Lipoaugmentation for aging hands: a comparison of the longevity and aesthetic results of centrifuged versus noncentrifuged fat

Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

Oral and Maxillofacial Autologous Fat Transplantation: History, Clinical Application Status and Research Progress

After more than a century of development, autologous fat transplantation (AFT), a repair method for soft tissue defects and deformities, has the advantages of being simple, rapid, effective and safe, and it is increasingly favoured by plastic surgeons. This article reviews the developmental history of AFT, analyses its clinical application status in the oral and maxillofacial regions, and provides a preliminary summary and discussion of the research progress related to AFT. The hope is that that this technique could be widely applied for oral and maxillofacial diseases as well as facial rejuvenation indications. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dorsal Hand Rejuvenation: A Systematic Review of the Literature

BACKGROUND

Dorsal hand appearance undergoes changes with aging. Grading systems have been designed to provide numerical scores to dorsal hand appearance. Various modalities have been utilized to improve the aesthetic appearance and rejuvenate the dorsal hand.

METHODS

The MEDLINE database was searched for articles investigating dorsal hand rejuvenation. Studies were grouped by method including fat grafting, injectable filler, laser/light-based treatments and miscellaneous treatments. Treatment protocols and outcomes were compiled along with patient information and complications.

RESULTS

Forty-six articles were identified for inclusion. This included 9 studies of fat grafting procedures, 20 studies of injectable filler, 10 studies of laser/light-based treatments and 7 miscellaneous. Most studies showed overall good results with high patient satisfaction. Satisfaction rates were lower in laser/light-based treatments compared with the other modalities. The average patient age for included studies ranged from 41.5 to 69. Across all studies, 96.8% of patients were female and 3.2% male.

CONCLUSIONS

Procedures for dorsal hand rejuvenation in the literature include procedures to address volume atrophy and superficial wrinkling. These procedures are overall safe with most studies reporting no complications or only mild adverse events. With high satisfaction rates and anecdotal reports of increasing patient interest, these procedures represent a developing area in aesthetic surgery likely to continue increasing in popularity.

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

Assessment of the Causes of Differences in Centrifugation Protocols as a Fat-Processing Technique: A Systematic Literature Review

BACKGROUND

Centrifugation has been widely used for fat graft processing. However, numerous different centrifugation protocols have been proposed in different studies. Investigation of these major differences is needed to clarify ambiguities and to achieve standardization. This review aimed to assess the causes of differences in centrifugation protocols as a fat-processing technique.

METHODS

Full-text and English-language articles between 1990 and 2020 were included in this study. Articles that assess the effect of centrifugation on fat graft survival with the following research purposes were selected: determination of the effect of centrifugation force/speed, determination of the effect of centrifugation time/duration, and comparison with other fat-processing techniques.

RESULTS

Fifty-four full-text, English-language articles were included. The number of articles that assessed centrifugation force/speed was 17 and centrifugation duration/time was 4, and the number of articles that compared centrifugation with other fat-processing techniques was 29 and centrifugation with noncentrifugation techniques was 4. Based on the study design, 25 experiments were performed in vivo, and 41 were performed in vitro.

CONCLUSION

Misuse of force (g) and speed (rpm) for defining the centrifugation protocol, differences in selected techniques for the graft harvest and graft transfer steps and differences in the analysis methods for fat graft survival are the main causes of these substantial variations among studies.

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

Fat Processing Techniques: A Narrative Review

OBJECTIVE

This study reviewed the literature regarding different fat processing techniques, in order to update the information for healthcare personnel and provide the latest evidence in selecting purification methods.

METHODS

PubMed (MEDLINE), EMBASE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were comprehensively searched to identify studies that compared different fat purification methods for animal and human studies published through July 2020. Papers were screened using inclusion and exclusion criteria, and relative data were collected for review.

RESULTS

A total of 3292 studies were identified, of which 30 were included for review. The findings of existing clinical studies showed that the filtration and washing filtration methods performed better in the volume retention rate of adipose tissue. In terms of postoperative complications (fat necrosis, nodules, cysts, etc.), the incidence of complications of centrifugation is generally higher than that of other purification methods, while Telfa gauze and washing filtration system show better safety. More comparative studies are needed to draw conclusions about clinical efficacy and satisfaction. The existing basic science studies generally believe that centrifugation has no advantage in the integrity and metabolic activity of adipose tissue. However, there is no definite conclusion about the volume retention rate of grafts in animal experiments.

