Autologous Fat Transfer for Periorbital Rejuvenation: Indications, Technique, and Complications

Nanofat: A therapeutic paradigm in regenerative medicine

Adipose tissue is a compact and well-organized tissue containing a heterogeneous cellular population of progenitor cells, including mesenchymal stromal cells. Due to its availability and accessibility, adipose tissue is considered a “stem cell depot.” Adipose tissue products possess anti-inflammatory, anti-fibrotic, anti-apoptotic, and immunomodulatory effects. Nanofat, being a compact bundle of stem cells with regenerative and tissue remodeling potential, has potential in translational and regenerative medicine. Considering the wide range of applicability of its reconstructive and regenerative potential, the applications of nanofat can be used in various disciplines. Nanofat behaves on the line of adipose tissue-derived mesenchymal stromal cells. At the site of injury, these stromal cells initiate a site-specific reparative response comprised of remodeling of the extracellular matrix, enhanced and sustained angiogenesis, and immune system modulation. These properties of stromal cells provide a platform for the usage of regenerative medicine principles in curbing various diseases. Details about nanofat, including various preparation methods, characterization, delivery methods, evidence on practical applications, and ethical concerns are included in this review. However, appropriate guidelines and preparation protocols for its optimal use in a wide range of clinical applications have yet to be standardized.

Integrating Fat Graft with Blepharoplasty to Rejuvenate the Asian Periorbita

BACKGROUND

Contemporary periorbital rejuvenation is undergoing a paradigm shift to an approach that prioritizes volume preservation and/or augmentation. However, the technical difficulties of using traditional fat grafting techniques in this area and the distinct ethnic features make periorbital rejuvenation in Asians especially challenging. Here, the authors present their approach to enhance the periorbita and outcomes.

METHODS

A retrospective chart review was performed for 33 consecutive patients who underwent microautologous fat transplantation (MAFT) to the periorbita using the MAFT gun device combined with excisional blepharoplasty. Additionally, preoperative and postoperative photographs were analyzed by external evaluators to grade the aesthetic outcomes and fat resorption rates.

RESULTS

Three months after surgery, patients looked on average 5.4 ± 3.4 years younger, and the aesthetic result was graded 7.4 ± 2 in a one-to-ten scale. The fat resorption rate was 19.6% ± 3.5% at 3 months and 32.2% ± 3.9% after 12 months (range: 12-24 months; P = 0.007). The overall morbidity rate was 12% (4 patients), including 1 visible lump (3%), an overcorrection case (3%) in the lower eyelid, and 2 palpable lumps in the upper eyelid (6%) which were not visible. One case of lower eyelid hollowness required secondary fat grafting.

CONCLUSIONS

Traditional blepharoplasty procedures can be combined with fat grafting techniques to address volume loss and tissue descend while keeping ethnic identity. A fat injection device like the MAFT gun is safe and effective and provides long-term predictable outcomes for fat grafting around the periorbital thin skin.

Complications in Brow Lifts: A Systemic Review of Surgical and Nonsurgical Brow Rejuvenations

Background:

Brow lift has been a part of plastic surgeons’ armamentarium for over a century. Although there are multiple different techniques available, there has been a dearth of literature comparing which technique is better and has lesser complications. In this study, we performed a systemic literature review of all brow lift techniques to determine and compare complication rates of each technique.

Methods:

We performed a computerized search of brow rejuvenation techniques using the MEDLINE database. Data regarding the type of brow lift procedure, number of patients, and complications were collected.

Results:

The systematic review was performed in December of 2017. A total of 326 articles were identified initially, and 76 studies remained after final review. The review showed highest revision rate in the hairline brow lift (7.4%), highest numbness rate in the direct brow lift (5.5%), highest asymmetry rate in the temporal/lateral brow lift (1.5%), and highest alopecia rate in the endoscopic brow lift (2.8%). In addition, we found 5 studies in nonsurgical brow rejuvenation (3 botulinum toxin, 1 fat injection, 1 radiofrequency).

Conclusion:

Our study shows that each brow technique has a different complication profile, and it is important for plastic surgeons to understand the difference. Furthermore, the study demonstrated the lack of randomized prospective outcome studies and standardization of outcome measures in brow rejuvenation. We believe this information would be the key and next frontier in providing technically safe and long-lasting aesthetic outcomes for the patients.

Autologous Fat Transfer for Facial Rejuvenation: A Systematic Review on Technique, Efficacy, and Satisfaction

Background

Parallel to the steady decline in surgical aesthetic procedures to the face, dermal fillers seem to have gained a more prominent place in facial rejuvenation over the last couple of years. As a dermal, facial filler, autologous fat transfer (AFT) seems to have real potential because of the biocompatibility of adipose tissue besides being a procedure with few and primarily minor complications. This systematic review aims to evaluate the available evidence regarding the safety and effectiveness of AFT for facial rejuvenation.

