Autologous Fat Transfer: An In-Depth Look at Varying Concepts and Techniques

Good Manufacturing Practice-Compliant Cryopreserved and Thawed Native Adipose Tissue Ready for Fat Grafting

Background: As adipose tissue-derived mesenchymal stem cells are becoming the tool of choice for many clinical applications; standardized cryopreservation protocols are necessary to deliver high-quality samples. For this purpose, the cryopreservation and thawing of native adipose tissue under GMP conditions could represent an extremely useful and powerful tool for the direct reinfusion of the tissue, and consequently, of its stromal vascular fraction. Methods: In this study, 19 samples of adipose tissue were cryopreserved and characterized before and after storage in liquid nitrogen vapors. Of these 19 samples, 14 were processed in research and 5 in a GMP-compliant environment. Storage with and without cryopreservation medium was also evaluated. After one week to three months of storage, samples were thawed, washed, enzymatically digested, and characterized with flow cytometry. Results: The results show that there is a loss of nearly 50% of total nucleated cells during the cryopreservation/thawing process. Non-GMP and GMP samples are comparable for all parameters analyzed. This study also allowed us to exclude the cryopreservation of adipose tissue without any cryopreservation medium. Conclusions: The data shown in this work are consistent with the idea that native adipose tissue, if properly processed and controlled, could be a useful source of cells for regenerative medicine, keeping in mind that there is a clear difference in the quality between fresh and thawed samples.

Evaluating Interventions for Sulcus Vocalis or Vocal Fold Scar: A Systematic Review and Meta-analysis

BACKGROUND

Sulcus vocalis reflects varying degrees of vocal cord lamina propria (LP) damage. Many interventions have been discussed in the literature for addressing sulcus vocalis, but there is no universally accepted gold standard for its management.

AIM

We aim in our study to collectively evaluate the effectiveness of different relevant interventions in the literature used for sulcus vocalis or vocal fold scar.

METHODS

We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled in our single-arm meta-analysis as mean change (MC) and with 95% confidence interval (CI).

RESULTS

Our systematic review and meta-analysis included 43 studies encompassing 1302 patients. The jitter parameter indicated that laser degeneration and LP regeneration/scar degradation led to the highest improvements compared to their baseline, with pooled MC of -0.897 and -0.893, respectively. Graft interposition showed a MC of -0.848, while medialization and dissection had less pronounced changes at -0.200. Shimmer parameter results were similar, with medialization and laser degeneration leading to MC of -2.129 and -2.123, while LP regeneration/scar degradation and graft interposition showed smaller changes MC -1.530 and -1.217. For the noise-to-harmonic ratio (NHR) parameter, LP regeneration/scar degradation demonstrated MC = -0.028. In aerodynamics outcomes, graft interposition and LP regeneration/scar degradation showed the highest MCs in mean phonatory time (MPT) (4.214 and 3.467, respectively). Endoscopic outcomes for mucosal wave showed high improvements in medialization and graft interposition (MC = 10.40 and 10.18, respectively). Perceptual outcomes favored graft interposition in various parameters, while laser degeneration performed well in most categories. Graft interposition and LP regeneration/scar degradation had a high voice handicap index (VHI) (MC = -27.195 and -19.269, respectively).

CONCLUSION

Laser degeneration and LP regeneration/scar degradation were particularly effective in improving acoustic parameters. In aerodynamics, graft interposition and LP regeneration/scar degradation improved vocal efficiency compared to their baselines. Medialization and laser degeneration had the largest impact compared to their baseline on shimmer and MPT. Endoscopic assessments showed that medialization and graft interposition had high improvement in mucosal waves, and perceptual outcomes were generally high with graft interposition and laser degeneration.

Salvage Treatments for Poor Voice Outcomes Following Autologous Fat Injection Laryngoplasty

OBJECTIVE

Fat injection laryngoplasty (FIL) is a common procedure used to correct glottic insufficiency. Nevertheless, few studies have discussed potential treatments for cases with poor voice recovery after FIL.

METHODS

Eighteen patients with unfavorable vocal outcomes from FIL were analyzed. Each of these patients presented persistent dysphonia for more than 2 months following FIL, together with bulging vocal folds and poor mucosal wave. We applied microsurgery as the standard treatment to remove excessive fat. Vocal fold steroid injection (VFSI) was administered to patients that were hesitant or declined to undergo microsurgery. Voice outcomes were evaluated using the Voice Handicap Index-10 (VHI-10), grade-roughness-breathiness (GRB) scores, and smoothed cepstral peak prominence (CPPs).

