The scientific basis for lipotransfer: is it the ideal filler?

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.

Stromal vascular fraction improves the durability of autologous fat temple augmentation-A split-face randomized study using ultrasound biomicroscopy

BACKGROUND

Autologous lipotransfer aims to restore aging-associated volume loss, but with low predictability owing to 20-90% first-year loss of transferred fat. Enrichment by adipose-derived stem cells within the stromal vascular fraction (SVF) aims to improve volume retention through their differentiation potential and paracrine actions exerted by secreted trophic and angiogenic factors. Assessing studies lacked split-face designs, and used multitudes of enrichment ratios, preparation techniques and evaluation methods ending in contradictory reports regarding enrichment advantage.

AIM

To test whether enriching the autologous fat graft with SVF will increase its residual volume as compared to non-enriched graft. A standardized enrichment protocol and ratio and objective assessment were employed.

PATIENTS AND METHODS

In a split-face design, and after random assignment, bilateral temple augmentation using non-enriched versus SVF-enriched autologous lipotransfer were compared in middle-aged females otherwise healthy non-pregnant or breast-feeding females abstaining from esthetic or weight-controlling procedures. Temple volume scale (TVS), skin layers' thickness measured by ultrasound biomicroscopy (UBM), visual analog scale for patients' satisfaction, and side effects were blindly assessed at 1 week, 3 months, and 6 months.

RESULTS

In the included 15 females, TVS was significantly lower (0.5 ± 0.5 versus 1.1 ± 0.7, P = 0.0001), and% hypodermal augmentation was significantly higher (70.92 ± 58.09 versus 18.93 ± 19.33, P = 0.001) on the SVF-enriched side at 6 months. Patient satisfaction was similar bilaterally (P = 1), as were sequelae frequencies as lumping, edema, and ecchymosis.

CONCLUSION

SVF enrichment of transferred fat significantly improved its residual volume at 6 months; a conclusion that needs further validation. UBM was an informative objective tool for the following temple skin thickness changes. Trial registration clinical trials.gov (NCT03965936).

Optimization of Adipose Tissue Cryopreservation Techniques in a Murine Model

Background:

The aim of this study was to develop an adipose tissue (AT) cryopreservation protocol that is effective, simple, and maintains the functionality and viability of AT after thawing and transplantation.

Methods:

Two cryopreservation temperatures (T°), −20°C and −80°C, and two cryoprotective agents (CPAs), trehalose and hydroxyethyl starch (HES), were compared first in an experimental study, using a slowfreezing protocol. The five experimental groups were the following: (a) Fresh AT (control group), (b) T = −20°C, 10%HES, (c) T = −80°C, 10%HES, (d) T = −20°C, 0.35M trehalose, (e) T = −80°C, 0.35M trehalose. We evaluated the morphology (histological studies) and tissue viability by glyceraldehyde 3-phosphate dehydrogenase (GAPDH) genic expression. Based on the results of the preliminary study, an in vivo study was performed, choosing as cryopreservation T° −20°C. HES and trehalose were compared as cryoprotective agents and with a control group (fresh AT). AT grafts were transplanted into immunodeficient mice. After 1 month of inoculation, animals were euthanized and samples were recovered. Samples were weighted and processed for histological study, viability study (GAPDH genic expression), and vascularization study (VEGF genic expression).

Results:

The initial histological study demonstrated that all AT cryopreserved group samples showed typical histological features of AT, similar to that of the control group. Statistically significant differences were not observed (P > 0.05) in GAPDH expression between different groups related to temperature or CPA. Referring to the in vivo studies, cryopreserved groups showed good take of the graft and normal AT architectural preservation, as well as a clear vascular network. Statistically significant differences were not found (P > 0.05) with regard to graft take (%), GAPDH, or VEGF expression.

Conclusion:

Slow freezing at −20°C using trehalose, and −20°C using HES as cryoprotective agents are both straightforward and easy AT cryopreservation procedures, with results similar to those of fresh AT in terms of tissue viability and morphohistological characteristics.

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

String Fat/Dermis Graft for Correction of Wrinkles and Scars

Established creases and wrinkles do not predictably respond to the fat injection technique. The authors describe a minimally invasive yet simple technique to address recalcitrant facial rhytides and minor depressed scars. This technique optimally requires a concomitant procedure whereby suitable fat or dermis graft could be available for grafting without having to make another incision. However, if needed, the graft can be harvested from an easily concealed area such as postauricular sulcus. Preferably, dermis or a combination of fat and dermis is harvested in the form of strings using a pair of straight iris scissors. The sharp end of an 18-gauge needle is then used to create a tunnel in the subcutaneous plane beneath each line while releasing any fibrous bands. The string of dermis/fat is then engaged at the end of the 18-gauge needle and delivered into the subcutaneous tunnel with rotation and advancement of the needle. The authors have used this graft on 49 sites on 39 patients. The mean age of the patients was 57.6 years, with eight male and 31 female patients. The sites included rhytides in upper and lower lips, oral commissure, labial mental groove, and frown lines, and scars in the forehead, nasal dorsum, nasal tip, and eyebrows. String fat grafting is a simple and reliable method to address limited rhytides or depressed scars. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Injectable Biomaterials in Plastic and Reconstructive Surgery: A Review of the Current Status

BACKGROUND

Injectable biomaterials have attracted increasing attention for volume restoration and tissue regeneration. The main aim of this review is to discuss the current status of the injectable biomaterials for correction of tissue defects in plastic and reconstructive surgery.

METHODS

Requirements of injectable biomaterials, mechanism of in situ gelation, characteristics, and the combinational usage of adipose-derived stem cells (ADSCs) and growth factors were reviewed.

