Lipofilling of the lips: ultrastructural evaluation by transmission electron microscopy of injected adipose tissue

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.

Buccal Fat Pad Transplantation for Correction of Asian Upper Eyelid Depression: A Clinical Study

OBJECTIVES

To investigate the effect of buccal fat pad transplantation in front of the aponeurosis to correct Asian upper eyelid depression.

METHODS

Eighty-five individuals who were treated with buccal fat pad transplantation were recruited for this study. The upper eyelid depression data were collected before and after treatment, and the aesthetic outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS) and the Likert scale.

RESULTS

All patients obtained natural-looking eyelids, and the sunken contour deformity improved. The mean preoperative sunken depth was 6.7±1.0 mm (4-12 mm), and the mean sunken depth at the last follow-up was 4.2±0.9 mm (2-6 mm) (P <0.05). The visual analogue scale score was 2.12±1.75 (1-4) in the immediate postoperative period. The GAIS scores were satisfactory (very much improved, 89.4%; much improved, 7.1%; and improved, 3.5%). According to the Likert scale scores, all patients were satisfied with the clinical outcomes (excellent, 87.1%; very good, 9.4%; and good, 3.5%). A 'fair' or 'poor' result was not reported by any patient.

CONCLUSION

Buccal fat pad transplantation corrects upper eyelid depression in a simple, safe, and effective manner and can efficiently fill the depressed portion and restore a beautiful double eyelid.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tear Trough Deformity: Study of Filling Procedures for Its Correction

The aim of this work is to discuss the anatomy of the tear trough region with relative danger areas, and to describe 2 different options to correct this deformity.The tear trough is a concave deformity of the orbital fat that is noticeable as a result of inherited anatomic differences and aging. However, the periorbital region is a complex area with its own septa and ligaments, fat compartments, muscles, vascularization, and lymphatic drainage and presents anatomic characteristics that must be taken into account in order to achieve good results and avoid complications.The use of hyaluronic acid gel or autologous fat for soft tissue correction is a good option.A total of 96 patients with periorbital hollowing were divided into 2 groups; each group received a different treatment, from December of 2013 to December of 2015, with hyaluronic- or lipo-filling.

The Use of Double-Layer Collagen Membrane for the Improvement of Nasal Dorsum Skin Thickness and Texture in Primary Nose Surgery

OBJECTIVES

To place a collagen membrane containing crushed nasal septal cartilage over the nasal dorsum to see how this graft can improve the results of visible postsurgical irregularities in thin skinned patients.

METHODS

Fifty-seven patients were treated between 2006 and 2010 (26 males and 31 females) whose ages ranged between 31 and 55 years old. They were divided into group a, defect <1 mm, group b defect between 1 and 2 mm, group c defect >3 mm. These patients presented intraoperative nasal dorsum irregularities that were corrected with 57 cartilage grafts in conjunction with collagen membrane.

RESULTS

All of our patients showed an initial over-correction. A dense network of collagen fiber bundles was observed running parallel to the surface of the membrane at the connective tissue-membrane interface. The clinical percentage of volume reabsorption was about 5% after 6 months, measured with clinical pictures and a clinical follow-up. No infection was noted, only 1 patient of dislocation was observed, and 5 patients required some refinements at the long-term follow-up.

CONCLUSIONS

In the authors' experience the use of bilayered combined cartilage and collagen membrane grafts gives the best aesthetic results with balanced tip projection and dorsum fullness, and avoids thickness and texture modification of the skin above the graft. The use of Bio-gide membrane avoids all problems related to the donor site and shortens surgical time.

A Systematic Review of Autologous Platelet-Rich Plasma and Fat Graft Preparation Methods

BACKGROUND

The addition of platelet-rich plasma (PRP) to adipose tissue may improve fat graft survival, although graft retention rates vary markedly between studies. To what extent this outcome heterogeneity reflects differing methodological factors remains unknown. This systematic review aims to synthesize and critically review methodological approaches to autologous PRP and fat cotransplantation in both human and animal studies.