RESULTS

Six patients underwent microsurgery directly, 6 patients received only VFSIs as a salvage treatment, and the remaining 6 patients received 1 to 3 courses of VFSIs before the decision to undergo microsurgery. Pathology reports were available for 10 patients, and contained 5 instances of adipose tissues, 3 of fat necrosis, 1 of chronic inflammation, and 1 of fibrosis. Seventeen patients reported satisfactory or improved outcomes. We found remarkable improvements in VHI-10, GRB, and CPPs (all P < .05) after salvage treatments for FIL. Subgroup analyses showed comparable voice outcomes for patients undergoing direct microsurgery, VFSI alone, and VFSI followed by microsurgery (P > .05).

CONCLUSIONS

This study demonstrated that fat overinjection and/or fibrotic change in the injected vocal folds may cause poor voice outcomes after FIL. Both microsurgery and VFSI could be applied as salvage treatments with good voice recovery profiles.

LEVEL OF EVIDENCE

Level 4.

Management of Unilateral Vocal Fold Paralysis after Thyroid Surgery with Injection Laryngoplasty: State of Art Review

Background

Unilateral vocal fold paralysis (UVFP) after thyroid surgery often leads to significant morbidity including dysphonia, dysphagia, and aspiration. Injection laryngoplasty (IL) is an effective treatment of UVFP with numerous readily available materials. However, few studies focus on IL for UVFP following thyroidectomy.

Objectives

This review aims to critically review current literature to determine the timing, materials, methods and outcomes of IL for UVFP after thyroid surgery.

Type of Review

Literature review.

Methods

A literature review was performed using the Pubmed, Medline and EMBASE databases. All relevant articles published in English addressing the effect of IL in post thyroid surgery related UVFP were analyzed. Studies using IL for UVFP of multiple etiologies were excluded. Meta-analysis was conducted using fixed and random effect model.

Results

Five original studies were identified, including 214 patients received IL for UVFP following thyroid surgery. Two studies injected autologous fat via direct suspension laryngoscope under general anesthesia, while the other 3 studies injected polyacrylamide, hyaluronic acid, and polymethyl methacrylate from cricothyroid membrane under local anesthesia. All 5 studies reported improved voice outcomes of IL for post-thyroidectomy UVFP. Meta-analysis showed MPT increased for 3.18 s (95% CI: 2.40-3.96, fix effect model) after IL. Another common acoustic parameter, jitter (%) also improved for 1.46 (95% CI: 0.73-2.19, random effects model) after IL for post-thyroidectomy UVFP.

Conclusions

This review supported that IL can improve the voice outcome for post-thyroidectomy UVFP. Autologous fat remains a good augmentation material with a potential longer lasting effect. More research and long-term surveys are needed to document the safety and longevity of other synthetic materials.

Autologous Fat Plus Platelet-Rich Plasma versus Autologous Fat Alone on Sulcus Vocalis

Sulcus vocalis is a frequent cause of glottic insufficiency that leads to incomplete vocal fold closure during phonation. Type II sulcus vocalis is defined as a partial defect of the lamina propria (LP). Treatment with fillers, such as fat or hyaluronic acid (HA), in the vocal folds is widely used, but the duration of effect is variable. Platelet-rich plasma (PRP) can enhance the survival of autologous fat in fat grafting, and also is used to treat sulcus vocalis. This study aimed to compare the effectiveness of autologous fat graft versus fat graft plus PRP to treat type II sulcus vocalis. Thirty-four patients with a voice handicap index (VHI) ≥ 11 were randomized to two groups, which received LP injections of fat graft (n = 17) or fat graft plus PRP (n = 17). At 1 month and 6 months after injection, the VHI decreased significantly in both groups. The fat plus PRP group had better Jitter, Shimmer, and noise to harmonic ratio (NHR) in 1 month and 6 months after surgery. The fat plus PRP group resulted in lower VHI scores one month after surgery, and stroboscopy revealed sustained smaller gaps after six months. These results indicate that a combination of fat graft plus PRP is safe and effective for treating sulcus vocalis type II and associated vocal atrophy.