RESULTS

The ideal injectable biomaterials should be biocompatible, non-toxic, easy to use, and cost-effective. Additionally, it should possess adequate mechanical properties and stability. In situ gelation method includes physical, chemical, enzymatic and photo-initiated methods. Natural and synthetic biomaterials carry their pros and cons due to their inherent properties. The combined use of ADSCs and growth factors provides enhanced potential for adipose tissue regeneration.

CONCLUSIONS

The usage of injectable biomaterials has been increasing for the tissue restoration and regeneration. The future of incorporating ADSCs and growth factors into the injectable biomaterials is promising.

Receptor for hyaluronan mediated motility (RHAMM/HMMR) is a novel target for promoting subcutaneous adipogenesis

Hyaluronan, CD44 and the Receptor for Hyaluronan-Mediated Motility (RHAMM, gene name HMMR) regulate stem cell differentiation including mesenchymal progenitor differentiation. Here, we show that CD44 expression is required for subcutaneous adipogenesis, whereas RHAMM expression suppresses this process. We designed RHAMM function blocking peptides to promote subcutaneous adipogenesis as a clinical and tissue engineering tool. Adipogenic RHAMM peptides were identified by screening for their ability to promote adipogenesis in culture assays using rat bone marrow mesenchymal stem cells, mouse pre-adipocyte cell lines and primary human subcutaneous pre-adipocytes. Oil red O uptake into fat droplets and adiponectin production were used as biomarkers of adipogenesis. Positive peptides were formulated in either collagen I or hyaluronan (Orthovisc) gels then assessed for their adipogenic potential in vivo following injection into dorsal rat skin and mammary fat pads. Fat content was quantified and characterized using micro CT imaging, morphometry, histology, RT-PCR and ELISA analyses of adipogenic gene expression. Injection of screened peptides increased dorsal back subcutaneous fat pad area (208.3 ± 10.4 mm²versus control 84.11 ± 4.2 mm²; p < 0.05) and mammary fat pad size (45 ± 11 mg above control background, p = 0.002) in female rats. This effect lasted >5 weeks as detected by micro CT imaging and perilipin 1 mRNA expression. RHAMM expression suppresses while blocking peptides promote expression of PPARγ, C/EBP and their target genes. Blocking RHAMM function by peptide injection or topical application is a novel and minimally invasive method for potentially promoting subcutaneous adipogenesis in lipodystrophic diseases and a complementary tool to subcutaneous fat augmentation techniques.

Analysis of Lipoasiprated Following Centrifugation: Wet Versus Dry Harvesting Technique

BACKGROUND

The success of lipotransfer strongly depends on the harvesting, processing, and placement of the lipoaspirated samples. This study was designed to assess the histomorphometric characteristics and viability of fat harvested using different techniques (wet and dry) following centrifugation, as described by Coleman.

METHODS

The study enrolled 85 consecutive, nonrandomized, healthy patients from March 2010 to December 2014 (45 males and 40 females). The mean age was 40 years (range, 18-59 years), and the mean body mass index was 25.8 (range, 24-32). The authors performed a histological analysis (hematoxylin/eosin), morphometry (ImageJ 1.33 free-share image analysis software), and a viability assessment (Trypan Blue exclusion test; Sigma-Aldrich, Milan, Italy) of the lipoaspirated samples.

RESULTS

The hematoxylin and eosin-stained sections exhibited similar features; in particular, clear-cut morphological signs of adipocyte disruption, apoptosis, or necrosis were not detected in the examined samples. Morphometry confirmed the visual findings, and the values of the mean surface area of the adipocyte vacuoles were not significantly different. Additionally, the adipocyte viability was not significantly different in the analyzed fat tissue samples.

CONCLUSIONS

The results from this study showed, for the first time, that there is not a reduction in the viability of fat grafts harvested with the dry or wet technique following centrifugation according to Coleman technique. Both methods of fat harvesting collect viable cells, which are not influenced by standard centrifugation. The fat grafts harvested and processed by this technique could be used in clinical settings without increasing the reabsorption rate.

LEVEL OF EVIDENCE

V.

[Postoperative complications in plastic surgery]

Plastic surgery covers a broad spectrum of diseases and conditions in the areas of reconstructive surgery, hand, burn and aesthetic surgery. Besides acquired defects or malformations an increasing number of patients are being treated for surgical or multimodal complications. In a considerable number of patients plastic and reconstructive surgery remains the only therapeutic alternative after other therapy has failed. Therefore complication management in plastic surgery is of utmost importance for a successful outcome. In addition patient expectations in the results of plastic surgery as a discipline of invention and problem solving are steadily increasing. This challenge is reflected in clinical patient management by intensive research in tissue engineering and regenerative medicine. Patients in plastic surgery are recruited from all age groups of either gender, involving traumatic and oncologic as well as congenital and aesthetic disorders. The demographics of aging, multimorbidity and obesity pose new challenges to plastic surgery. Although age over 70 years is not an independent risk factor per se for complications in plastic surgery, e.g. for complex free flap transfer, medical problems are present at a higher rate, which is to be expected in this age group. Risk factors such as alcoholism and coronary heart diseases seem to be independent predictors of perioperative complications. Therefore older patients can also benefit from plastic surgery and recurrent operations by the corresponding risk and complication management. Complication management necessitates careful patient selection, estimation of operative risks and patient-adapted selection of procedures. In addition to expertise in plastic surgery a thorough knowledge of non-surgical and surgical back-up procedures for technical incidents as well as vascular circulatory and wound healing disorders is required to deal successfully with complications in plastic surgery. This article presents these specific aspects of postoperative complication management in plastic surgery.