Regen Fat Code: A Standardized Protocol for Facial Volumetry and Rejuvenation.

BACKGROUND: Facial aging is a degenerative process that impairs contour and angle prominence. Rejuvenation is based on tissue replacement, volumization of the atrophic areas, and improving flaccidity and cutaneous photoaging. OBJECTIVES: The aim of this study was to apply structural fat grafting to manage volumetric deficits of the face, following a new systematic protocol called "Regen Fat Code" (RF Code) that was created to standardize structural lipotransfer methods. METHODS: This is a prospective clinical trial involving 80 healthy candidates for facial rejuvenation who were split into 2 groups. Group A underwent only structural lipotransfer; Group B underwent replacement of deep facial structures by face-lifting plus structural lipotransfer. Structural lipotransfer followed the protocol "RF Code" and 3 clinical tools were adopted for pre- and postoperative facial volumetric analysis. RESULTS: Total volume (mL) of lipotransfer in Groups A and B ranged between 1 and 20 mL (mean [standard deviation], 12 [5] mL), distributed to the different areas as follows: nasolabial fold, 3.32 [0.92] mL; superior lip, 2.0 [0.62] mL; inferior lip, 2.76 [0.71] mL; malar, 8.51 [5.25] mL; inferior eyelid, 1.2 [0.54] mL; and chin, 7.18 [1.99] mL. Areas with less mobility showed a lower absorption index than dynamic areas. CONCLUSIONS: The development of the RF Code protocol demonstrated the potential of grouping many parameters based on the lipotransfer method used to volumize and regenerate atrophic areas of the face. The protocol is easy to apply, and allows different volumizing and regenerative effects to be proposed, according to the demands of each surgical area.

Drainage on augmentation mammoplasty: Does it work?

BACKGROUND: Breast prostheses could be associated with complications, despite many studies on surgical materials and techniques. The role of surgical drainage in preventing complications on breast prostheses surgery is controversial. OBJECTIVES: This study aimed to evaluate the role and effectiveness of vacuum drainage in the augmentation mammoplasty. METHODS: A prospective multicentric randomized comparative clinical trial was conducted with 150 patients, who were the candidates for breast augmentation. The candidates were split into two groups to analyze the breast drain role. Group1: closed-suction drainage; measurements were taken every 24 h for 48 h. Group2: control (no drainage); all the patients were submitted to a clinical and postoperative ultrasonography evaluation (7th day and 3rd month). The late consultations (1st-, 2nd-, and 3rd-year postoperative time) were carried out to identify any complication, such as infection, seroma, hematoma, asymmetry, hypertrophic scarring, rippling, implant position, visible edges, and sensibility alteration. RESULTS: A total of 150 female patients were operated with 300 breast implants placed into subglandular pocket. In the first 24 h postoperative (D1), the drainage volume ranged from 12 ml to 210 ml (mean= 74.90 ml; SD= 43.29 ml). After 24 h, on the second day (D2), the collected volume ranged from 10 ml to 120 ml (mean= 44.76 ml; SD= 24.80 ml). The total drainage volume in the 48 h ranged from 22 ml to 320 ml (mean= 119.7 ml; SD= 62.20 ml). The breast ultrasonography series (BUSGS) analysis was done on the 7th day and 3rd month in both groups. There was no significant difference between G1 and G2 groups (p = 0.05 and 0.25, respectively). In the follow-up, some patients (33-44%) declared sensitivity disturbing on the nipple-areola complex (NAC) and lower breast segment. CONCLUSIONS: The closed-suction breast drainage in breast augmentation was associated with high cost and time-consuming and not demonstrated any benefit in a recent postoperative time.

Photoaged Skin Therapy with Adipose-Derived Stem Cells.