An immunologically active, adipose-derived extracellular matrix biomaterial for soft tissue reconstruction: concept to clinical trial

Soft tissue reconstruction remains an intractable clinical challenge as current surgical options and synthetic implants may produce inadequate outcomes. Soft tissue deficits may be surgically reconstructed using autologous adipose tissue, but these procedures can lead to donor site morbidity, require multiple procedures, and have highly variable outcomes. To address this clinical need, we developed an "off-the-shelf" adipose extracellular matrix (ECM) biomaterial from allograft human tissue (Acellular Adipose Tissue, AAT). We applied physical and chemical processing methods to remove lipids and create an injectable matrix that mimicked the properties of lipoaspirate. Biological activity was assessed using cell migration and adipogenesis assays. Characterization of regenerative immune properties in a murine muscle injury model revealed that allograft and xenograft AAT induced pro-regenerative CD4⁺ T cells and macrophages with xenograft AAT additionally attracting eosinophils secreting interleukin 4 (Il4). In immunocompromised mice, AAT injections retained similar volumes as human fat grafts but lacked cysts and calcifications seen in the fat grafts. The combination of AAT with human adipose-derived stem cells (ASCs) resulted in lower implant volumes. However, tissue remodeling and adipogenesis increased significantly in combination with ASCs. Larger injected volumes of porcine-derived AAT demonstrated biocompatibility and greater retention when applied allogeneicly in Yorkshire cross pigs. AAT was implanted in healthy volunteers in abdominal tissue that was later removed by elective procedures. AAT implants were well tolerated in all human subjects. Implants removed between 1 and 18 weeks demonstrated increasing cellular infiltration and immune populations, suggesting continued tissue remodeling and the potential for long-term tissue replacement.

Biochemical and biomechanical comparisions of decellularized scaffolds derived from porcine subcutaneous and visceral adipose tissue

Decellularized adipose tissue (DAT) is a promising biomaterial for adipose tissue engineering. However, there is a lack of research of DAT prepared from xenogeneic porcine adipose tissue. This study aimed to compare the adipogenic ability of DAT derived from porcine subcutaneous (SDAT) and visceral adipose tissue (VDAT). The retention of key collagen in decellularized matrix was analysed to study the biochemical properties of SDAT and VDAT. For the biomechanical study, both DAT materials were fabricated into three-dimensional (3D) porous scaffolds for rheology and compressive tests. Human adipose-derived stem cells (ADSCs) were cultured on both scaffolds to further investigate the effect of matrix stiffness on cellular morphology and on adipogenic differentiation. ADSCs cultured on soft VDAT exhibited significantly reduced cellular area and upregulated adipogenic markers compared to those cultured on SDAT. In vivo results revealed higher adipose regeneration in the VDAT compared to the SDAT. This study further demonstrated that the relative expression of collagen IV and laminin was significantly higher in VDAT than in SDAT, while the collagen I expression and matrix stiffness of SDAT was significantly higher in comparison to VDAT. This result suggested that porcine adipose tissue could serve as a promising candidate for preparing DAT.

Complications Associated with Fat Grafting to the Lower Eyelid

Fat grafting is effectively used in the lower eyelid and periorbital area for rejuvenation of the aging face. Several complications may occur with fat grafting, including volume undercorrection or overcorrection, contour irregularities, prolonged bruising and swelling, infection, granulomas and inflammation, and vascular embolization with visual loss or stroke. In many cases, complications can be effectively treated, although permanent and serious injury can occur. Appropriate surgical techniques help to prevent most of these complications. An understanding of how and why complications of fat grafting of the lower eyelid occur aids in the avoidance and treatment of these complications.

A Comprehensive In Vitro Comparison of Preparation Techniques for Fat Grafting

BACKGROUND

Lipomodeling is a technique that uses the patient's own fat for tissue regeneration and augmentation. The extent of regenerative effect is reported to be determined by the numbers of adipose-derived stem cells and the viability of cells in processed adipose tissue which, together with other factors, influence the degree of graft retention. This study addresses whether differences exist in properties of fat graft obtained by three commonly used techniques.

METHODS

Adipose tissue harvested from the hypogastric regions of 14 patients was processed by decantation, centrifugation, and membrane-based tissue filtration. The morphology of each preparation was assessed by electron microscopy and overall cell viability was assessed by live/dead assay. The number of adipose-derived stem cells was determined and their stem cell character was assessed by the presence of cell surface molecules (i.e., CD105, CD90, CD31, and CD45) and by their capacity to differentiate into adipogenic and osteogenic lineages.

RESULTS

First, morphologies of processed fat samples obtained by individual procedures differed, but no preparation caused obvious damage to cellular or acellular components. Second, although the highest numbers of adipose-derived stem cells were contained in the upper fraction of centrifuged lipoaspirates, the difference between preparations was marginal. Third, the maximal concentration of adipose fraction (removal of watery component) of lipoaspirate was achieved by membrane-based tissue filtration. Finally, no significant differences in overall viability were detected.

CONCLUSIONS

Properties of processed lipoaspirate were influenced by the preparation procedure. However, the differences were not dramatic; both centrifugation and membrane-based filtration are methods of choice whose selection depends on other criteria (e.g., practicality) for individual surgical settings.

Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review of the Literature

BACKGROUND

The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing.

METHODS

A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation.

RESULTS

Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction.

CONCLUSIONS

The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician's ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

Studies in fat grafting: Part I. Effects of injection technique on in vitro fat viability and in vivo volume retention

BACKGROUND

Fat grafting has become increasingly popular for the correction of soft-tissue deficits at many sites throughout the body. Long-term outcomes, however, depend on delivery of fat in the least traumatic fashion to optimize viability of the transplanted tissue. In this study, the authors compare the biological properties of fat following injection using two methods.

METHODS

Lipoaspiration samples were obtained from five female donors, and cellular viability, proliferation, and lipolysis were evaluated following injection using either a modified Coleman technique or an automated, low-shear device. Comparisons were made to minimally processed, uninjected fat. Volume retention was also measured over 12 weeks after injection of fat under the scalp of immunodeficient mice using either the modified Coleman technique or the Adipose Tissue Injector. Finally, fat grafts were analyzed histologically.

RESULTS

Fat viability and cellular proliferation were both significantly greater with the Adipose Tissue Injector relative to injection with the modified Coleman technique. In contrast, significantly less lipolysis was noted using the automated device. In vivo fat volume retention was significantly greater than with the modified Coleman technique at the 4-, 6-, 8-, and 12-week time points. This corresponded to significantly greater histologic scores for healthy fat and lower scores for injury following injection with the device.

CONCLUSION

Biological properties of injected tissues reflect how disruptive and harmful techniques for placement of fat may be, and the authors' in vitro and in vivo data both support the use of the automated, low-shear devices compared with the modified Coleman technique.

Simplified lipostructure: a technical note

BACKGROUND

The Coleman technique is universally recognized as the gold standard for fat transfer, but although effective, it is tedious, time consuming, and costly. This report proposes a new and more efficient method of fat grafting (simplified lipostructure).

METHODS

This report introduces a modification of the standard Coleman transfer and injection technique, performed by connecting a 10-ml syringe to a 1-ml syringe and to a blunt infiltrating cannula through a "three-way stopcock valve." The study retrospectively evaluated two groups of patients who had undergone either Coleman or simplified lipostructure, comparing surgical staff, operative time, volume of infiltrated fat, cosmetic outcome, and complications. Statistical analyses were conducted using the Wilcoxon rank sum test and Spearman's rank-order correlation.

RESULTS

The simplified lipostructure group compared with Coleman lipostructure showed a reduced operative staff (1 vs. 2 members), a reduced operative time (66 vs. 74.2 min) (α = 0.0035), and an increased volume of infiltrated fat (167.2 vs. 138.7 ml) (p < 0.0001) while retaining comparable cosmetic results (7.45 vs. 7.25; visual analog scale 0-10), and only minor complications.

CONCLUSION

The three-way stopcock valve system appears to be a smart technical solution that eases syringe refilling, improves fat transplantation times, and reduces costs. The findings show this technical modification to be easy and effective. The authors therefore recommend it to all surgeons performing fat transfer.

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 .

Autologous fat grafting: in search of the optimal technique

OBJECTIVE

Recent advances in adipose cellular biology have repopularized autologous fat grafting as a method widely used in both reconstructive and aesthetic surgery. This review aims to summarize our current knowledge on autologous fat grafting emphasizing harvesting techniques and processing methods as well as current trends and approaches.

METHODS

A thorough search of earlier and recent literature until October 2013 was conducted using the terms autologous fat grafting, autologous fat transfer, lipoaspirate, lipoinjection, fat harvest, and lipotransfer in PubMed and ClinicalTrials.gov databases, and relevant English- and German-language articles were included.

RESULTS

Findings were categorized in a step-by-step approach of the fat grafting procedure into indications, selection of donor site, techniques for harvesting, processing, and reimplantation of autologous fat.

CONCLUSIONS

Further in-depth knowledge will provide definite answers on fat graft survival; demonstrate safe methods to increase cell viability, grafting outcome predictability; and reliability; enhance safety; and strengthen the scientific and clinical establishment of this increasingly promising method.

Comparison of in vivo adipogenic capabilities of two different extracellular matrix microparticle scaffolds

BACKGROUND

The extracellular matrix is an essential microenvironment for cell survival activity. The adipose tissue extract microparticle scaffolds from human adipose tissue and small intestine submucosa microparticle scaffolds from porcine jejunum were prepared. Their effects on the adipogenic capabilities of human adipose-derived stem cells were compared in vivo.