CONCLUSION

In recent years, studies on the cost-effectiveness of various purification methods have emerged, and the efficiency advantages of commercial systems have also been gradually reflected. In the future, the purification efficiency will be improved based on ensuring clinical efficacy, which will be translated into cost savings.

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

Principles and Applications of Fat Grafting in Plastic Surgery

Autologous fat transplantation has become increasingly popular in recent years. Its biocompatable properties and availability made it a widely used treatment modality for soft tissue augmentation and volume replacement in both reconstructive and aesthetic plastic surgery. Multiple protocols and clinical applications have been described in the literature, with wide variations in the harvesting, processing, and injection techniques. In this review, the authors will discuss the basic principles and clinical applications of fat grafting in plastic and reconstructive surgery. The article will then conclude with a discussion of fat grafting limitations as well as potential future applications, giving the reader a well-rounded understanding of autologous fat transfer.

Facial aesthetic fat graft retention rates after filtration, centrifugation, or sedimentation processing techniques measured using three-dimensional surface imaging devices

OBJECTIVE

How to increase the long-term retention rate of autologous fat grafting has been widely discussed. This study aimed to evaluate long-term fat graft retention rates for the most widely used fat processing methods in the area of facial esthetic surgery, including centrifugation, filtration, and sedimentation, using three-dimensional (3D) imaging.

DATA SOURCES

PubMed, Embase, Wiley/Cochrane Library, and Web of Science databases were comprehensively searched from inception to July 2018 according to the guidelines of the American Society of Plastic Surgeons Fat Graft Task Force Assessment Methodology.

STUDY SELECTION

Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, follow-up devices, fat grafting techniques, and clinical outcomes. Patient cohorts were pooled, and fat graft retention rates were calculated. Complications were summarized according to different clinical characteristics.

RESULTS

Of 77 articles, 10 clinical studies met the inclusion criteria and reported quantified measurement outcomes with 3D imaging which provide precise volumetric data with approximately 2% standard deviation compared to real volumes. Data of 515 patients were included. Fat grafting retention varied from 21% to 82%. We found filtration and centrifugation techniques could result in better retention outcomes. However, retention varied within each processing technique, with no significant difference among the 3 techniques. Twenty-two complications were reported among 515 patients, including donor-site hematoma (1 case), mild post-operative erythema (2 cases), mild volumetric asymmetries (2 cases), chronic edema (2 cases), overcorrection (2 cases), skin irregularity (6 cases), and headache or dysesthesia (7 cases).

CONCLUSIONS

Filtration and centrifugation techniques may result in better fat grafting retention outcomes than gravity sedimentation; however, more accurate statistical evidence is needed. Controversies continue to exist with respect to the performance of the different fat-processing techniques in fat graft retention.

Autologous fat grafting: Harvesting techniques

Autologous fat grafting is widely used for soft-tissue augmentation and replacement in reconstructive and aesthetic surgery providing a biocompatible, natural and inexpensive method. Multiple approaches have been developed in the past years, varying in the location of adipose tissue donor-sites, use of wetting solutions, harvesting, processing and placing techniques. Despite many advances in this subject, the lack of standardization in the protocols and the unpredictability of the resorption of the grafted tissue pose a significant limitation for graft retention and subsequent filling. In this review, we discuss several approaches and methods described over the last years concerning the harvesting of autologous fat grafts. We focus on contents such as the best donor-site, differences between existing harvesting techniques (namely tissue resection, hand aspiration or liposuction techniques), recommended harvesting cannula diameters, pressure application and volume of wetting solution injected prior aspiration. Results and comparisons between methods tend to vary according to the outcome measured, thus posing a limitation to pinpoint the most efficient methods to apply in fat grafting. Additionally, the lack of a standard assay to determine viability or volume augmentation of fat grafting remains another limitation to obtain universally accepted grafting procedures and protocols.

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Distinct harvesting procedures associate with different outcomes of fat graft take.

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Flank, abdomen, thigh and knee are the more consistently used donor-sites for fat.

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Higher vacuum pressures in liposuction are more traumatic for the tissue.

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The tumescent technique is a safer procedure with improved aesthetic results.

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Comparing harvesting techniques is a big challenge given the multiple variables.

The Current State of Fat Grafting: A Review of Harvesting, Processing, and Injection Techniques

BACKGROUND

Interest in and acceptance of autologous fat grafting for use in contour abnormalities, breast reconstruction, and cosmetic procedures have increased. However, there are many procedural variations that alter the effectiveness of the procedure and may account for the unpredictable resorption rates observed.

