Facial Augmentation by Fat Transfer: Lipostructure, Stem Cells, Regeneration

Use of adipous tissue transfer for correction of maxillo-facial defects was reported for the first time at the end of the 19th century and has been the subject of numerous studies.

Fat tissue grafting has been for many years one of the ideal fillers for enhancing and recontouring the face. Several techniques have been proposed for harvesting and grafting the fat but, due to the damage of many adipocites during these manoeuvres, the results were not satisfied, requiring a lot of fat for small correction. In 1988 the american plastic surgeon Sidney Coleman developed a personal technique, called “Lipostructure”, that allows the fat to be harvested and injected minimizing the risks of necrosis and reabsorption.

This technique is used  not only for aesthetic reasons but also to correct deficits after trauma, congenital deformities, or after tumor resections, to complete orthognatic procedures and all the operations that needs not only a bony repositioning but also a smooth distribution of the soft tissues.

Recent international studies and researches have proven that human adipose tissue represents a rich source of mesenchymal stem cells.ASCs  remain an important source of multipotent cells,with their abundance  and ease of access making ASCs a popular choice in modern tissue engineering strategies. Evidence exists that stem cells contribute to the restoration of tissue vascularisation, neo-angogenesis and regeneration. For these reasons, adipose tissue transfer represents a tremendous  potential tool for clinical use in soft tissue facial augmentation and restoration, even if further studies are needed to confirm the benefit of the full regenerative potential of ASCs.

Lipostructure in aesthetic and reconstructive surgery. MICRO and NANO facial fat transfer. 

Lipostructure or autologous facial fat transfer (injections of fat taken from the same patient) is a method which has been used for about 20 years. After the advent of regenerative medicine and after recognizing the presence of stem cells in variously treated collected fat ,the procedure has taken on new aspects also in the field of facial rejuvenation-regeneration and in reconstructions for various types of problems. In aesthetic surgery, facial wrinkles can now be filled with fat removed from the abdomen, flanks, or buttocks. The fat  is centrifuged to eliminate the  unnecessary components such as blood and oil, and injections in the face can be done with smaller sized cannulas (microcannulas with a diameter of about 0.7 mm) up to the use of very thin needles with a diameter of 0.3 or 0.4 mm (26-27 gauge) like those used to inject fillers or botulinum. In these cases the fat is emulsified until it becomes a very liquid injectable tissue. Thus, today we are talking about MICRO FAT  and also about NANO FAT. This emulsion does not contain many fat cells, but it does have many stem cells and endothelial cells with regenerative capabilities; it has potentialities not found in the common fillers in use today in aesthetics and cosmetics. Differently from the traditional lipostructure, which is performed with cannulas with a diameter greater than about 1.5 mm, volumetric possibilities in micro and nano lipostruture are reduced with an advantage for the regenerative potential of  the injected fat.  We may well say that these reconstructions represent the field of tissue engineering. No large volumes are created in the face, rather particular areas are regenerated such as peri-orbital wrinkles, orbital furrows, wrinkles around the mouth, nose, upper lip, lower lip, and lateral furrows, also called “marionettes” as they recall the furrows of marionettes. The regenerative capabilities are used to improve areas after radiotherapy, scars, skin ulcers, and also for skin rejuvenation, especially  when skin is thermally damaged  (sun, cold). The techniqe allows using mesenchymal stem cells (ADSCs – adipose derived stem cells) contained in the appropriately treated sampled fat tissue.

The staminality of autologous adipose tissue. It is now confirmed that autologous adipose tissue (taken from the same patient) contains more mesenchymal stem cells when compared to bone marrow. They are called ADSCs, and are found in a particular area of ​ adipose tissue called stromal vascular fraction (SVF).The fat is taken from the abdominal area, flanks, and buttocks using cannulas or microcannulas. After aspiration, the fat is centrifuged to remove unneeded liquids.  The purified fat is then injected and placed  into the various facial areas, following the preoperative planning program ,agreed upon with the patient. Fat grafting versus hyaluronic acid. Hyaluronic acid is a synthetic injectable, therefore not an autologous injectable, with a limited duration capacity. A maximum of injectable vials can be used, and the reabsorption is certain after a period of about 9 – 12 months. Hyaluronic acid lacks the regenerative effect; it works just as a temporary filler, and should not be used in adolescents or in the growth and development period. In any case, fillers should  not be used before adult age. After  many treatments, the use of fillers should be discouraged so as not to create filler-addicted , people  that unfortunately represent a new, more and more frequent pathology, also exacerbated by the media. The “advantage” of hyaluronic acid is that there is no downtime for the patient, that is, no absence from work because the procedure is fast and can be performed in an outpatient . Many fillers also include an anesthetic solution which avoids local anesthesia. Nonetheless, even the use of fillers may involve problems, especially if performed by someone who is not aware of the type of injected material . Fat, on the other hand, is a safe and natural alternative to other current treatments for filling tissues of the head-neck region. The autologous fat transfer technique certainly requires extended education and  training. Thus, we can say that fat transfer and stem cells regenerate the tissue in addition to reestablishing the volume of the face, representing a better technique than other filler treatments. Fat grafting has instead no age limit for the treatment. Depending on the case, repeated operations are often required over time to consolidate the final result. Usually, the first injection works as the base on which additional touchups can be added. Surgery is always  best performed  in the operating room, with maximum sterility and in any case with anesthesiologist assistance. For small touchups the Day Hospital is indicated. For major operations it is advisable to stay overnight. The immediate postoperative period involves adhesive facial dressing to stabilize the positioning of the fat, to be kept in place for a few days, with no immediate massages being indicated. The patient is presentable after about 6-10 days, depending on the amount of fat injected. In this period it is good to wear an abdominal binder so as to minimize bruising and also other possible irregularities in the donor area .The procedure,  like all surgical procedures, must be implemented so as to avoid complications and to safeguard the patient. The patient must also be fully advised about signing the appropriate informed consent.