METHODS

A combination of physical and chemical methods was used to decellularize human fat and porcine jejunum. Expression of CD molecules on the adipose-derived stem cell surface was determined by flow cytometry. The stem cells were then cultured with the scaffold materials in vitro. The cell-scaffold complexes were implanted subcutaneously into nude mice, and samples were collected 4 and 8 weeks later. The adipogenic differentiation capabilities of adipose-derived stem cells were studied by histologic methods and real-time polymerase chain reaction.

RESULTS

The authors observed high expression of CD90 and CD44; no expression of CD34, CD45, CD31, or CD106; and weak positive expression of CD49d on the extracted cells, which indicates that the cells were adipose-derived stem cells. The main constituent of the decellularized adipose tissue extract and small intestine submucosa microparticles was collagenous fiber, and the cells proliferated faster on the adipose tissue extract than on small intestine submucosa. Formation of adipocytes in the adipose tissue extract group was closer to that of normal human fat tissue compared with that of the small intestine submucosa group.

CONCLUSIONS

Extracellular matrix microparticle scaffolds could promote proliferation, adhesion, and adipogenic differentiation of adipose-derived stem cells. The role of the adipose tissue extract microparticle scaffold in promoting adipogenesis was stronger and more suitable as a vector in fatty tissue engineering.

Augmentation blepharoplasty: a review of 500 consecutive patients

BACKGROUND

Volume loss in the upper and lower eyelids and in the malar area is now considered a major component of periorbital aging. As classical resection blepharoplasty does not address this loss, filling procedures are becoming increasingly common.

OBJECTIVES

The authors present their experience with periorbital fat grafting in conjunction with routine blepharoplasty to address periorbital aging.

METHODS

Outcomes were retrospectively reviewed for 500 consecutive patients who underwent blepharoplasty in conjunction with the authors' periorbital augmentation technique from January 2008 to September 2011. The augmentation technique was a fine particle fat (microfat) grafting procedure that involved the use of small-diameter cannulae for transfer of autologous fat to the medial part of the upper eyelid, the orbitomalar groove, and the malar area.

RESULTS

Clinical evaluation and review of patient photographs revealed favorable, natural-looking, and long-lasting improvement of the treated areas. Shortcomings of classical resection blepharoplasty, such as hollowing of the upper eyelids, incomplete blending of the eyelid-cheek junction, and persistent deflation of the midface, were avoided; the full and crisp aspect of the upper and lower eyelids seen at a younger age was regained; and the technique was not associated with the complications seen in an earlier patient series. No major complications occurred. Minor complications included bruising and swelling.

CONCLUSIONS

Augmentation of the upper and lower eyelids through microfat grafting can be a useful alternative to existing blepharoplasty techniques. This study documents very natural and pleasing results that avoid the shortcomings of classical resection. Microfat grafting appears to be a valuable and safe alternative to complicated, difficult, and potentially dangerous eyelid and midface rejuvenation techniques.

Staged stem cell-enriched tissue (SET) injections for soft tissue augmentation in hostile recipient areas: a preliminary report

BACKGROUND

Autologous fat transplantation is frequently used for a variety of cosmetic treatments and difficult reconstructive indications such as involutional disorders, hemifacial atrophy, sequelae of radiation therapy, or similar problems. However, the limitations of fat transplantation are well known in such difficult cases, particularly the long-term unpredictability of volume maintenance. The ideal method of preparing autologous fat grafts optimizes tissue survival and reduces the variability of outcomes. We propose that enriching traditionally prepared fat grafts with adipose-derived regenerative cells (ADRCs) represents one such method.

METHODS

Using a staged approach, we performed cell-enriched fat transfer by injecting autologous ADRCs into soft tissue that was recently grafted using traditional methods of fat transfer. Over a 3-year period, data were prospectively collected from 29 patients who underwent a single session of stem cell-enriched tissue injections (SET).

RESULTS

Cell-enriched grafts ranged in volume from 10 to 390 cc per recipient area and were obtained by manual or automated processes. The mean follow-up period was 10 months. Postoperative atrophy of the injected tissue was minimal and subjectively did not change after 8 weeks. Of note, historically reported rates of atrophy range from 20 to 80%. All patients were satisfied with the primary result with no need for a secondary session except for the cosmetic cases.

CONCLUSION

These preliminary results suggest that SET is safe and may provide superior results compared to traditional fat grafting. By performing the procedure in a staged approach, operating room expenses are minimized, which ultimately decreases the cost of the procedure. Adipose-derived regenerative cells may mitigate early ischemia by increasing angiogenesis, decreasing apoptosis, and modulating the local inflammatory response. This technique may be of particular value to the surgeon when grafting high volumes of fat or when faced with hostile recipient area conditions, including fibrosis and post radiation.

