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30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.28 Pre and post 12months
413
Fig. 30.29 Pre and post face lipolling
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D. De Fazio
Fig. 30.30 Pre and post 2years
Fig. 30.31 Pre and post
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.32 Pre and post
415
Fig. 30.33 Pre and post at 6months
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D. De Fazio
Fig. 30.34 Correction of the depressed area
Fig. 30.35 Correction of the skin retraction
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Fig. 30.36 Pre and post 2year
417
Fig. 30.37 Pre and post 2year
30.4 Complications
Postoperative hematoma and infections are usually not a
recurrent neither relevant complications. Even asymmetries
are not typical of lipolling technique; in most cases, they
are already present in the preoperative, and it must be claried very well with the patient if and how they can be
corrected.
On the other hand, edema and ecchymosis are always
present in the rst 2–3weeks postoperative. Furthermore, at
the level of the eyelids, the edema can also persist even lon-
ger; in this case, it is often prescribed a lymphatic drainage to
accelerate the healing process.
Very rare are nerve injuries because of the use of blunt
cannulas that will protect from many of these complications
and even if paralysis may sometimes occur, it will resolve
within 60days.
It is always necessary to avoid the presence of palpable
and evident spaghetti-like appearance of injected adipose
tissue, especially in the eyelids and lips areas. However, this
is nowadays avoided with the use of much smaller and blunt
cannulas.
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D. De Fazio
Rare cases of fat embolisms are described, therefore it is
always recommended to inoculate the adipose tissue with a
retraction movement of the cannula, especially at risk areas.
Pearls and Pitfalls
The advantages of this technique are numerous:
• There is no possibility of developing allergies neither
rejection.
• Results are extremely natural.
• The transferred fat is permanent.
• The intervention invasiveness is reduced thanks to the use
of Coleman micro-cannulas.
• Surgery can be performed under local anesthesia in day
hospital.
• This technique can be repeated several times without con-
traindications, if the result achieved in the rst session is
not sufcient.
• Immediately after treatment patients are able to perform
their usual activities.
• In case of eyelid lipolling, it is recommended to use an
extremely ne method to extract the fat tissue.
Disadvantages are:
• Possible swelling and redness in the treated area.
• The need sometimes to reoperate two or three times in
order to obtain and stabilize the desired result. Indeed,
we can appreciate an unavoidable resorption of about
20–30% of the adipose tissue grafted in the first
3months. However, it is extremely recommended not
to hypercorrect the area, especially the in face region.
Indeed, it is always better and easier to add some vol-
ume rather than remove the excess of adipose
tissue.
Further Reading
Avelar RL, Goelzer JG, Azambuja FG, De Oliveira RB, Pase PF.Use
of autologous fat graft for correction of facial asymmetry stemming
from Parry-Romberg syndrome. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2010;109(2):e20–5.
CAPITOLO 72—LIPOFILLING DEL VOLTO 13.
Carraway JH, Mellow CG.Syringe aspiration and fat concentration:
a simple technique for autologous fat injection. Ann Plast Surg.
1990;24(3):293–6.
Coleman SR.Long-term survival of fat transplants: controlled demon-
strations. Aesthetic Plast Surg. 1995;19(5):421–5.
Coleman SR.Facial recontouring with lipostructure. Clin Plast Surg.
1997;24:347–67.
Coleman SR. Structural fat grafts: the ideal ller? Clin Plast Surg.
2001;28(1):111–9.
Coleman SR. Structural fat grafting. St Louis: Quality Medical
Publishing; 2004.
Coleman SR.Structural fat grafting: more than a permanent ller. Plast
Reconstr Surg. 2006;118(3 Suppl):108S–20S.
De Fazio D, et al. Autologous fat transfer for the treatment of HIV-
related face lipoatrophy: a long follow-up experience [Abstract 87].
6th international workshop on adverse drug reactions and lipodystrophy in HIV, Washington, DC, 2004a.
De Fazio D, etal. Long-term follow-up of graft hypertrophy after autolo-
gous fat transfer for HIV-related face lipoatrophy (hamster syndrome
1 year later) [Abstract 90). 6th international workshop on adverse
drug reactions and lipodystrophy in HIV, Washington, DC, 2004b.
