it is minimally invasive, can restore volume, and has regenerative capabilities. This review summarizes the emerging evidence regarding the safety and efficacy of AFG to the hand in several conditions, including systemic sclerosis, Dupuytren disease, osteoarthritis, burns, and traumatic fingertip injuries. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search on the use of AFG in hand pathologies was performed on October 8, 2020, in Ovid MEDLINE, Elsevier Embase, Clarivate Web of Science, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by 2 independent reviewers and a third reviewer adjudicated when required. Reviewers identified 919 unique hits. Screening of the abstracts identified 22 manuscripts which described the use of AFG to treat an identified hand condition. Studies suggest AFG in the hands is a safe, noninvasive option for the management of systemic sclerosis, Dupuytren contracture, osteoarthritis, burns, and traumatic fingertip injuries. While AFG is a promising therapeutic option for autoimmune, inflammatory, and fibrotic disease manifestations in the hand, further studies are warranted to understand its efficacy and to establish more robust clinical guidelines. Studies to date show the regenerative, immunomodulatory, and volume-filling properties of AFG that facilitate wound healing and restoration of hand function with limited complications.

MiR-24-3p regulates the differentiation of adipose-derived stem cells toward pericytes and promotes fat grafting vascularization

Adipose-derived stem cells (ADSCs) enhance fat graft survival by promoting neovascularization. The mechanism that promotes ADSCs differentiation toward pericytes was not known. We treated ADSCs with conditional medium (CM) from endothelial cells (ECs) or human recombinant transforming growth factor β (TGF-β) to induce differentiation into pericytes. Pericytes markers, including platelet-derived growth factor receptor β (PDGFRβ), alpha-smooth muscle actin (α-SMA), and desmin, were examined. Pericytes differentiation markers, migration, and their association with ECs were examined in ADSCs transfected with miR-24-3p mimics and inhibitors. Bioinformatics target prediction platforms and luciferase assays were used to investigate whether PDGFRβ was directly targeted by miR-24-3p. In vivo, fat mixed with ADSCs transfected with miR-24-3p mimics or inhibitors was implanted subcutaneously on the lower back region of nude mice. Fat grafts were harvested and analyzed at 2, 4, 6, and 8 weeks. Results showed that endogenous TGF-β derived from CM from EC or human recombinant TGF-β promoted migration, association with ECs, and induced expression of pericyte markers (PDGFRβ, α-SMA, Desmin) in ADSCs. MiR-24-3p directly targeted PDGFRβ in ADSCs by lucifer reporter assays. Inhibition of miR-24-3p promoted pericytes differentiation, migration, and association with ECs in ADSCs. Inhibition of miR-24-3p in ADSCs promoted survival, integrity, adipocyte viability, vascularization, pericytes association with ECs, and reduced fibrosis, whereas overexpression of miR-24-3p in ADSCs yielded the opposite results. Collectively, TGF-β released by ECs induced ADSCs differentiation toward pericytes through miR-24-3p. Downregulation of miR-24-3p in ADSCs induced survival, integrity, adipocyte viability, vascularization, pericytes association with ECs, and reduced fibrosis after fat grafting.

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.