Autologous cell-enriched fat grafting for breast augmentation

Autologous fat grafting for breast augmentation has faced some historical hurdles. However, in recent years it has been gaining acceptance from the medical community. This prospective, nonrandomized open-label study of 20 Japanese women supports the use of autologous fat grafting in breast augmentation and explores enhancement of fat graft tissue with autologous adipose-derived regenerative cells (ADRCs). After adipose harvesting using syringe liposuction, the tissue is processed in the Celution 800 System(®), which washes the graft and isolates ADRCs. The average cells per gram of harvested adipose tissue was 3.42 × 10(5), and the mean cell viability measured using an automated cell counting system before graft delivery was 85.3%. All patients demonstrated improvement in circumferential breast measurement (BRM) from their baseline state, and breast measurements were stable by 3 months after surgery. The mean BRM 9 months after surgery had increased 3.3 cm from preoperative measurements. Through 9 months, overall physician satisfaction was 69% and patient satisfaction was 75%. No serious or unexpected adverse events were reported, and the procedure was safe and well tolerated in all patients. Postoperative cyst formation was seen in two patients. These prospective results demonstrate that ADRC-enriched fat grafts processed with a closed automated system maintain high cell viability and that the procedure is safe and effective, with all patients showing improvement after a single treatment.

Adipose tissue engineering for soft tissue regeneration

Current treatment modalities for soft tissue defects caused by various pathologies and trauma include autologous grafting and commercially available fillers. However, these treatment methods present a number of challenges and limitations, such as donor-site morbidity and volume loss over time. As such, improved therapeutic modalities need to be developed. Tissue engineering techniques offer novel solutions to these problems through development of bioactive tissue constructs that can regenerate adipose tissue in both structure and function. Recently, a number of studies have been designed to explore various methods to engineer human adipose tissue. This review will focus on these developments in the area of adipose tissue engineering for soft tissue replacement. The physiology of adipose tissue and current surgical therapies used to replace lost tissue volume, specifically in breast tissue, are introduced, and current biomaterials, cell sources, and tissue culture strategies are discussed. We discuss future areas of study in adipose tissue engineering.

Comparison of three methods for the derivation of a biologic scaffold composed of adipose tissue extracellular matrix

Extracellular matrix (ECM)-based scaffold materials have been used successfully in both preclinical and clinical tissue engineering and regenerative medicine approaches to tissue reconstruction. Results of numerous studies have shown that ECM scaffolds are capable of supporting the growth and differentiation of multiple cell types in vitro and of acting as inductive templates for constructive tissue remodeling after implantation in vivo. Adipose tissue represents a potentially abundant source of ECM and may represent an ideal substrate for the growth and adipogenic differentiation of stem cells harvested from this tissue. Numerous studies have shown that the methods by which ECM scaffold materials are prepared have a dramatic effect upon both the biochemical and structural properties of the resultant ECM scaffold material as well as the ability of the material to support a positive tissue remodeling outcome after implantation. The objective of the present study was to characterize the adipose ECM material resulting from three methods of decellularization to determine the most effective method for the derivation of an adipose tissue ECM scaffold that was largely free of potentially immunogenic cellular content while retaining tissue-specific structural and functional components as well as the ability to support the growth and adipogenic differentiation of adipose-derived stem cells. The results show that each of the decellularization methods produced an adipose ECM scaffold that was distinct from both a structural and biochemical perspective, emphasizing the importance of the decellularization protocol used to produce adipose ECM scaffolds. Further, the results suggest that the adipose ECM scaffolds produced using the methods described herein are capable of supporting the maintenance and adipogenic differentiation of adipose-derived stem cells and may represent effective substrates for use in tissue engineering and regenerative medicine approaches to soft tissue reconstruction.

Automated isolation and processing of adipose-derived stem and regenerative cells

The popularity of nonhematopoietic, adult tissue-derived stem and progenitor cells for use as a cellular research tool, and ultimately as a clinical therapeutic, has increased exponentially over the past decade. Almost all adult-derived stem/progenitor cells (autologous and allogeneic), with one exception, require at least some ex vivo expansion or further manipulation prior to use to satisfy efficacy and safety requirements for preclinical or clinical use. The principal reason is the relatively low frequency of these therapeutically valuable cells within any given adult tissue, except for adipose tissue, which has been shown to have at least two log greater concentrations of these progenitor cells. Therefore, use of autologous adipose-derived cells as both a research tool and cell therapeutic is feasible and has been shown to be both safe and efficacious in preclinical and clinical models of injury and disease. The development and utilization of automated processes and instrumentation such as Cytori Therapeutics' Celution® System to reduce variability and increase quality of the recovered cells is requisite for clinical use and preferred by basic researchers. Here, use of an automated, closed processing platform for isolation and concentration of adipose-derived stem and regenerative cells is described, including a profile of the isolated cells immediately prior to use, and commonly used methods to quantify and qualitatively assess the recovered cells.

