Fat Grafting India
FAT GRAFTING WITH ADIPOSE DERIVED STEM CELLS (ADSCs)
GRAFTING OF ASPIRATED ADIPOSE TISSUE
Soft tissue augmentation is performed by grafting autologous tissues or artificial materials to correct inborn or acquired tissue defects such as breast augmentation, facial rejuvenation and many more.
AUTOLOGOUS (SELF) FAT TRANSPLANTATION CLINICAL APPLICATIONS
World wide standard approaches to soft tissue remodulation include autologous tissue flaps, autologous fat transplantation, and alloplastic implants.
All of these approaches have disadvantages, which may include donor site morbidity, implant migration and foreign body reaction.
A minimally invasive cannula harvest Autologous fat transplantation has lower donor site morbidity than tissue flaps do.
Human adipose tissue which has long been thought of as an unwanted part of the body by the figure conscious people is an ideal source of autologous cells that is both easily and plentifully obtainable in large quantities through the simple surgical procedure of liposuction. Non vascularized autologous fat grafting(lipoinjection) definitely has emerged as a promising option for soft tissue augmentation because there is no associated incisional scarring or complications derived from foreign materials.
Autologous fat transplantation is frequently used for a variety of cosmetic and reconstructive indications not only limited to post traumatic defects of the face and the body, but evolutional disorders such as hemifacial atrophy, sequelae of radiation therapy and many other aesthetic uses such as lip, facial and other ares augmentation and as wrinkle therapy.
Fat grafting Yes but why with ADSCs
ADIPOSE DERIVED STEM CELLS FOR TISSUE REPAIR/REMODELLING
ASC are thought to be the main proliferating cell population in any types of adipose tissue remodelling, such as development growth, hyperplasia in obesity, repair processes after injury, or tissue expansion induced by mechanical forces. They have been shown to have angiogenic characteristics, to release angiogenic factors responding to ischemia or stimulation of growth factors, therefore are considered to be bipotent progenitor cells for both adipocytes and vascular cells.
CURRENT HUMAN APPLICATIONS
The various applications are as follows:
- Transplantation in patients with lipodystrophy
- Cosmetic and functional results of facial remodelling
- Cosmetic and functional results of reconstructive breast surgery
- Cosmetic results of gluteal remodelling
- Reconstruct breast deformities after lumpectomy
- Cosmetic result of depressed scar
Use Of Stem Cells in Aesthetic Procedure
The Composition Of Adipose Derived Stem and Regenerative cells
ADSCs are prepared by a series of steps which includes digesting adipose tissue with the enzyme collagenase and if required expanding the adipocyte depleted fraction in tissue culture under standard conditions to create a homogeneous population of adherent ADSCs. The fact that ADSCs can be cultured from the adipocyte-depleted fraction of cells leads us to the conclusion that the adherent ADSCs is contained within the heterogeneous population. The adipocyte-depleted nucleated cell population is commonly referred to as stromal vascular fraction, adipose derived stem and regenerative cells, or processed lipoaspirate cells.
The SVF population includes cells contained with the stroma and vasculature of adipose tissue. In essence this population includes all cells present within the adipose tissue, with the exception of lipid-laden adipocytes.
SVF cells are obtained by first washing the adipose tissue to remove blood cells, which are inevitable contaminant of the liposuction process, then treating the washed tissue with collagenase to release the cells from the extracellular matrix. Adipocytes are then removed on the basis of their natural therapy buoyancy, leaving behind an adipocyte-depleted population of stromal and vascular cells.
Potential Regenerative Mechanism of SVF
The observation that ADSCs can differentiate into multiple cell lineages suggests that the differentiation into various different tissue types may be an important mechanism by which the cultured cell population would provide traffic.
SVF contains vessel-forming cells including endothelial, smooth muscle, endothelial progenitor cells and pericytes. Angiogenesis is a key factor for successful incorporation of an autologous fat graft into the recipient site and for long term retention of the graft. The ability of SVF cells to promote angiogenesis may explain why supplementation of fat grafts with these cells leads to a significant increase in graft retention.
The SVF population also has the potential to reduce cell apoptosis by means of growth factor secretion and direct cell-cell interaction. With the anti-apoptosis mechanism, SVF can carry through the graft tissue through hypoxic conditions and thus limit the extent of graft tissue damage and apoptosis.
Anti-inflammation and Anti-scar Formation
Another potential therapeutic role of SVF is SVF mediated reduction in inflammation associated with a reduction in the size of scar. Supplementing fat grafts with SVF cells leads to reduced tissue fibrosis at both 6 and 9 month follow up time.