BACKGROUND: The major intrinsic cause of facial skin degeneration is age, associated with extrinsic factors such as exposure to sun. Its major pathologic causes are degeneration of the elastin matrix, with loss of oxytalan and elaunin fibers in the subepidermal region, and actinic degeneration of elastin fibers that lose their functional properties in the deep dermis. Therapy using autologous adipose mesenchymal stem cells for regeneration of extracellular matrix in patients with solar elastosis was addressed in qualitative and quantitative analyses of the dermal elastic fiber system and the associated cells. METHODS: Mesenchymal stem cells were obtained from lipoaspirates, expanded in vitro, and introduced into the facial skin of patients submitted after 3 to 4 months to a face-lift operation. In the retrieved skin, immunocytochemical analyses quantified elastic matrix components; cathepsin K; matrix metalloproteinase 12 (macrophage metalloelastase); and the macrophage M2 markers CD68, CD206, and hemeoxygenase-1. RESULTS: A full de novo formation of oxytalan and elaunin fibers was observed in the subepidermal region, with reconstitution of the papillary structure of the dermal-epidermal junction. Elastotic deposits in the deep dermis were substituted by a normal elastin fiber network. The coordinated removal of the pathologic deposits and their substitution by the normal ones was concomitant with activation of cathepsin K and matrix metalloproteinase 12, and with expansion of the M2 macrophage infiltration. CONCLUSION: The full regeneration of solar elastosis was obtained by injection of in vitro expanded autologous adipose mesenchymal stem cells, which are appropriate, competent, and sufficient to elicit the full structural regeneration of the sun-aged skin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fat Grafting for Facial Contouring Using Mechanically Stromal Vascular Fraction-Enriched Lipotransfer.

Autologous fat graft has limitations, especially long-term unpredictability of volume maintenance. The mechanical enrichment of fat graft with adipose-derived stem cells (ADSCs) could guarantee the survival of fat grafts. After decantation, washing, and centrifugation of lipoaspirate, the authors carried out histochemical analysis and flow cytometry to determine the best layers for preparing ADSC-enriched fat. After centrifugation, the stromal vascular fraction (SVF) was separated by mechanical dissociation and mixed with another layer of intact adipocytes, which was injected into patients. All patients showed volumetric improvement after a single lipotransfer section, without overcorrection. The method is safe, has low cost, and is easily reproducible.

Effect of Use of Platelet-Rich Plasma (PRP) in Skin with Intrinsic Aging Process.

BACKGROUND: In previous papers, we demonstrated that the treatment of human photoaged skin with stromal-vascular fraction-enriched fat or expanded adipose-derived stem cells showed a decrease of elastosis and the appearance of new oxytalan elastic fibers in dermis and an increase in the vascular network. The utilization of fat plus platelet-rich plasma (PRP) led to an increase in the vascular permeability and reactivity of the nervous component. OBJECTIVES: The purpose of this study was to analyze the histologic and ultrastructural changes of human skin after the injection of only PRP in the retroauricular area that was not exposed to sun and did not present the photoaging process, in comparison with our previous results. METHODS: This study was performed in 13 patients who were candidates for facelift and whose ages ranged between 45 and 65 years. The PRP injection was performed in the mastoidea area. Fragments of skin were removed before and 3 months after treatment and analyzed by optical and electron microscopy. RESULTS: After the injection of PRP, we observed an increase of reticular dermis thickness because of the deposition of elastic fibers and collagen, with a fibrotic aspect. A modified pattern of adipose tissue was also found at the dermohypodermal junction. Significative regenerative aspects were not found at histologic and ultrastructural analysis. The presence of foci of moderate inflammation and microangiopathy were observed. CONCLUSIONS: Treatment with PRP increased reticular dermis thickness with a fibrotic aspect. In the long term, the presence of inflammation and microangiopathy caused by PRP injection could lead to trophic alteration of the skin and the precocious aging process.

Mechanical Supplementation With the Stromal Vascular Fraction Yields Improved Volume Retention in Facial Lipotransfer: A 1-Year Comparative Study.

Background: Unpredictable volume maintenance in the long term is a major limitation of autologous fat grafting. Objectives: The authors compared results of autologous lipotransfer to the face with or without enrichment of fat with the stromal vascular fraction (SVF). Methods: Thirty patients with asymmetric depletion of facial volume were included in a prospective study. Patients were randomly assigned to undergo a single session of autologous fat transfer with washed adipose tissue (control group) or with washed adipose tissue combined with the pellet of centrifuged lipoaspirate, which contained the SVF (enriched group). Patients were evaluated clinically and from photographs. A subset of 5 patients in each group underwent computed tomography (CT) preoperatively and 12-months postoperatively for quantitative assessment of graft retention. Washed and fractionated lipoaspirates were evaluated histochemically and with flow cytometry to determine relative abundances of viable cells. Results: No major complications occurred. CT findings 12 months postoperatively indicated that patients who received SVF-enriched fat had significantly better volume retention (9.6% volume loss vs 24% in the control group; P = 0.013). Independent surgeons more frequently rated long-term aesthetic outcomes as "excellent" for patients in the enriched group (82.5% vs 47.6% for control group). Laboratory results indicated that each pellet contained approximately 16,000 intact adipose-derived stem cells. Conclusions: Lipotransfer with SVF-enriched adipose tissue is safe and associated with improved volume retention, compared with transplantation of unenriched fat. The SVF can be dissociated from lipoaspirate by centrifugation to yield a large quantity of viable regenerative cells, without enzymatic digestion. Level of Evidence: 2.