Supplementation of fat grafts with adipose-derived regenerative cells improves long-term graft retention

Current practice of autologous fat transfer for soft tissue augmentation is limited by poor long-term graft retention. Adipose-derived regenerative cells (ADRCs) contain several types of stem and regenerative cells, which may help improve graft retention through multiple mechanisms. Using a murine fat transplantation model, ADRCs were added to transplanted fat to test whether ADRCs could improve the long-term retention of the grafts. This study showed, at both 6 and 9 months after transplantation, ADRCs not only increased graft retention by 2-fold but also improved the quality of the grafts. ADRC-supplemented grafts had a higher capillary density, indicating ADRCs could promote neovascularization. Further cell tracking and gene expression studies suggest ADRCs may promote angiogenesis and adipocyte differentiation and prevent apoptosis through the expression of various growth factors, including VEGFA and IGF-1. Taken together, these results suggest a potential clinical utility of ADRCs in facilitating autologous fat transfer for soft tissue augmentation.

Human adipose-derived stem cells isolated from young and elderly women: their differentiation potential and scaffold interaction during in vitro osteoblastic differentiation

BACKGROUND AIMS

Several authors have demonstrated that adipose tissue contains multipotent cells capable of differentiation into several lineages, including bone, cartilage and fat.

METHODS

This study compared human adipose-derived stem cells (hASC) isolated from 26 female donors, under 35 and over 45 years old, showing differences in their cell numbers and proliferation, and evaluated their in vitro adipocytic and osteoblastic differentiation potential.

RESULTS

The cellular yield of hASC from older donors was significantly greater than that from younger donors, whereas their clonogenic potential appeared slightly reduced. There were no significant discrepancies between hASC isolated from young and elderly women regarding their in vitro adipocytic differentiation, whereas the osteoblastic potential was significantly reduced by aging. We also assessed the influence of hydroxyapatite (HAP) and silicon carbide (SiC-PECVD) on hASC. Even when cultured on scaffolds, hASC from younger donors had better differentiation into osteoblast-like cells than hASC from older donors; their differentiation ability was up-regulated by the presence of HAP, whereas SiC-PECVD produced no significant effect on hASC osteoblastic differentiation.

CONCLUSIONS

The large numbers of hASC resident in adipose tissue and their differentiation features suggest that they could be used for a successful bone regeneration process in vivo. We have shown that age does not seem to affect cell viability and in vitro adipocytic differentiation significantly, whereas it does affects osteoblastic differentiation, in the absence and presence of two-dimensional and three-dimensional scaffolds.

Abdominal fat harvest technique and its uses in maxillofacial surgery

Abdominal fat harvest and augmentation to the maxillofacial region is a relatively inexpensive, safe, and readily available procedure. The use of abdominal fat free transfer has been well documented for cosmetic, trauma, and temporomandibular joint reconstruction. Fat is the closest we have to an ideal filler, it is readily available and inexpensive, it is autologous and therefore lacks a host immune response, it is safe and noncarcinogenic, and it is easily acquired with a minimally invasive procedure. Abdominal fat donor site is the most commonly used owing to ease of access and availability of fat stores. Complications are rare and easily managed in the office. Free abdominal fat harvest is a predictable surgical technique that allows the maxillofacial surgeon access to autologous graft material that is ideal for multiple facial procedures.

Periocular autologous fat transfer

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

Body shaping and volume restoration: the role of hyaluronic acid

Driven by the rising popularity of minimally invasive techniques, the demand for cosmetic procedures is increasing. Cosmetic body-shaping procedures can be categorized into those that remove tissue and those that add volume. This review focuses on the latter of these categories, particularly on the use of resorbable hyaluronic acid gels specifically developed for minimally invasive volume enhancement. Pilot studies of hyaluronic acid involving its injection to contour various body deformities and its recent use in female breast augmentation are discussed. Injectable hyaluronic acid is effective and well tolerated. It represents an attractive treatment option for volume restoration or augmentation by providing predictable long-lasting results after minimally invasive administration. Alternative treatment options for volume enhancement also are summarized including fat transfer, silicone implants, and the use of injectable nonresorbable products such as silicone, polyalkylimide, and polyacrylamide gels. As patients continue to opt for nonsurgical procedures that offer predictable results, the development of minimally invasive products such as hyaluronic acid is increasingly important.

