April 2020 HSC Section 4 - Plastic and Reconstructive Problems

The Journal of Craniofacial Surgery

Volume 30, Number 3, May 2019

Future of Facial Fat Grafting

clinical evidence before it becomes a standard reconstructive option.

Platelet-Rich Plasma Enrichment Platelet-rich plasma (PRP), released from the a -granules of platelets, contains numerous growth factors including platelet- derived growth factor (PDGF), transforming growth factor beta (TGF- b ) and vascular endothelial cell growth factor (VEGF). 67 Liao et al reviewed the field of PRP enrichment in fat grafting, identifying 5 animal studies published to date which together suggested an improvement in graft volume maintenance. 68 The authors hypothesize that this improvement is due to PRPs nutrient effect through the plasma component; enhancing adipogenesis through a range of growth factors including PDGF, platelet-derived angiogenesis factor (PDAF), and VEGF; stimulating the prolifera- tion and differentiation of preadipocytes and ASCs. 68 Liao and colleagues’ own study employed human-derived ASCs and expanded the cells in one of four culture mediums: ASCs cultured in general culture medium alone; ASCs in general culture medium þ 5%, 10%, 15%, or 20% PRP; ASCs cultured in adipogenic differentiation medium alone; ASCs cultured in adipogenic medium þ 5%, 10%, 15%, or 20% PRP. 69 It was found that PRP significantly increased ASC proliferation while inhibiting adipo- genic differentiation even in adipogenic media which appeared to be mediated through the bone morphogenetic protein receptor and the fibroblast growth factor receptor. 69 One of the earliest studies of PRP-enriched facial fat grafting was undertaken by Cervelli et al who utilized a patient and operator assessment of various aspects of facial volume and contour. It was found that PRP-enriched grafts maintained 70% of contour resto- ration at 18 months compared to 31% for fat grafting alone. 61 Gentile and colleagues reported similar results in their study 60 where 10 patients received PRP-enriched fat (5 males, 5 females, 5 with burn scars, 5 with posttraumatic scars), ten received SVF- enriched adipose tissue (discussed earlier) and 10 patients simple fat grafting. Patients receiving PRP-enriched grafting demonstrated a 69% contour restoration and volume retention at 1 year of follow-up compared to 63% with the SVF-enriched fat and 39% in the control group receiving only fat grafting. 60 Pre- and postoperative of both SVF and PRP-enriched grafting are shown in Figure 5.

with undifferentiated with ASC, while others have shown that only osteo-induced ASC are effective. A clinical report of ASC-seeded matrices describes injection into the calvarial defect scarred by infection in a 7-year-old girl and another report describes treatment in the hemimaxilla of a 65-year-old male. 65,66 This area of ASC utilization in the head and neck will require considerably more FIGURE 3. Image (A) shows patients with Parry Romberg syndrome prior to adipose grafting, image (B) shows patient 2 years postgrafting. The top patient received grafting alone, the bottom patient received grafting enriched with SVF. 37 Adapted from ‘‘Mechanical Supplementation With the Stromal Vascular Fraction Yields Improved Volume Retention in Facial Lipotransfer: A 1-Year Comparative Study’’ by N.F. Gontijo-de-Amorim et al, 2017, Aesthetic Surgery Journal , 37, p. 979-980. Copyright 2017 by the American Society for Aesthetic Plastic Surgery.

FIGURE 4. Figure shows front-on views of patient with Parry-Romberg syndrome undergoing microfat injection enriched with autologous adipose- derived stem cells expanded in culture. Images were taken preoperatively (A), 6 months postoperatively (B), and 12 months postoperatively (C). 55 Adapted from ‘‘Clinical application of human adipose tissue-derived mesenchymal stem cells in progressive hemifacial atrophy (Parry-Romberg disease) with microfat grafting techniques using 3-dimensional computed tomography and 3- dimensional camera’’ by KS Koh et al, 2012, Annals of Plastic Surgery, 69(3), 335. Copyright 2012 by Lippincott Williams and Wilkins.

FIGURE 5. Preoperative images (A-B) of patient with posttraumatic scarring and same patient 9 months after stromal vascular fraction-enriched facial fat grafting (C-D). Preoperative images (E-F), and same patient 9 months after platelet-rich plasma-enriched facial fat grafting (G-H). 60 Adapted from ‘‘Adipose-derived stromal vascular fraction cells and platelet-rich plasma: basic and clinical evaluation for cell-based therapies in patients with scars on the face’’ by P. Genitle et al, 2014, Journal of Craniofacial Surgery , 25, p. 269. Copyright 2014 by Mutaz B. Habal MD (Permission to reproduce given by the EIC, Dr Habal).

# 2019 Mutaz B. Habal, MD

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