April 2020 HSC Section 4 - Plastic and Reconstructive Problems

The Journal of Craniofacial Surgery

Volume 30, Number 3, May 2019

Brooker et al

Sasaki published one of the largest human studies to date with 106 patients undergoing PRP-enriched facial fat grafting in addition to face lift for cosmetic purposes. 57 Ninety two patients received un- enriched fat grafting while 9 patients received SVF-enriched adi- pose and 29 received SVF and PRP-enriched adipose. Volumetric analysis was performed using 3-dimensional photography and both PRP and SVF enriched grafts had significantly greater volume retention at 12 months compared to fat grafting alone though the combination of SVF and PRP did not yield any further improve- ment. 57 Luck et al published one of the most comprehensive systematic reviews of PRP-enriched fat grafting. 70 While not specific to the face, multiple facial grafting studies are included in the overall analysis which found that in all but 3 studies the addition of PRP augmented volume retention. Luck et al did however point out the huge methodology variation in the studies published as well as the highly variable ratio of PRP to fat studied meaning that further clinical trials will be needed before this technique becomes a fixture of clinical practice. This echoes the conclusions of Serra-Mestre et al in their 2014 review of the subject which included 3 facial grafting studies and which found significant potential for the use of PRP enrichment and a possible dose-dependent efficacy. 71 Facial rejuvenation using PRP has been extensively reviewed by Motosk et al in their review on the subject. 72 They identified 437 patients across 7 studies who underwent singular or multiple PRP- enriched lipofilling injections primarily in the nasolabial folds and malar regions all but one of which reported improved outcomes with the addition of PRP. 72 The proangiogenic influence of PRP is the proposed mechanism for these improved outcomes. 72 Finally, Picard et al in their review identified 11 human clinical studies and 7 animal studies using PRP-enriched grafting facial rejuvenation and reconstruction with 9 reporting a significant improvement in survival of adipocytes and propose vascularization as the mechanism for this. 73 Based on their findings, it was recommended 20% of calcium activated PRP to enhance aesthetic and reconstructive facial fat grafts. 73 CONCLUSION Although great strides have been made in the field of facial fat grafting in the past three decades, challenges which have dogged the field for nearly a century remain including unreliable and irregular resorption over time. A multitude of techniques have been attempted to augment the graft and improve its survival, including cultured ASC, SVF, and PRP all of which have been described in this review. While these treatment modalities are advocated by many clinicians, they have several things in common; a much greater animal-based body of evidence than clinical, significant inconsistencies in study design across human-based studies which often preclude comparisons, small sample sizes in human-based studies which limit power and a complete absence of randomized, controlled trials. The ASCs and modified adipose tissue grafting have the capac- ity to fundamentally alter clinical practice and to introduce a new paradigm in head and neck reconstruction particularly in the realm of osseous healing which continue to represent some of the greatest surgical challenges. However, a much greater body of evidence in human-based trials is still needed in order for strong validation and widespread adoption in clinical practice. This review provides a fairly comprehensive summary of the many exciting possibilities which exist in the field of facial fat grafting.

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# 2019 Mutaz B. Habal, MD

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