[Fillers. An overview]

The demand for minimally invasive cosmetic procedures is increasing rapidly every year. In addition to botulinum toxin and laser treatments, the injection of dermal fillers is one of the most relevant methods. Dermal fillers can be used for a multitude of indications: wrinkles (fine to deep), lip augmentation, facial deformities, sunken scars, and HIV-related lipoatrophy in hands, neck and décolleté. There are currently 160 dermal fillers on the market. They differ greatly in terms of origin (own or cadaveric-derived, animal, bacterial fermentation or synthesis), duration of the effect and breakdown properties (temporary, semi-permanent, permanent), injection depth (dermal, subcutaneous, supraperiosteal), and risk profile. Physicians who administer dermal fillers should have a thorough knowledge of their characteristics and of the anatomy of the area to be treated. This is essential for correct administration and optimal aesthetic results. Prior to any treatment, details of the procedure, the desired effects, durability, and potential risks of the filler to be injected should be discussed with the patient. The choice of dermal filler, the injection technique, and the volume to be administered are determined according to the anatomic site, the type of defect, the desired effect, and physician experience.

Injectables and fillers in male patients

Traditionally, in facial plastic surgery, male patients were known to focus on function over form. Men typically did not consider rejuvenation surgery until they had advanced changes associated with aging, and it was often coupled with a functional concern. However, over the last several years, the number of men seeking minimally invasive cosmetic products, such as dermal fillers and injectables, has increased significantly. Motives include the desire to be more competitive and youthful in the workforce, the growing social acceptability of cosmetic procedures, and increased awareness of nonsurgical options. The optimal use of these products and procedures requires appropriate patient selection, knowledge of the products, and a thorough understanding of the regional anatomy and clinical applications.

Advances in minimally invasive facial rejuvenation

PURPOSE OF REVIEW

Current cosmetic surgical practice for facial rejuvenation has undergone a significant change due to the introduction of technologies to improve the age-associated changes of the face. The most widely adopted methods of minimally invasive facial rejuvenation include the use of neuromuscular blocking agents and injectable fillers. The topic of minimally invasive procedures might include a variety of subjects including nutritional and hormonal modulation, light-based and laser-based therapies, minimal incision surgical procedures, as well as the use of botulinum toxin and fillers. The focus of this study will be on the minimally invasive facial rejuvenation efforts achieved by injection techniques.

RECENT FINDINGS

Botulinum A neurotoxin has been shown to be effective in the reduction of hyperfunctional lines in the upper and lower face. Anatomic areas that have been found to benefit include the glabella, the forehead, the periorbital area, lips, and the platysma muscle. The more recently introduced hyaluronic acid and other injectable fillers are receiving increasing usage. These temporary fillers have been found to improve creases and wrinkles, augment deep nasolabial folds, augment thin lips, and improve hollowing in the periorbital and other depressions and deformities.

SUMMARY

There has been a significant paradigm shift in the field of rejuvenation surgery. Injectable minimally invasive methods have been offered to remedy age-related and other acquired deformities of the head and neck region. These methods have provided temporary correction of undesirable characteristic that were traditionally approached with more invasive surgically oriented modalities.

Lipoplasty of the face and neck

PURPOSE OF REVIEW

Facial aesthetic surgery has gained wider acceptance and demand for it is increasing. Patients seeking a more youthful facial look often request lipoplasty. This article reviews the recent advances in lipoplasty and related fat contouring for the face and neck.

RECENT FINDINGS

Lipoplasty of the face and neck continues to be popular. There have been improvements in instrumentation, with laser and powered lipoplasty improving the efficiency of fat removal. Lipoplasty indications for neck lipodystrophy have been extended to patients previously only offered neck lifting. Additionally, limited procedures for patients with isolated anterior neck deformities, including direct lipectomy and skin excision, are gaining in popularity. Considerable attention in the lay and professional literature has been paid to mesotherapy for dissolving unwanted fat. Evidence supporting its efficacy is elusive. Finally, there remains enthusiasm for injection fat transfer for facial volume restoration as a component of rejuvenation.

SUMMARY

The treatment of lipodystrophy of the face and neck involves the removal of undesirable fat and the transfer of fat to other areas to produce improved aesthetic results. With the current emphasis on restoring volume, lipoplasty and fat transfer will continue to be important in facial plastic surgery.