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G. A. Mecott and S. G. Hernández-Soto
differences in pure fat [56]. Similarly, the evidence discussed in this section has
failed to undoubtedly show if removing blood or oil from the lipoaspirate has a
benecial effect in regard to viability of the fatty graft.
10.10 Filtration andConcentration
Filtration and concentration are two commonly used techniques of processing, also
designed to remove unwanted materials from the lipoaspirate. They typically consist of lavage and passage of the fat trough a lter, similar to dialysis, or absorbing
the uids with some absorbable material. There are some studies about the efcacy
of some systems designed to wash and lter the fat, which will be discussed below.
Puregraft™ consists of a closed bag with three ports: one for adding and removing the lipoaspirate, the second for injecting Lactated Ringer’s solution (washing),
and the third for removing the unwanted materials. Within the bag there are two
membranes for ltering or dialyzing the uids. Zhu et al. demonstrated that
Puregraft™ removed more liquid than decantation, although less than centrifugation.
They also proved that this system is superior to decantation and centrifugation in
removing red and white blood cells compared to centrifugation and decantation [70].
Revolve™ consists of a device with an outer canister and an inner lter basket
with 200-μm pores that allows fat to be separated from the tumescent uid. It also
requires to wash the lipoaspirate with Lactated Ringer’s solution, and have ports for
the fat extraction. Ansorge et al. compared Revolve™ with centrifugation and
decantation. They found that this system led to more adipose content than centrifugation and decantation, but centrifugation could remove more liquid. Graft take was
similar in the Revolve™ system and the centrifugated samples. Decantation produced signicantly less graft retention [71].
Hanson et al. compared both devices: Puregraft™ (passive ltration) and
Revolve™ (Active ltration) and found similar amount of “graftable” fat with both
devices. However, the active ltration system could process almost four times more
fat per minute that the passive system [72]. They did not realize viability tests.
Tissu-Trans Filtron canister is a ltration system with lter pore sizes of 500 and
800μm. Fisher etal. assessed its utility to separate the components of the lipoaspirate and concluded that it produced virtually pure fat with either ultrasound-assisted
liposuction and suction-assisted liposuction [73]. It is important to note that they
collected the fat from a single patient.
With regard to concentration, Ramon etal. used an operating-room cotton towel to
separate uid, oil, and debris from the lipoaspirate and compared it with centrifuged
samples. They found no signicant differences regarding volume and weight of the
grafted samples. Histologically, they found signicantly less brosis in ltered fat [62].
Salinas etal. found that ltration with mesh and Gauze produced a concentration
of fat similar to centrifugation at 1200g. In regard to the number of stem cells, concentration was similar to centrifugation [56]. Conversely, Pfaff stated that rolling
the aspirate in Telfa Gauze pads led to increased viability and a higher number of
ASCs that centrifugation at 1500rpm for 3min [74].
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10.11 Cell-Assisted Lipotransfer
Adipocytes constitute 70–90% of the volume of the adipose tissue in adults, and
account for approximately 25% of the total cell population of the human body [75].
Nonadipocyte cell types in adipose tissue include preadipocytes, broblasts, endothelial cells, immune cells, and, more importantly, adipocyte-derived stem cells [76].
It was proposed that the supplementation of the fat grafting with ASCs, also
called cell-assisted lipotransfer (CAL), might improve the retention rate of the fat
grafting [77]. The proposed mechanisms for this improvement include increased
neovascularization of the grafts [78] and resistance for necrosis [78, 79]. The rationale for the use of CAL is that the lipoaspirate has low numbers of ASCs. So, by
supplementing the lipoaspirate with ASCs, the probability for retaining the volume
of the graft would be increased.
There are four possible roles for ASCs in enhancing the fatty graft
• The ASCs could differentiate into adipocytes and contribute to the regeneration
of the adipose tissue [32].
• ASCs could differentiate into vascular endothelial cells [80].
• Release of angiogenic factors, possibly improving vascularity of the recipient
site [81].
• Surviving as ASCs cells [77].
Adipose tissue has been identied as an abundant source of mesenchymal stem
cells (MSCs), with characteristics similar to those obtained from bone marrow,
which can easily be isolated and multiplied invitro [82]. These cells appear to be
more resistant and have a major and more prolonged effect on the grafted fat and its
surrounding tissues than adipocytes [31, 82–84].