METHODS

In accordance with PRISMA guidelines, Ovid MEDLINE, Scopus, and Cochrane Library databases were searched from inception to April 2017. Data were extracted from all in vivo studies involving autologous PRP and fat cotransplantation. A secondary aim was to assess reporting of technical detail; authors were not contacted to provide missing data.

RESULTS

From 335 articles, 23 studies were included in the qualitative synthesis. Some 21 were performed in humans and 2 in rabbits. Six studies were randomized control trials; the remainder reported on observational data. Methods of PRP extraction and activation varied markedly between studies. Fat graft preparation was comparatively more consistent. Methods of PRP and fat mixing differed significantly, especially with regards to relative volume/volume ratios.

CONCLUSIONS

Our study represents the first systematic review of methodological factors in autologous PRP and fat cotransplantation. It demonstrates that technical factors in graft preparation and administration vary significantly between in vivo studies. Such methodological heterogeneity may explain observed differences in experimental and clinical outcomes. Reporting of key procedural information is inconsistent and often inadequate. These issues make meaningful evaluation of the PRP-enhanced fat grafting literature difficult and may limit its translation into clinical practice.

Hydroxyapatite/Collagen Composite Is a Reliable Material for Malar Augmentation

PURPOSE

To evaluate the long-term results of cheekbone augmentation using porous hydroxyapatite granules mixed with microfibrillar collagen in a large group of patients.

MATERIALS AND METHODS

Four hundred thirty patients who underwent zygomatic augmentation and intermaxillary osteotomy were evaluated clinically, radiologically, and histologically.

RESULTS

Complications were found in 13 patients (1.56%). There were no relevant radiologic differences in prosthesis volume after 1 month (T1) or after 24 months (T2) in any patient; there were no clinically relevant differences in 110 patients after 36 months. At T1, the prosthesis had a granular structure and the granules had not migrated; at T2, the prosthesis was staunchly adhering to the underlying bone. Over time, the radiopacity of the material increased. Histologic results of 19 biopsy specimens obtained from 8 patients 2 years after the procedure showed prominent ossification with low inflammation, confirming new bone formation over time. According to the visual analog scale, the patients were generally satisfied with the aspects that were considered.

CONCLUSION

Hydroxyapatite and collagen composite used during malarplasty produced a successful outcome. Its main drawback is a learning curve that is longer than for more frequently used implantable biomaterials.

The discordant histology of grafted fat: a systematic review of the literature

BACKGROUND

All combinations of harvesting, processing, and injection have been attempted to maximize fat graft take following transplantation. Two theories behind fat transplantation have been proposed: cell survival and host replacement. Although the cell survival theory states that fat cells survive and undergo neovascularization following transfer, host replacement theory predicts adipocyte necrosis and replacement of cells by host tissues. Whether or not transferred fat survives, proliferates, or is replaced by fibrous tissue is relevant for the investment of future resources into this thriving field of research.

METHODS

A literature search of the MEDLINE and Cochrane databases was performed for studies focusing on the histology of grafted fat after transplantation up to December of 2013. Histologic examinations of grafted fat were reviewed and compared in humans and animals.

RESULTS

Sixty-six articles met inclusion criteria, and eight of them were human studies. There was widespread diversity in the method of fat harvest and transfer among the studies, and the date of examination after transfer. Many studies reported the presence of viable adipocytes, although an extensive amount of fibrosis and inflammatory infiltration was also seen, depending on the period of examination.

CONCLUSIONS

Free fat grafts show a variable response following transplantation, with significant disagreement in the reported evidence. Although neovascularization and preservation of adipocyte architecture appear possible, other fat grafts are completely replaced by necrotic ghost cells and fibrotic ingrowth. Adipocyte survival likely contributes to volume maintenance, but fibrosis may also play a role.

Systematic review of "filling" procedures for lip augmentation regarding types of material, outcomes and complications

BACKGROUND

The ideal lip augmentation technique provides the longest period of efficacy, lowest complication rate, and best aesthetic results. A myriad of techniques have been described for lip augmentation, but the optimal approach has not yet been established. This systematic review with meta-regression will focus on the various filling procedures for lip augmentation (FPLA), with the goal of determining the optimal approach.