METHODS

The authors highlighted studies investigating the effects of harvesting procedures, processing techniques, and reinjection methods on the survival of fat grafts. This review focused on the impact different techniques have on outcomes observed in the following: in vitro analyses, in vivo animal experiments, and human studies.

RESULTS

This systemic review revealed the current state of the literature. There was no significant difference in the outcomes of grafted fat obtained from different donor sites, different donor-site preparations, harvest technique, fat harvesting cannula size, or centrifugation speed, when tumescent solution was used. Gauze rolling was found to enhance the volume of grafted fat, and no significant difference in retention was observed following centrifugation, filtration, or sedimentation in animal experiments. In contrast, clinical studies in patients found more favorable outcomes with fat processed by centrifugation compared with sedimentation. In addition, higher retention was observed with slower reinjection speed and when introduced into less mobile areas.

CONCLUSIONS

There has been a substantial increase in research interest to identify methodologies for optimizing fat graft survival. Despite some differences in harvest and implantation technique in the laboratory, these findings have not translated into a universal protocol for fat grafting. Therefore, additional human studies are necessary to aid in the development of a universal protocol for clinical practice.

Fat grafting and breast reconstruction: tips for ensuring predictability

Autologous fat grafting is widely used in breast surgery to refine and optimize aesthetic outcomes. Despite its widespread use, obtaining predictable, reliable, and consistent outcomes remains a significant challenge and is influenced by the technique used for procurement, processing, and placement of the fat. At present, there is no published consensus on the optimal technique. The purpose of this article is to review current techniques at each stage of fat grafting and provide tips on best practices based on the published literature as well as our extensive clinical experience.

Nonanimal stabilized hyaluronic acid for tissue augmentation of the dorsal hands: a prospective study on 38 patients

BACKGROUND

Often ignored, hands are one of the most telltale signs of aging. This prospective study was initiated to evaluate the effect of subcutaneous hyaluronic acid (HA) injections in aging hands, with special attention to complications and long-term outcomes.

METHODS

Between January 2010 and December 2010, a total of 38 patients with skin phototypes II-IV and between 58 and 76 years old were treated with HA injection for aging hands. The quantity of injection never exceeded 1.0-1.5 ml HA per hand. A clinical follow-up was performed at 2 weeks, 4 weeks, 3 months, and 6 months after injection. Complications were reviewed for the whole series. At the first follow-up, 2 weeks after the procedure, ultrasound was carried out to determine if additional filling material was required. At each follow-up, patients were asked to fill out a satisfaction questionnaire.

RESULTS

Nine patients developed slight ecchymosis that disappeared after 1 week. No other complications were seen in the series. Pain during the injection and discomfort after the procedure were minimal. At the 2-week follow-up, after ultrasound control, nine patients received a complementary injection. At each follow-up, overall patient satisfaction was high and was validated by clearance of rhytids, veins, bony prominences, and dermal and subcutaneous atrophy.

CONCLUSION

Skin revitalization with injectable HA can improve the clinical appearance of the back of the hands. However, this therapy requires knowledge of the possible complications and their remediation as well as knowledge and respect of injected doses. Moreover, despite excellent results at each follow-up, the results of our series are not as good after 6 months, and a longer follow-up would be needed to determine if this procedure provides long-lasting benefit.

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

Effects of a new centrifugation method on adipose cell viability for autologous fat grafting

The use of adipose tissue transfer in plastic and reconstructive surgery is not new and has been studied extensively. Due to different results with regard to adipose cell damage and the level of survival of the transferred tissue in clinical practice, the authors aimed to investigate the effects of centrifugation on fat aspirates to optimize the centrifugal force for fat transplantation and to obtain an increased number of intact adipose progenitor cells. The following different centrifugation forces were evaluated in vitro in terms of fat decantation: 3,000 rpm (1,500×g), 1,300 rpm (250×g), and 500 rpm (50×g). Moreover, the density level, morphology of fat cells, cell viability, and progenitor cell number also were evaluated. Centrifugation leads to a good fat tissue density, with a significant number of progenitor cells, and efficiently removes the liquid portion. High centrifugal forces (at 3,000 rpm) caused significant damage to fat cells with low cell viability, whereas very low centrifugal forces (at 500 rpm) showed little effect on adipose tissue density, resembling fat decantation. Fat aspirates, withdrawn from 30 healthy donors in vivo, were centrifuged at different rotations per minute (rpm), as follows. For the 10 patients in group A, Coleman's technique was used with a centrifugation of the aspirated fat at 3,000 rpm (1,500×g) for 3 min. For the 10 patients in group B, the authors' technique was used, with centrifugation of the aspirated fat at 1,300 rpm (250×g) for 5 min. For the 10 patients in group C, simple decantation of fat was used. In conclusion, a centrifugal force of 1,300 rpm resulted in better density of adipose tissue, with good cell viability and increased ability to preserve a significant number of progenitor cells.