Some patient-related variables might inuence negatively the utility of the
CAL.It has been shown that the vitality of the ASCs decreases with the age of the
patient [85] and in the presence of some metabolic diseases, such as diabetes [86].
Experimental data (in rodent models) suggests that supplementation of the fat
grafting with allogeneic ASCs improves its long-term volume retention [87]. This
nding might open new therapeutic options for those cases where the condition of
the patients is not ideal for using their own ASCs, such as older or diabetic patients.
However, the literature about CAL is still sparse, although promising. More
research and clinical trials about it is required before its use would be considered as
a standard in fat grafting.
10.12 Ultrasound-Assisted Liposuction
Since its rst description in 1987 by Scuderi et al. [88] Ultrasound-Assisted
Liposuction (UAL) has gained popularity in body contouring. It has been stated that
this technology is fat-selective and reduces trauma and blood loss [89]. However,
since this modality uses energy and was designed to destroy adipocytes [90], there
160
is concern about the viability of the adipocytes obtained with this technology for
grafting purposes.
Grippaudo etal. studied samples of conventional liposuction versus UAL.They
found that UAL produced signicantly more triglycerides (considered as a measurement of rupture of the adipocytes membranes), while free fatty acids were similar in both samples [91]. Similar results have also been observed in a porcine model
[89]. These results were interpreted as increased lysis of adipocytes with UAL but
no actual viability studies were performed to the cells. We believe that the purpose
of the authors was to prove that UAL was effective in destroying adipocytes, and
then the studies were not designed to assess residual viability of the cells.
Conversely, Schafer etal. designed their study to demonstrate that UAL could
provide viable cells, suitable for grafting. They found that adipocytes obtained with
UAL (60% amplitude, pulsed mode 1min/100 mL of inltration) had a viability
rate of 85% (± 11%). No comparison was made with SAL to assess any difference
between these two modalities, but the study clearly demonstrated that the fat
obtained with UAL is suitable for grafting [92].
Duscher etal. demonstrated that ASCs are not damaged by UAL [93]. They also
found similar amounts of viable ASCs with UAL and suction-assisted liposuction
(SAL) [94].
With the available evidence, we can conclude that even if the UAL was designed
to selectively destroy the adipocytes, the obtained fat could be used as fat grafting.
However, it is also clear that some adipocytes are indeed destroyed with the cavitation process. Thus, more studies are necessary to assess if the lipoaspirate after UAL
should be further processed (to remove destroyed cells) before it is used as a fat graft.
G. A. Mecott and S. G. Hernández-Soto
10.13 Additives
The addition of some substances such as insulin [95], enriched culture medium
[96], and even Botulinum Toxin A [97–99] has been described as strategies to
improve cell viability of the lipoaspirate. However, the results are still experimental
and we don’t recommend its use as of today.
10.14 Recipient Site andGrafting Technique
There is almost no literature about the role of the recipient site in fat grafting. That
is probably because we infer that, as long as there is enough blood supply for the
grafted cells, the recipient site is not important. Karacaoglu etal. stated that supramuscular placement of the fat grafting results in better survival compared to submuscular or subcutaneous placement [100].
Also, there is very scarce data about the effect of the injection technique in the
viability or retention of the fat graft. Lee etal. studied the effect of shear forces and
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positive pressure on the adipocytes. They found that applying positive pressure (up
to 6atm. for 3min) in a static pressurized chamber had no effect of the outcome of
the fat graft [53]. However, they found that shear forces signicantly affected the
architecture and weight of the fat. They injected the fat at two different speeds:
0.5–1mL/seg and 2–5mL/seg and found better retention (volume) and less brosis
and vacuoles at slow injection speeds. They concluded that adipocytes are not
affected by positive pressures up to 25atm., but shear forces of 25atm. have tremendous impact in fat survival.
Other studies, apparently related to the effect of injection techniques on fat viability, mainly focus on techniques or devices that allow controlled volume injections
and thus a possible reproducible effect [54, 101].
10.15 Conclusion
The science of fat grafting is fascinating. Great scientic advances have been made
in just a few decades, but there is still a long road ahead. Plastic surgery is not just
science, but also art. No wonder every surgeon is still innovating and adding their
personal preference to the fat processing. However, evidence-based medicine should
be the guide for every surgeon that performs fat grafting. A standardized protocol,
based on science, should be the nal goal.
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G. A. Mecott and S. G. Hernández-Soto
Part IV
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Surgical Technique in Fat Transfer
Соседние файлы в папке Библиотека им академика М.И. Перельмана