|Year : 2018 | Volume
| Issue : 2 | Page : 58-62
Facial recontouring with autologous cryopreserved fat graft
Hsu Ma, Yin-Han Fang, Chih-Hsun Lin, Cherng-Kang Perng, Chi-Han Tsai, Fu-Yinn Hsiao
Department of Surgery, Division of Plastic Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
|Date of Submission||22-May-2017|
|Date of Decision||12-Aug-2017|
|Date of Acceptance||06-Nov-2017|
|Date of Web Publication||24-Apr-2018|
Dr. Hsu Ma
19F, No. 201, Section 2, Shipai Road, Beitou District, Taipei City 112
Source of Support: None, Conflict of Interest: None
Background: Autologous fat graft is a well established technique for soft tissue augmentation and the most significant drawback remains the unpredictability of the absorption rate and the possible repeating fat harvest procedures. In our basic study, we found evidence to support that fat cryopreservation is a practical method of storing fat tissue and several anecdotal clinical experiences suggest its clinical efficacy.
Methods: Thirty two patients who received autologous cryopreserved fat grafts for facial deficiencies were retrospectively reviewed. Autologous cryopreserved fat grafts were transplanted for “touch up” or augmentation of other soft tissue deficiencies at least three months after fresh fat grafting, The patients' satisfaction was evaluated by a study-specific questionnaire.
Results: 84 autologous fresh fat graft and 178 autologous cryopreserved fat graft procedures for the face were performed in 32 patients. There was no infection, skin retraction, fibrosis or necrosis identified except one patient complained of lump formation in the left upper lid (1/178, 0.6%). The self-assessment questionaaire revealed no statistical difference of effectiveness rating between the fresh and cryopreserved fat grafting results (mean± standard deviation: 8.64±1.09 vs 8.73±0.985; P > 0.05) but there was significant statistical difference of convenience rating between the fresh and cryopreserved fat grafting (mean± standard deviation: 2.68±1.07 vs 8.41±1.05; P < 0.05). Of the twenty-two patients who returned the questionnaire, all reported willing to have the treatment in the future (9.73±0.456) and all said that they would like to recommend this treatment to their friends (9.82±0.395).
Conclusions: Autologous cryopreserved fat graft is a safe, simple, and convenient technique to restore facial soft tissue defects with acceptable patient satisfaction rate.
Clinical Question/Level of Evidence: Therapeutic, IV.
Keywords: Autologous fat, cryopreserved fat graft, facial recontouring
|How to cite this article:|
Ma H, Fang YH, Lin CH, Perng CK, Tsai CH, Hsiao FY. Facial recontouring with autologous cryopreserved fat graft. Formos J Surg 2018;51:58-62
|How to cite this URL:|
Ma H, Fang YH, Lin CH, Perng CK, Tsai CH, Hsiao FY. Facial recontouring with autologous cryopreserved fat graft. Formos J Surg [serial online] 2018 [cited 2018 May 25];51:58-62. Available from: http://www.e-fjs.org/text.asp?2018/51/2/58/231146
| Introduction|| |
Autologous fat transplantation was first reported by Neuber in 1893. He also found that resorption rate was proportional to the size of graft particle. Today, autologous fat transplantation is a well-established technique for soft-tissue augmentation, and various techniques have been proposed to enhance the fat graft survival rate. However, the most significant drawback of fat grafting remains the unpredictability of the absorption rate and the possible repeating fat harvest procedures. Trying to solve these problems, lots of studies focused on improving the techniques of fat harvesting, grafting, or cryopreserving the unused fat. In fat harvesting and grafting, lipostructure technique proposed by Coleman  was one of the important milestones in improving fat graft survival rates. The concept of microinjection was introduced and neovascularization from the surrounding viable tissue was believed to be one of the key elements for fat survival.,, In the cryopreserved fat graft, although divergent results of basic studies, it seemed more encouraging in clinical experiences. Moscatiello et al. reported a stable result in a case of gluteal augmentation with cryopreserved fat after 1-year follow-up. A study by Butterwick et al. found that the longevity and esthetic appearance of the autologous frozen fat grafts in the dorsum of hands were at least equivalent to the fresh ones, though the frozen time was only 10 days. Although anecdotal clinical experiences suggest its clinical efficacy, there exists a rare amount of published clinical series analysis of autologous cryopreserved fat graft. Therefore, a retrospective analysis was performed to evaluate the results of autologous cryopreserved fat grafting in patients with facial soft tissue deficiencies.