SVF are also used as fillers in Plastic and Reconstructive surgery.
Advantages of the Transplantation of Fat in Plastic and Reconstructive Surgery
There can be several plastic and reconstructive surgery procedures utilizing fat grafting addressing the increase in the volume and contour of the body and facial tissues.
Facial cases enjoy the outstanding advantage of this procedure that can improve both muscle and nerve activity allowing better results than compared with those that were obtained prior to the use of the lipo-injection.
Sequelae of Facial Paralysis
After facial paralysis the voluntary muscles of the face lose their motor innervations leading to changes both biochemical and histological including atrophy which causes a progressive thinning of its fibers between 50 and 80% which is visible because the portion of the affected becomes notoriously thin. Therefore, patients suffering from these deformities are suitable for having the facial contour raised by thickening soft tissues, especially the affected muscle, and fat autologous transplantation is the best alternative to achieve aesthetic and functional improvement.
Autologous Fat Transfer: Risk or benefit?
Benefits of Fat Grafts
Fat grafting is an increasingly popular surgical tool in modern medicine for numerous favourable reasons. Fat grafting is a rather uncomplicated and inexpensive procedure. The whole operation requires syringes in different sizes equipped with a blunt needle for liposuction, a centrifuge, and a needle for fat injection. Secondly fat is easily available with uncommon complicated accessibility. The introduction of the liposuction technique simplified fat extraction immensely.
Risks of Fat Grafts
The lipofilling procedure itself is a rather straightforward procedure with manageable complication rates. The incidence of complications notably increases with volume of liposuction therefore the specialist should rather perform a staged procedure than a single high volume lipotransfer. As in any other surgery, minor complications include infections, edemas, ecchymois, dyschromias, or seromas at both the site of harvest and site of injection.
Fat Necrosis and Graft Resorption
Fat necrosis and resorption represent no severe risk to the patient they still are often mentioned issue resulting in serial lipofilling procedures, decreasing patient’s satisfaction. The simplest way to counterfact graft resorption is to transplant more fat than actually required. To avoid fat necrosis, suggest small volume injections in thin layers to grant sufficient perfusion at the recipient site.
Adipose Tissue Anatomy
Issue are found in mammals, including humans, the brown adipose tissue and the white adipose tissue.
The BAT: A thermogenic Tissue
The BAT is a thermogenic tissue that produces heat by oxidizing fatty acids in specialized, uncoupled mitochondria, thereby contributing to nonshivering thermogenesis. BAT is mainly located in visceral area and it is characterized by a typically multilocular lipid deposit. BAT activation depends on sympathetic stimulation. Nonshivering thermogenesis plays an important physiological role in the perinatal period, when other thermogenic mechanisms are still immature, as well as during the cold stimulus ; in adults the BAT contributes to the diet-induced component of nonshivering thermogenesis.
A Single WAT or Several WATs?
In the humans the most abundant fat is accumulated in the WAT, which shows a typically unilocular lipid deposit, and it has a major role in the storage and release of fatty acid. Its main locations are subcutaneously, but a considerable visceral WAT deposit can also be found in the mediastinum and in retroperitoneal areas.
The Subcutaneous Adipose Tissue
The “fat” located subcutaneously generally represent a rather pure form of WAT without admixtion with BAT, which is usually present in visceral “fat”. Subcutaneous adipose tissue represents an almost unlimited reservoir of stem cells that can be harvested with minimally invasive procedures.
Classification of the Subcutaneous Adipose Tissue
Distinct adipose tissue typologies are present in fatty depots. In fat depots of large size, also in the same depot are evident differences that can be correlated to the superficial or deep localization. It should be clarified that inside larger depots, the aspect could be inhomogeneous.
The WAT Deposit (or Type 1 WAT)
Type 1 is located essentially in large depots in the abdominal area and in particular in the periumbilical region. It is a typical non-lobulated adipose tissue that could be defined as metabolic fat due to its large lipidic mass and its very poor collagenic component.