De Fazio D, et al. Long-term follow-up of graft hypertrophy after
autologous fat transfer for HIV-related face lipoatrophy (hamster
syndrome 1 year later) [Abstract 90). 6th international workshop
on adverse drug reactions and lipodystrophy in HIV, Washington,
DC, 2004c.
De Fazio D, et al. Chapter 55. Autologous fat transfer. In: Shiffman
MA, editor. Facial fat hypertrophy in patients who receive autologous fat tissue transfer. Springer; 2010.
Eder H. Importance of fat conservation in lower blepharoplasty.
Aesthetic Plast Surg. 1997;21(3):168–74.
Fitzgerald R, Graivier MH, Kane M, Lorenc ZP, Vleggaar D,
Werschler WP, Kenkel JM.Facial aesthetic analysis. Aesthet Surg
J. 2010;30(Suppl):25S–7S.
Foyatier JL, Mojallal A, Voulliaume D, Comparin JP.Clinical evalua-
tion of structural fat tissue graft (Lipostructure) in volumetric facial
restoration with face-lift. About 100 cases. Ann Chir Plast Esthet.
2004;49(5):437–55.
Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg.
1993;20(2):393–400.
Moore JH, Kolaczynski JW, Morales LM, etal. Viability of fat obtained
by syringe suction lipectomy: effects of local anesthesia with lidocaine. Aesthetic Plast Surg. 1995;19(4):335–9.
Moseley TA, Zhu M, Hedrick MH. Adipose-derived stem and pro-
genitor cells as llers in plastic and reconstructive surgery. Plast
Reconstr Surg. 2006;118(3 suppl):121S–8S.
Piasecki JH, Gutowski KA, Lahvis GP, et al. An experimental model
for improving fat graft viability and purity. Plast Reconstr Surg.
2007;119(5):1571–83.
Rohrich RJ, Joel E.Chapter 29 - the subcutaneous fat compar tments
and their role in facial rejuvenation - Pessa. In: Coleman SR,
Mazzola RF, editors. Fat injection from lling to regeneration. St
Louis: Quality Medical Publishing; 2009.
Rohrich RJ, Sorokin ES, Brown SA.In search of improved fat transfer
viability: a qualitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;113(1):391–5.
Schaverien MV, Pessa JE, Rohrich RJ.Vascularized membranes deter-
mine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2009;123(2):695–700.
Shiffman MA, Mirrafati S.Fat transfer techniques: the effect of harvest
and transfer methods on adipocyte viability and review of the literature. Dermatol Surg. 2001;27(9):819–26.
Sperber SM, Dawid IB.Barx1 is necessary for ectomesenchyme prolif-
eration and osteochondroprogenitor condensation in the zebra- sh
pharyngeal arches. Dev Biol. 2008;321(1):101–10.
Sterodimas A, Huanquipaco JC, De Souza FS, Bornia FA,
Pitanguy I. Autologous fat transplantation for the treatment
of Parry-Romberg syndrome. Plast Reconstr Aesthet Surg.
2009;62(11):e424–6.
30 Lower Eyelid Blepharoplasty andMidface: Liposculpture andBiorevitalization
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Szabo-Rogers HL, Geetha-Loganathan P, Nimmagadda S, Fu KK,
Richman JM.FGF signals from the nasal pit are necessary for nor-
mal facial morphogenesis. Dev Biol. 2008;318(2):289–302.
Ten Cate AR. Oral histology. Development and structure. St Louis:
Mosby; 1998.
Von Heimburg D, Hemmrich K, Haydarlioglu S, etal. Comparison of
viable cell yield from excised versus aspirated adipose tissue. Cells
Tissues Organs. 2004;178(2):87–92.
Yoshimura K, Matsumoto D, Gonda K.A clinical trial of soft tissue
augmentation by lipoinjection with adipose-derived stromal cells.
Presented at the international fat applied technology society (IFTAS) third annual meeting, Charlottesville, VA, 2005.
Zoumalan RA, Larrabee WF Jr. Anatomic considerations in the aging
face. Facial Plast Surg. 2011;27(1):16–22.
Fat Grafting toTreat Genital Lichen
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Sclerosus
MassimilianoBrambilla
Contents
31.1 Introduction 421
31.2 Fat Graft and Lichen Sclerosus 422
31.3 Before Surgery and Preoperative Procedures 423
31.4 General Considerations on Fat Graft for Lichen Sclerosus 423
31.5 Vulvar Inltration 423
31.6 Volume of Fat Graft 423
31.7 Injection Technique 424
31.8 Number of Procedures and Final Results 426
31.9 Summary of Instruments and Equipment 430
31.10 Complications 430
31.11 Conclusions 430
References 430
31
Key Messages
• Fat graft may improve tissue quality in LS.