| Materials and Methods|| |
From January 2008 to December 2009, patients who received autologous cryopreserved fat grafts for facial deficiencies were retrospectively collected by chart review. Thirty-two patients were enrolled in the study. All the patients received suction-assisted lipectomy from abdomen with infiltration of tumescent solution (1:1000 epinephrine 1 ml, 7% sodium bicarbonate 20 ml, and 2% xylocaine 40 ml in Ringer's lactate solution 1000 ml). Fat was harvested by a 3-mm, blunt tip Mercedes cannula attached to the liposuction machine (Dominant 50, Medela Co., Switzerland). The lipoaspirates were centrifuged at 3000 rpm for 5 min. The middle layer of fat was collected and grafted into the desired sites immediately, with the lipostructure technique. The unused fats were packed into sterile syringes. Then, the syringes were put into sterile plastic bags and then covered with two layers of sterile towels. Finally, it was put into another sterile plastic bag and put into the refrigerator (Thermo Electron Co., Asheville, NC, USA) at − 80°C under the sterile package. Patients were evaluated at least 3 months after fresh fat grafting and autologous cryopreserved fat grafts were considered for “touch up” or augmentation of other soft tissue deficiencies. Before grafting procedure, the frozen fats were claimed from the refrigerator and thawed in room temperature water bath for 15 min. All the procedures including harvesting, packaging, and defreezing steps were performed in the operative theater. The grafting technique was identical to the first episode of fat transfer, mainly lipostructure with microinjection techniques. Twenty-two of the thirty-two patients returned a study-specific questionnaire concerning satisfaction with the results of the fresh and cryopreserved fat grafting procedures modified from Abbreviated Treatment Satisfaction Questionnaire for Medication-9 [Table 1]. The questionnaire used the linear analog scales (10-point scale) with 10 indicating high satisfaction and one indicating low satisfaction. The satisfaction rating of the fresh fat graft served as control group and the rating of the cryopreserved fat graft served as study group. Statistical analysis of the data was performed with a paired t-test and Fisher's exact test, using SPSS version 16.0 software (SPSS, Inc., Chicago, IL).
|Table 1: Abbreviated Treatment Satisfaction Questionnaire for Medication-9|
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The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
Eighty-four autologous fresh fat grafts and one hundred and seventy-eight autologous cryopreserved fat grafts procedures for the face were performed in 32 patients. There were one male and thirty-one females, ranged from 15 to 65 years old (45.9 ± 11.9; mean ± standard deviation [SD]). Mean follow-up was 21.5 ± 7.49 months (12–37 months; mean ± SD). The distributions of graft sites are listed in [Table 2]. Only infection, skin retraction, gross fibrosis or necrosis, and serious complications were recorded in this series. Adverse effects such as swelling, edema, and bruise were commonly seen after both fresh and frozen fat grafts. There were no infection, skin retraction, fibrosis, or necrosis identified in this series. One patient complained of lump formation in the left upper lid and the lump was excised 1 year after grafting (1/178, 0.6%). Normal fibroadipose tissue was demonstrated by the histological study of the lump [Figure 1]. Pre- and post-operative photography revealed obvious change in the contour of the faces [Figure 2] and [Figure 3] The self-assessment questionnaire revealed no statistical difference of effectiveness rating between the fresh and cryopreserved fat grafting results (mean ± SD: 8.64 ± 1.09 vs. 8.73 ± 0.985; P > 0.05), but there was significant statistical difference of convenience rating between the fresh and cryopreserved fat grafting (mean ± SD: 2.68 ± 1.07 vs. 8.41 ± 1.05; P < 0.05). Of the 92 patients who returned the questionnaire, all reported willing to have the treatment in the future (9.73 ± 0.456) and all said that they would like to recommend this treatment to their friends (9.82 ± 0.395).
|Figure 1: Normal fibroadipose tissue demonstrated by H and E staining (×40, 1 year after cryopreserved fat graft, bar = 50 μm)|
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|Figure 2: A 52-year-old female, received autologous fat grafts for her deep nasolabial grooves and bilateral sunken temples. Four months after this procedure, lots of improvements achieved by fresh fat grafts and she asked for touch up the nasolabial grooves and depressions over bilateral cheek-lid junctions (left above and below: White elliptical zones) autologous cryopreserved fat was implanted into the nasolabial grooves and cheek-lid junctions. 26 months follow-up after touch up treatment (right above and below)|
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|Figure 3: A 15-year-old female with abortive Rhomberg's disease, right face (left above and below). Cryopreserved fat grafts for depressed right cheek, nasolabial groove (white elliptical zone), and right Marionette line twice in 6-month intervals (right above and below) the grafted volume maintained well in 2-year follow-up|
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| Case Reports|| |
A 52 year-old female, received autologous fat grafts for her deep nasolabial grooves and bilateral sunken temples. The unused fat was cryopreserved at −80°C under sterile package. Four months after this procedure, lots of improvements achieved by fresh fat grafts and she asked for touch up the nasolabial grooves and depressions over bilateral cheek-lid junctions. Autologous cryopreserved fat was claimed from the refrigerator and 12 ml of fat was implanted into the nasolabial grooves and cheek-lid junctions. The results of the cryopreserved fat grafts were satisfactory in 26 months after touch up treatment [Figure 2].