Expanded Stem Cells, Stromal-Vascular Fraction, and Platelet-Rich Plasma Enriched Fat: Comparing Results of Different Facial Rejuvenation Approaches in a Clinical Trial.

BACKGROUND: In a previous study, the authors demonstrated that treatment with expanded adipose-derived stem cells or stromal vascular fraction (SVF)-enriched fat modify the pattern of the dermis in human beings, representing a skin rejuvenation effect. Considering that expanded stem cells require a cell factor, the authors wanted to assess similar results by replacing them with platelet-rich plasma (PRP), which is easier to obtain and for which an empirical regenerative effect has been already described. OBJECTIVES: To determine if PRP injection could replace the cutaneous regenerative effect of adipose-derived stem cells. METHODS: This study was performed in 13 patients who were candidates for facelift. The patients underwent sampling of fat by liposuction from the abdomen and submitted to one of three protocols: injection of SVF-enriched fat or expanded adipose-derived stem cells or fat plus PRP in the preauricular areas. Fragments of skin were removed before and 3 months after treatment and analyzed by optical and electron microscopy. RESULTS: The use of fat plus PRP led to the presence of more pronounced inflammatory infiltrates and a greater vascular reactivity, increasing in vascular permeability and a certain reactivity of the nervous component. The addition of PRP did not improve the regenerative effect. CONCLUSION: The use of PRP did not have significant advantages in skin rejuvenation over the use of expanded adipose-derived stem cells or SVF-enriched fat. The effect of increased vascular reactivity may be useful in pathological situations in which an intense angiogenesis is desirable, such as tissular ischemia.

Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells.

BACKGROUND: The regenerative property of fat grafting has been described. However, it is not clear whether the clinical results are attributable to the stem cells or are linked to other components of the adipose tissue. This work is aimed at analysis of the histologic and ultrastructural changes of aged facial skin after injection of fat graft in addition to its stromal vascular fraction, obtained by centrifugation, and to compare the results with those obtained by the injection of expanded adipose-derived mesenchymal stem cells. METHODS: This study was performed in six consecutive patients who were candidates for face lift and whose ages ranged between 45 and 65 years. The patients underwent sampling of fat by liposuction from the abdominal region. The injection of fat and its stromal vascular fraction or expanded mesenchymal stem cells was performed in the preauricular areas. Fragments of skin were removed before and 3 months after each treatment and analyzed by optical and electron microscopy. RESULTS: After treatment with the autologous lipidic component and stromal vascular fraction, the skin showed a decrease in elastic fiber network (elastosis) and the appearance of new oxytalan elastic fibers in papillary dermis. The ultrastructural examination showed a modified tridimensional architecture of the reticular dermis and the presence of a richer microvascular bed. Similar results following treatment with expanded mesenchymal stem cells were observed. CONCLUSION: This study demonstrates that treatment with either fat and stromal vascular fraction or expanded mesenchymal stem cells modifies the pattern of the dermis, representing a skin rejuvenation effect.

Repeated expansion in burn sequela.

This paper presents a retrospective study of the use of 346 expanders in 132 patients operated at the Ivo Pitanguy Clinic, between the period of 1985 and 2000. The expanders were used in the treatment of burn sequela. In the majority of cases, more than one expander was used at the same time. In 42 patients, repeated tissue expansion was done. The re-expanded flaps demonstrated good distension and viability. With the increase in area at each new expansion, larger volume expanders were employed, achieving an adequate advancement of the flaps to remove the injured tissue. The great advantage of using tissue re-expansion in the burned patient is the reconstruction of extensive areas with the same color and texture of neighboring tissues, without the addition of new scars.