The WAT Deposit (or Type 2 WAT)
With respect to type 1 type 2 adipose tissue is more polymorphous and viable from site to site and it plays different roles based on the relationships with the surrounding structures. Type 2 fat is characteristic of more localized depots where its function goes undoubtedly beyond the storage only. In such areas the adipose tissue appears mainly finalized to mould which is to give shape to its structure. Type 2 is a non lobular adipose tissue with a variable collagenic component, often performing a network around the adipocytes. These cells appear relatively easy to dissociate. THe stroma appears generally fairly good and well vascularized and the staminiality is also generally fair
The WAT Deposit (or Type 3 WAT)
Type 3 adipose tissue has a remarkable fibrous component. This morphologic characteristic is related to a well defined mechanism function. Adipocytes are smaller than in other WAT types and show a thick fibrous shell wrapping them one by one. This kind of adipose tissue characterized by a conspicuous prevalence of collagenic stroma can represent in two subtypes:
- Lobular Fibrous WAT
- Non-Lobular Fibrous WAT
Current Therapeutic Uses of Adipose-Derived Stem and Regenerative Cells
Therapeutic Uses of Autologous Fat and Stem Cell Transfer
Autologous fat grafting is used for aesthetic soft tissue volume replacement and for reconstruction of soft tissue defects. The therapeutic uses for cell-assisted lipotransfer (CAL ) include all areas of soft tissue volume preplacement that one may consider standard autologous transfer:
- Facial rejuvenation
- Facial lipodystrophy
- Natural breast augmentation
- Breast defect reconstruction
- Hand rejuvenation
- Gluteal reshaping and augmentation
- Lower limb atrophy and rejuvenation
- Liposuction indentation repair
- Cellulite indentation repair
Stem Cell Lipotransfer Surgical Steps
Stem Cell Use in Natural Breast Augmentation
Therapeutic Uses of Stem Cell
The therapeutic uses of stem cells include:
- Treatments for bone defects
- Rectovaginal fistula
- Graft-versus-host disease
- General orthopedic surgery
- Wound healing
- Breast reconstruction
- Radiation necrosis
- Wrinkle treatment
- Acute myocardial infarction and chronic cardiovascular disease
- Liver insufficiency
- Nonalcoholic chronic liver disease
- Stress urinary incontinence
- Renal ischemia
Stem Cell use in Orthopedic Surgery also is showing promising results
Stem Cell Use in Wound Healing
Dermal wound healing is a highly coordinated process where fibroblasts interact with surrounding cells and produce extracellular matrix, glycoproteins, and various cytokines. After tissue injury, fibroblasts migrate into the initial fibrin based matrix and proliferate and begin the production of ECM and collagen.
Stem cells can influence adjacent cells, in this case fibroblasts, to migrate, proliferate and secrete substances. The cellular influence is from both direct cellular contact and by growth factors secretion. . The efficacy of ASCs, when supplied either alone or along with PRP to improve wound healing. A porcine full thickness wound model was used to compare six topical treatments: PRP, autologous adipose stem cells plus PRP, allogenic adipose stem cells PRP, allogenic adipose stem cells containing green fluorescent protein plus PRP and saline.
Another therapeutic component of whole blood is platelet –poor plasma(PPP), that is plasma where the platelet count has been significantly reduced below baseline. Whilst PPP can be a useful tool in adjusting plasma concentration and as a protocol, it may also have elevated levels of fibrinogen, allowing it to form a fibrin –rich clot when activated. This facilitates cell migration and attachment which is necessary in wound healing. Key elements of the plasma products are the innumerable growth factors contained. These in conjunction with the cellular components providing a plethora of signaling factors and growth pathways providing an exciting regeneration pathway.
Adipose-Derived Stem Cells (ADSCs): What are the Present Findings and what we can hope for the Future in Structural Facial Fat Grafting for face lifting and rejuvenation
Potential Areas for Facial Fat Transfer
Although fat transfer can be used to volumize any depressed area on the face, the most commonly addressed areas are the following:
- Nasolabial folds marionette lines
- Cheeks and infraorbital regions
- Trough area
- Glabellar area temple and forehead
- Inferior orbital rim
These areas can be addressed individually or sometimes together to achieve the desired result.
- Inferior Orbital Rim
It stands as the most technically difficult area
The index finger of the nondominant hand is used to protect the globe during the infiltration.
Provides structural support to the skin, helps eliminate wrinkles and reduces pore size also affects skin color.
- Nasojugal Groove
The bony nasojugal groove is the triangular bony fossa bordered superiorly by the media inferior orbital rim and medially by the nasal sidewall. For the purposes of fat injection we make a distinction between the nasojugal groove, defined by the bony landmarks and the tear trough. Nasojugal groove injection is done in a deep supraperiosteal plane using the bony landmarks as a guide. In contrast filling of the tear trough is done in a more superficial plane but still below the orbicularis oculi muscle.
- Supraorbital Area: Lateral Brow, Upper Eyelids, and Temples
- A definite fullness of the supraorbital region is essential for a sensual, healthy appearance.
- Unlike the brow and temples the frontal region is difficult to rejuvenate with structural fat grafting because the forehead is more dynamic
- The brow is defined as the soft tissue that resides principally inferior and deep to the hair-bearing portion of the eyebrow and superior to upper yield itself. With advancing age the brow gets deflated thus revealing a more skeletonized superior orbital rim.