A 15-year-old female, was a victim of abortive Rhomberg's disease, right face. She received autologous fat grafts for her right cheek, nasolabial groove, and right Marionette line. The unused fat was cryopreserved at −80°C under the sterile package. The depressed deformities improved and she received further two touch up procedures in 6-month intervals. A volume of 12 ml cryopreserved fat was implanted into her right cheek, nasolabial groove, and right Marionette line, respectively. Two years after cryopreserved fat grafting, the grafted volume maintained well, as shown in [Figure 3].
| Discussion|| |
Cryopreservation of autologous fat for fat transplantation has been proposed to avoid repeated harvesting procedures. Although anecdotal clinical experiences have been reported to suggest its clinical efficacy, there exists little published clinical series analysis to evaluate the safety, efficacy, and longevity of autologous cryopreserved fat graft. Uncertainties still exist and some suggested that frozen fat can only serve as filler and provided no advantage over inert fillers., In our previous study, we preserved the adipose tissue at −80°C without cryoprotective agents (CPA) for 8 months and then transplanted it into nude mice. Five months later, the transplanted adipose tissue was harvested and processed with H and E stain and DAPI (4',6'-diamino-2-phenylindole dihydrochloride, Millipore, Billerica, MA) fluorescent stain. There was viable adipose tissue demonstrated by the H and E and DAPI stains. In addition, no significant differences were found between graft weight, volume, or histological parameters in fresh and frozen fat groups. This finding provided evidence to support us that cryopreserved fat graft is a clinically practical and effective method for soft-tissue augmentation.
In the clinical studies, Butterwick et al. conducted a pilot side-by-side study to evaluate the effect of frozen fat grafting. Autologous fresh and frozen fats were injected in the dorsum of hands in ten patients, and they concluded that the longevity and esthetic appearance of the autologous frozen fat grafts were at least equivalent to the fresh ones. Although the frozen time was only 10 days, this study provided information that frozen fat augmentation might be effective. According to the study-specific questionnaire in this series, satisfying results were obtained in cryopreserved fat graft for facial recontouring. Fat frozen time was variable from 3 to 12 months and the postoperative follow-up was 1 year at least. The study results suggested the accountability of the safety, efficacy, and longevity of autologous cryopreserved fat graft.
Autologous fat graft was used clinically for many years. For the cryopreserved fat, only very few viable adipocytes and stromal cells can be recovered from frozen status., However, it may serve as a matrix instead of just simply a filler. Theoretically, cryopreserved fat in autologous transplantation might be served as biological filler, adipocytes and stem cell container, or a scaffold inducing incipient cells migration. This concept had been proposed yet not proved. Further basic investigations are recommended for more detailed evaluation.
We believed that the size of the grafted fat is very critical and lipostructure technique is important for success. Neovascularization from the surrounding viable tissue was believed to be one of the key elements for fat survival.,, Neuber found that resorption rate was proportional to the size of graft particle. Niechajev and Sevćuk suggested that the largest fat particle should be <2 mm in diameter. Otherwise, central necrosis is inevitable due to the lack of revascularization. In our series, fat was infiltrated in different planes, and the estimated volume of each droplet was around 0.02 ml [Figure 4].
|Figure 4: The size of fat droplets used in lipostructure technique. Fat was infiltrated in different planes and the estimated volume of each droplet was around 0.02 ml|
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The beneficial effect of added CPA is known for many tissues; however, its effect for adipocytes remains controversial. Some studies suggested that use of CPA, controlled rate freezing, and storage in liquid nitrogen could maintain cell viability.,, With dimethyl sulfoxide as the CPA, a case of gluteal augmentation with cryopreserved fat was presented with satisfying result. Moscatiello et al. suggested several critical factors for the result, including adequate cannula and pressure, slow freezing with the aid of CPA, a rapid thawing procedure, and a good injection plane. The belief of adding CPA may improve cell survival promotes the search for an optimal CPA. Trehalose was shown to have the similar cryoprotective effect to dimethyl sulfoxide and was suggested to be one of the candidates as a CPA in the future., In our previous studies, adding hydroxyethyl starch to adipose tissue does not produce a better result in preservation. Applying this finding clinically, we can see the satisfying results in this series which implicates that simple storage of fat graft is applicable.
In summary, autologous cryopreserved fat graft is a simple, and convenient technique to restore facial soft tissue defects. Although only anecdotal clinical experiences were reported previously to suggest its clinical efficacy, here we presented a clinical series analysis of autologous cryopreserved fat graft. Further, larger cases series is welcome to reconfirm the result of autotransplantation with cryopreserved lipoaspirates. The needed facilities are not expensive, and cryoprotectant is not necessary. Multiple harvesting procedures induced morbidities can be minimized, the cost can be reduced, and patient satisfaction rates are improved.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]