METHODS

A systematic search for all English, French, Spanish, German, Italian, Portuguese and Dutch language studies involving FPLA was performed using these databases: Elsevier Science Direct, PubMed, Highwire Press, Springer Standard Collection, SAGE, DOAJ, Sweetswise, Free E-Journals, Ovid Lippincott Williams & Wilkins, Willey Online Library Journals, and Cochrane Plus. The reference section of every study selected through this database search was subsequently examined to identify additional relevant studies.

RESULTS

The database search yielded 29 studies. Nine more studies were retrieved from the reference sections of these 29 studies. The level of evidence ratings of these 38 studies were as follows: level Ib, four studies; level IIb, four studies; level IIIb, one study; and level IV, 29 studies. Ten studies were prospective.

CONCLUSIONS

This systematic review sought to highlight all the quality data currently available regarding FPLA. Because of the considerable diversity of procedures, no definitive comparisons or conclusions were possible. Additional prospective studies and clinical trials are required to more conclusively determine the most appropriate approach for this procedure.

LEVEL OF EVIDENCE

IV.

Importance of mesenchymal stem cells in autologous fat grafting: a systematic review of existing studies

Autologous fat grafting (lipofilling) enables repair and augmentation of soft tissues and is increasingly used both in aesthetic and reconstructive surgery. Autologous fat has several advantages, including biocompatibility, versatility, natural appearance, and low donor site morbidity. The main limitation is unpredictable graft resorption, which ranges from 25%-80%, probably as a result of ischaemia and lack of neoangiogenesis. To obviate these disadvantages, several studies have searched for new ways of increasing the viability of the transplanted tissue. One promising approach has been to enrich the fat graft with adipose tissue-derived mesenchymal stem cells (ASC) before transplantation. We have reviewed original studies published on fat transplantation enriched with ASC. We found four murine and three human studies that investigated the subject after a sensitive search of publications. In the human studies, so-called cell assisted lipotransfer (CAL) increased the ASC concentration 2-5 times compared with non-manipulated fat grafts, which caused a questionable improvement in survival of fat grafts, compared with that of traditional lipofilling. In contrast, in two of the murine studies ASC-concentrations were increased 1250 and 6250 times, respectively, by ASC ex vivo expansion, which resulted in considerably improved fat transplant survival as well as quality. This effect of high-level enrichment with ASC is thought to have been caused by paracrine signalling, cellular differentiation, or both. The surgical and tissue handling techniques used in lipofilling are well proved, but the added effect of high-level enrichment with ex vivo expanded ASC still needs to be investigated properly in human lipofilling studies, combined with a thorough follow up and matched control groups. In conclusion, ASC-enriched lipofilling theoretically has the potential for transforming lipofilling from a relatively unpredictable intervention into one in which the resorption rate, quality of tissue, and safety can be predicted, and possibly superior to prosthetic implantation.

Lipofilling with minimal access cranial suspension lifting for enhanced rejuvenation

BACKGROUND

Loss of volume is an important aspect in facial aging, but its relevance is frequently neglected during treatment.

OBJECTIVES

The authors discuss lipofilling as an ancillary procedure to improve the impact of facelifting procedures.

METHODS

Fifty patients who underwent minimal access cranial suspension (MACS) lifting alone were retrospectively analyzed, and their results were compared to 42 retrospective cases of MACS lifting with adjuvant lipofilling. The results were evaluated with a photographic ranking system by two panels (five plastic surgeons and five medical students).

RESULTS

Combined MACS lifting and lipofilling yielded overall cosmetic results that were significantly better than the results achieved with MACS lifting alone. Photographic evaluations showed that improvements were more pronounced in the tear trough (P < .05) and malar eminence (P < .01) than in the nasolabial groove (P > .05).

CONCLUSIONS

Volume restoration with lipofilling following MACS lifting procedures produces significantly better postoperative results than MACS lifting alone. This combined procedure produces the most dramatic improvements in the tear trough and malar eminence regions.

Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force

TASK FORCE STATEMENT: In 2007, the American Society of Plastic Surgeons formed a task force to conduct an assessment regarding the safety and efficacy of autologous fat grafting, specifically to the breast, and to make recommendations for future research. The task force formulated specific issues regarding fat grafting and then compiled them to focus on five broad-based questions: 1. What are the current and potential applications of fat grafting (specifically breast indications, and if data are available, other cosmetic and reconstructive applications)? 2. What risks and complications are associated with fat grafting? 3. How does technique affect outcomes, including safety and efficacy, of fat grafting? 4. What risk factors need to be considered for patient selection at this level of invasiveness? 5. What advancements in bench research/molecular biology potentially impact current or future methods of fat grafting? To answer these questions, the task force reviewed the scientific literature, critically appraised the information available, and developed evidence-based practice recommendations. Although the primary issue of interest was fat grafting to the breast, other aspects of fat grafting were evaluated.

Autologous Fat Transfer for Facial Recontouring: Is There Science behind the Art?

BACKGROUND

Clinical use of autologous fat grafts for facial soft-tissue augmentation has grown in popularity in the plastic surgery community, despite a perceived drawback of unpredictable results.

METHODS

The authors' review of the literature and their current techniques of autologous fat transfer focused on (1) the donor site, (2) aspiration methods, (3) local anesthesia, (4) centrifugation and washing, (5) exposure to cold and air, (6) addition of growth factors, (7) reinjection methods, and (8) longevity of fat grafts.

RESULTS

Clinical experience and basic science data showed a slight preference for the following: harvesting abdominal fat with "nontraumatic," blunt cannula technique, preparation by means of centrifugation without washing or addition of growth factors, and immediate injection of small amounts of fat by means of multiple passes. Quantitative evidence of clinical fat survivability and predictability of volume restoration does not exist, yet reports of patient satisfaction with this procedure do. Clinicians report the need for revisionary procedures to optimize results.

CONCLUSIONS

Although there is an increased trend in replacement of soft-tissue volume with autologous fat transfer, the literature fails to provide definitive evidence of fat survival. A large-scale clinical assessment using three-dimensional volumetric imaging would provide useful outcome data.

Adipocyte death defines macrophage localization and function in adipose tissue of obese mice and humans

Macrophage infiltration of white adipose tissue (WAT) is implicated in the metabolic complications of obesity. The precipitating event(s) and function(s) of macrophage infiltration into WAT are unknown. We demonstrate that >90% of all macrophages in WAT of obese mice and humans are localized to dead adipocytes, where they fuse to form syncytia that sequester and scavenge the residual "free" adipocyte lipid droplet and ultimately form multinucleate giant cells, a hallmark of chronic inflammation. Adipocyte death increases in obese (db/db) mice (30-fold) and humans and exhibits ultrastructural features of necrosis (but not apoptosis). These observations identify necrotic-like adipocyte death as a pathologic hallmark of obesity and suggest that scavenging of adipocyte debris is an important function of WAT macrophages in obese individuals. The frequency of adipocyte death is positively correlated with increased adipocyte size in obese mice and humans and in hormone-sensitive lipase-deficient (HSL-/-) mice, a model of adipocyte hypertrophy without increased adipose mass. WAT of HSL-/- mice exhibited a 15-fold increase in necrotic-like adipocyte death and formation of macrophage syncytia, coincident with increased tumor necrosis factor-alpha gene expression. These results provide a novel framework for understanding macrophage recruitment, function, and persistence in WAT of obese individuals.

Injectable bulking agents for treating faecal incontinence

BACKGROUND

Reports of the use of injectable bulking agents for faecal incontinence are currently confined to a small number of pilot studies. However, the use of these agents is rapidly becoming widespread based on this limited knowledge.

METHODS

This review provides an overview of the products available and the methods of delivery based on the pilot studies, selected articles reporting experience of these agents in urology, plastic surgery and laryngology, and some animal studies.

RESULTS AND CONCLUSIONS

Although bulking agents have been used to treat urinary incontinence for over four decades, their use in faecal incontinence has so far been limited. The large choice of products now available and the lack of a defined injection strategy will hamper efforts to produce meaningful prospective randomized trials.