- The aging forehead is especially affected by the active and intrinsic action of the frontalis muscle. This results in wrinkles or creases.
- Placement of fat into into the brow, subcutaneous and into the muscle can restore the youthful convexity and highlight in this area.
- Lateral Canthus
At times a small depression remains visible or becomes exaggerated, at the lateral canthus following superior and inferior orbital rim injections.
- Anterior Cheek
- Emphasis is on the malar depressions, which is usually the area of greatest volume loss.
- Fat is infiltrated into all three tissue planes(deep, middle, superficial)
- Equal distribution
- Buccal region and Lips
The Buccal region tends to be more important to fill in the very gaunt individual. In patients with a thin face, even if the buccal region does not appear deficient as fat is placed in the adjacent areas(cheek, submalar, and jawline) buccal hollowing will be accentuated.
Structural fat grafting to the lips can produce long lasting enhancement of the upper and lower lip with purely autologous material.
- Prejowl sulcus/Anterior Chin
The Prejowl sulcus is defined as the depression immediately anterior to the jowl. This is an important area to fill both in younger patients with a minimal jowl and in older patients who will be undergoing concurrent facelifting.
In the younger patient, volume restoration to the prejowl sulcus is often sufficient for masking the jowl and recreating a youthful jawline.
In patients with more advanced signs of aging where the facelift is the primary treatment for the jowl, filling the prejowl sulcus will produce a more ideal result.
At the conclusion of the surgery there is no need for dressings or bandages on the harvest or recipient sites following isolated fat grafting procedure.
Head elevation and icing for 48-72 will reduce and expedite resolution of postoperative edema.
Beyond the first few postoperative days, the cheek area may feel a bit flushed or sore. Patients are encouraged to rest the week following fat grafting and not engage in any excessive that require Valsalva or bending over.
A sustainable result can persist for a minimum of 12 months without any trend toward reabsorption. Mostly approximately 32% of the injected volume remains at 16 months, and microaugmentation injections seem to help promote better fat graft survival. It tends to last the longest in the cheek areas and midface and less long in the nasolabial or smile regions. The temple areas are variable and the eyelid regions seem to persist.
For long term survival of transplanted autologous fatty tissue, the harvested and processed fatty tissue parcels must be viable before implantation.
Fat Transplantation for Hemifacial Atrophy
Autologous fat transplantation is an excellent choice to improve facial aesthetics in patients with Romberg disease. It is a good alternative to the historical free tissue transfer in moderate cases with minimal mordibity and good long term outcome. Fat used as a filler for various soft tissue deficiencies or for facial rejuvenation is the most convenient choice, as there is no foreign body rejection, it is not expensive, it is safe and it can result in complete patient satisfaction.
Meticulous harvesting and special injection techniques are critical in fat graft survival. Dr Satya Saraswat is a meticulous and thoughtful surgeon who believe in state of art technique.
Because fat tissue is the most important source of stem cells in the body, ADSC-enriched autologous fat transfer has been successfully used to improve graft uptake and survival.
Fat Stem Cell for Restoration of Facial Asymmetries (Secondary Corrections of Facial Deformities Following Major Resection and Reconstruction)
Autologous fat grafting is a recognized reconstructive and cosmetic procedure used to restore form and function in many areas of the body. It can restore the natural tissue defects by sequential injection of lipoaspirate, using dedicated instrumentation.
Manual liposuction, being less traumatic as compared with power-driven systems is usually favored for small volume defects.
Volume Restoration and Regenerative Potential of Fat grafting in the Face
The progress of lipofilling procedures has dramatically improved the reconstructive repertoire of head and neck surgeons. The addition of one or multiple sessions of fat graft injection is becoming a mainstay of the workup of facial reconstruction. Primary reconstruction of the inferior and middle third of the facial skeleton can be a real challenge when surroundings facial soft tissues have to be resected simultaneously.
Initially fat graft injection of the facial tissues was prompted to restore deficient volumes and correct asymmetrics following traumatic injuries, and ablative surgery.
Ear Lobe Revolumization
Ear lobules lose volume and start to crease and appear stretched with earrings. Revolumization of the ear lobule will help restore the anatomical structure and support. In non-pierced ear lobes, the crease that is formed from the volume loss may be corrected with fat grafting. In a pierced ear lobe the fat grafting will restore the support structure to allow for earrings to sit better and for the soft ear lobule not to appear long stretched. In pierced ear lobes, we do take care to position the fat to restore the volume without closing or damaging the pierced opening.