Adipose-derived stem cells for clinical applications: a review

The use of stem cells derived from adipose tissue as an autologous and self-replenishing source for a variety of differentiated cell phenotypes, provides a great deal of promise for reconstructive surgery. In this article, we review available literature encompassing methods of extraction of pluripotent adipose stem cells (ASCs) from lipoaspirate locations, their storage, options for culture, growth and differentiation, cryopreservation and its effect on stem cell survival and proliferation, and new technologies involving biomaterials and scaffolds. We will conclude by assessing potential avenues for developing this incredibly promising field.

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

Fat augmentation is safe, relatively inexpensive, and readily available. Now that cosmetic surgeons are recognizing that facial aging is not simply due to gravity but also to atrophy of tissues, the use of fat for volume restoration is becoming even more popular. Newer techniques of Lipostructure, facial fat rebalancing, and fat autograft muscle injection (FAMI) are targeted to achieve true full-face three-dimensional rejuvenation; however, practical means of objectively measuring outcome are lacking. Basic questions remain regarding the optimal harvesting site, processing technique, and most effective injection technique. Scientific research is emerging th address these issues.

Fat Transplantation Using Fresh Versus Frozen Fat: A Side-by-Side Two-Hand Comparison Pilot Study

BACKGROUND

Autologous fat in both fresh and frozen forms has been used for many years as a filler for various dermatologic conditions. However, it is not clear whether fat that has been frozen survives as well as, and gives aesthetic results similar to, fresh fat. The efficacy of frozen fat has been debated in the literature.

OBJECTIVE

To evaluate the clinical aesthetic appearance and longevity of fresh fat versus frozen fat in a side-by-side two-hand comparison in the same patient.

METHODS

Ten patients underwent fat augmentation on their hands, utilizing 10 cc of fresh fat in one hand and 10 cc of frozen fat in the contralateral hand within 17 days of fresh fat placement. Follow-up evaluation was conducted at 1, 3, and 5 months in a randomized, double-blind comparison study. Physician-determined aesthetic preference, prominence of veins, and depth of metacarpal spaces were evaluated. Photographs were taken of both hands during each patient follow-up visit.

RESULTS

All three areas of physician-assessed gradation: aesthetics, vein prominence, and depth of metacarpal space were superior for the hand injected with frozen fat at 1-, 3-, and 5-month follow-up visits.

CONCLUSIONS

This pilot study supports the use of autologous frozen fat for equivalent to improved results regarding longevity and aesthetic appearance versus fresh fat at 1, 3, and 5 months for fat augmentation of aging hands.

Rejuvenation of the aging hand

This article reviews aging of the hand and the treatment options for cosmetic rejuvenation. Options available for cutaneous rejuvenation include microdermabrasion, chemical peeling, intense light sources, and laser therapy, including pigment lasers, ablative resurfacing, and noninvasive rejuvenation. Protuberant veins of the aging hand can be treated effectively with sclerotherapy. The soft tissue atrophy of the aging hand is best treated with fat augmentation. The article concludes with a mention of new fillers that are just beginning to be used for soft tissue atrophy of the hand.

Utilization of the 1320-nm Nd:YAG Laser for the Reduction of Photoaging of the Hands

BACKGROUND

Nonablative laser resurfacing has been shown to improve the appearance photoaged skin. Clinical improvement has been associated with dermal collagen remodeling.

OBJECTIVE

The objective was to determine the efficacy of a 1320-nm Nd:YAG laser for the treatment of photoaging hands.

METHODS

Seven patients with photoaged hands received six monthly treatments with a 1320-nm Nd:YAG laser. Improvement in skin smoothness was evaluated by objective and patient assessment using a 6-point improvement scale: 1=no improvement and 6=80% to 100% improvement.

RESULTS

Mild to moderate improvement was achieved as determined by both objective and patient assessment. Mean improvement by objective assessment was 2.4 points. Objective improvement was noted in four of seven patients, and these patients demonstrated a mean improvement score of 3.5 points. The mean improvement by patient assessment was 3.1 points.

CONCLUSION

This case series demonstrates that the 1320-nm Nd:YAG laser with cryogen cooling can be effective for rejuvenation of photoaged hands.