• Microfatgraft percutaneous release reduces scar
retraction.
• Multilayer fat graft (micro- and nanofatgraft with or with-
out PRP) is fundamental for the treatment of different
levels.
• Quality and quantity of fat graft is key for a successful
treatment.
M. Brambilla (*)
Plastic Surgery Unit, Department for the Health of Women,
Children and Newborn, IRCCS Policlinico Mangiagalli Hospital
Foundation, Milan, Italy
University of Milan, Milan, Italy
e-mail: dr@massimilianobrambilla.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_31
31.1 Introduction
Lichen sclerosus (LS) is a scripting inammatory dermatosis
affecting anogenital region caused by autoimmune response
whose mechanism is still uncertain. Family history may be
seen. The association between LS and autoimmune disease
is common in women (thyroid, bowel, skin diseases, rheumatoid arthritis) and less in men [1–4].
There is evidence that LS is an immunogenic disease,
given increased expression in genes responsible for immune
response [5], with increased proinammatory cytokines (IL1, IL-7, IL-15, IFN-γ, and TNF-α) and decreased antiinammatory cytokines (TNF-β), suggesting a mediation by
a T-helper type 1 (Th1) course of action [6].
Autoimmune and genetic tissue targets are as follows:
– ECM1 is increased; as an autoantigen for humoral auto-
immunity serving as a “biological glue” especially at the
dermal–epithelial junction; it disrupts the scaffold struc-
ture, interfering with collagenase activity [7–10].
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– TNF-a and IL-6 are increased, determining upstreaming
Treg cell function [7].
– miR-155 promotes broblast proliferation and reduces
Treg cells activity [5, 11–13].
– Elastic bers are decreased.
– Endothelial ECM1 is decreased and induces hyalinized
dermal vessels.
– P53 is increased and induces ischemic stress and increased
the risk of malignancy.
Histologically, the lesions are characterized by lymphatic
inltrate in a sclerotic dermis with thickened hyalinized collagen and homogenized collagen brils, hyperkeratosis and
orthokeratosis may be seen frequently. In early stages, a conned supercial involvement may be found (Fig. 31.1),
while in later stages a full-thickness one is seen with sclerosis from the dermis [14–16] (Fig.31.2).
The diagnosis is based upon clinical evidence, and there
is a lack of unanimity regarding the reliability of histologi-
cal biopsy, especially in the early stages [17]. The loss of
structural anatomical architecture determines developing
lesions leading to itching, bruising, burning sensation, stenosis, and sexual dysfunction. The sclerosis process determines progressive vulvar stenosis. With progressive
narrowing of the vaginal introitus, fusion, and resorption
of the labia minora and clitoral phimosis. The inammatory process may be the cause of malignant transformation
so that periodical vulvoscopy is crucial to exclude degeneration into vulvar cancer [18].
Lichen sclerosus may determine severe impact on psychosexuology [19]. There is actually no consensus regarding
a classication of lichen sclerosus, thus recent publications
attempt to dene grading according to anatomical modications [20–23]. Current local treatments of LS are topical steroids, emollients, topical calcineurin inhibitors, topical
androgens, progesterone, and estrogens [24]. Recently,
lasers, TCA, LED, and carboxitherapy have been suggested
as possible therapies [25–27]. In case of vaginal dryness,
vaginal treatments are advisable with local hormones, bioidentical hormones, or lasers.
31.2 Fat Graft andLichen Sclerosus
Fig. 31.2 Lichen sclerosus: full thickness involvement
Fig. 31.1 Lichen sclerosus: supercial involvement
The benets of fat grafts are both regenerative [28–32] and
mechanical.
The specic use of fat graft for the treatment of LS has
been reported in the literature [33, 34].
As well as a preliminary report to the use of nanofatgraft
as a unique procedure [35].
The combination of fat graft and prp has been reported
as well with an emphasis on the anti-inammatory role of
PRP [36].
The combination of microfatgraft and nanofatgraft has
been an attempt for the treatment of GSM [37].