Method

A systematic review after the Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analysis (PRISMA) statement was conducted. MEDLINE, Embase, and Cochrane Library were searched up to December 2016, with no language restrictions imposed. Case series, cohort studies, and randomized controlled trials (RCTs) reporting on relevant outcomes were included.

Results

Eighteen clinical articles were included, reporting on 3,073 patients in total over a mean follow-up period of 13.9 months. Meta-analysis showed an overall complication rate of 6% (95% CI 3.0-14.0), with hematoma/ecchymosis (5%), fat necrosis/oil cysts (2%), and irregular fat distribution and scars (both 2%) being among the most reported. No major complications were reported, and the overall patient satisfaction rate was 81%.

Conclusion

Although the evidence in this systematic review is still limited and plagued by heterogeneity between studies, AFT seems to be a promising method in facial rejuvenation with fewer complications than other fillers and high patient satisfaction rates. Further large-cohort, preferably multicenter, RCTs should substantiate these results through quantifiable volumetric assessment tools and validated patient questionnaires, while adhering to predetermined nomenclature in terms of complications.

Development and Validation of a Photonumeric Scale for Evaluation of Infraorbital Hollows

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of infraorbital hollows (i.e., tear troughs) before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Infraorbital Hollows Scale.

METHODS

The scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each grade. The clinical significance of a 1-point score difference was evaluated in a review of image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 297) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A score difference of ≥1 point was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 0.90 [0.79-1.02] for clinically different image pairs and 0.33 [0.19-0.46] for not clinically different pairs). Intrarater agreement between the 2 validation sessions was substantial (mean weighted kappa = 0.79). Interrater agreement was substantial during the second rating session (0.70, primary end point).

CONCLUSION

The Allergan Infraorbital Hollows Scale is a validated and reliable scale for physician rating severity of hollowing in the infraorbital area.

Eyelid-associated complications after autogenous fat injection for cosmetic forehead augmentation

Background

We report two cases of unilateral upper eyelid swelling with multiple small lumps as an unusual complication of autogenous fat injection for cosmetic forehead augmentation.

Case presentation

Two female patients were referred to our clinic for unusual unilateral eyelid swelling, with multiple small lumps. The duration of symptoms differed in each case, but both patients had a history of autogenous fat injection for cosmetic forehead augmentation at a local plastic surgery clinic. The lumps were small (diameter 5 mm~10 mm), palpable, hard, and nonmobile, and were evaluated by magnetic resonance imaging (MRI). Lumps from the eyelids of two patients were excised under general anesthesia. All of the masses were located deeply and found near the superior orbital rim or lateral orbital rim. The lumps exhibited chronic inflammation with fibrosis. Some of the lumps showed foamy histiocytic aggregation and foreign body lipogranuloma, resulting from iatrogenic fat injection. After excision, all masses and swelling disappeared, and moderate ptotic eyelid or lagophthalmos of affected eyes also improved.

Conclusions

To our knowledge, eyelid swelling with multiple lumps in the eyelid is a very rare complication of autogenous fat injection for cosmetic forehead augmentation. This report should be helpful for ophthalmic clinicians who encounter these unusual symptoms.

Nonsurgical volumetric upper periorbital rejuvenation: a plastic surgeon's perspective

In the aging process, upper periorbits can be divided broadly into two groups. Group 1 is characterized primarily by soft tissue ptosis of the upper eyelid, which requires surgical excision. The patients in group 2, show volume depletion of the soft tissue and bony resorption of the orbit, characterized by deflation of the upper eyelid as well as sunken, hollow, and skeletonized orbits. Currently, structural fat grafting is the only means for adding volume the depleted upper periorbit. It is, however, an invasive procedure associated with fairly significant morbidities, long downtime, and hence poor patient acceptance. The advent of safe hyaluronic acid (HA)-based dermal filler has, in the authors' opinion, revolutionized treatment for this group of oculoplastic patients. In the current series, 36 patients with volume depletion of the periorbit were treated with HA dermal fillers to restore the smooth arc of the upper periorbit. The average volume required ranged from 0.2 to 0.6 ml of filler. Despite the relatively small volume required, the upper periorbital aesthetics of the patients were successfully and dramatically transformed. At this writing, the longest follow-up period has been 3.5 years, with the patient still maintaining periorbital volume. No significant morbidities occurred. Given the multiple risks and the resistance of patients to structural fat grafting compared with HA dermal fillers, the authors believe that this nonsurgical technique for adding volume to the periorbit should become the method of choice for this group of oculoplastic patients.

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.