Tissue regeneration takes place when the fat graft induces
neovascularity and broblast production of “soft” collagen
type 1 and 2 [38]. Reducing brosis [39] interferes positively
with local autoimmune response [40]. Moreover, fat graft
reduces inammatory response [41] and pain through pain
ber modulation [42].
Mechanical expansion through tissue expansion is
achieved with the interruption of the scar and the interposition of fat clusters. This procedure is performed through
percutaneous scar release (“rigottomy”) [43, 44] or during a surgical amplification of the stenosis (open wound
scar release) and before flap or skin graft reconstruction.
Regenerative treatments do not exclude all the other
“standard” treatments such as the use of topical corticosteroids in case of severe inflammations, topical and general hormones administration, and modified dietary
supply.
31 Fat Grafting toTreat Genital Lichen Sclerosus
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423
31.3 Before Surgery andPreoperative
Procedures
Accurate general and genital anamnesis, vulvoscopy, images
recording, and subjective reports have to be given.
Appropriate general and local hormones are given if possible
as well as diet modications.
If presence of an inammation is found, appropriate local
treatment is applied according to inammatory cause (corticosteroid, antimycotic, and antibacterial treatment).
Preoperative exams are suitable for sedation or spinal, or
general anesthesia is given.
31.3.1 Procedure
Procedures are carried out under local anesthesia plus sedation or under spinal or general anesthesia on a one-day surgery basis according to the skill and experience of the
surgeon and anesthetist.
An antibiotic prophylaxis is given 1h preoperatively. The
patient is set in a lithotomy Trendelenburg position. There is
no need of catheter, but if a surgical anterior vulvar amplication is planned, a catheter is set in place; otherwise, an
extemporary catheterization will be performed at the end of
the procedure.
31.4 General Considerations onFat Graft
forLichen Sclerosus
Fat graft varies according to lichen grade, local inammatory
condition, and subjective report.
Quality, quantity, tissue level of grafting, grafting modality, and eventually combination with prp are crucial to
achieve best results.
31.4.1 Fat Cluster Dimension andFat Quality
In the treatment of delicate tissues such as the ones in LS,
cluster dimension plays an important role [45, 46].
Due to the fragility of the tissues it is advisable to use
microfatgraft for subdermal to fascial fat graft, while nanofatgraft and/or prp has to be used for intradermal injection
[47, 48].
Centrifuged and more concentrated microfatgraft is used
in early stages while decanted and diluted microfatgraft is
indicated in later stages with sclerotic tissues due to better
tissue expansion and cell spreading into tissues.
Nanofatgraft that is a more regenerative than antiinammatory treatment may be injected into the dermis if
low inammation is found while PRP, which has more antiinammatory than regenerative, is advisable in inammatory
conditions.
31.4.2 Fat Harvesting
Fat harvesting may be performed where more is convenient,
according to the patient’s wishes.
Inltration is performed, and an average of 100cc of fat is
collected via a 14-gauge multihole cannula and 10 mL
syringes with low negative pressure [49].
The fat is transferred into 60 mL syringes and washed
with saline solution (30% of saline and 70% of harvested fat)
in order to decrease lidocaine potential negative effect on
cells viability [50], and then decanted for 5/10min. Then fat
is transferred into 5mL syringes.
If a more dense preparation is needed, the fat is centrifuged for 3min at 3000rpm.
Inltration of the vulvar area of 10–20cc of saline+0.5mL
of lidocaine+adrenaline 1:500,000 is carried out with a 5cc
syringe.
31.5 Vulvar Inltration
Inltration of the vulvar area of 10–20cc of saline+0.5mL
of lidocaine+adrenaline 1:500,000 is carried out with a 5cc
syringe.
After 5–10min, the procedure can be performed having
achieved vascular constriction.
31.5.1 Injection Site andLevel ofInjection
Multilayer injection is advisable. Microfatgraft is done from
the dermis to the fascia and nanofatgraft or prp is injected
into the dermis.
Vaginal microfatgraft and nanofatgraft may be combined
in case of vaginal atrophy.
It is advisable to treat the entire vulvar area even if the
extension of lichen sclerosus seems to be limited to a specic
area. This is to promote better vulvar vascularization.
31.6 Volume ofFat Graft
Injected volume varies according to brosis and distention
tissue capability.
1–2cc of microfatgraft + 0.5cc of microfatgraft or
0.5 prp is the average quantity for the treatment of
10cm2.
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