S. CAPURRO: MATERIALI E METODI DELL'ADIPOFILLING – www.crpub.org - CAPURRO RESEARCH PUBBLICATION - ISSN 1971-8152- (WWW.CRPUB.ORG) – EDITIONS D’ARSONVAL ON LINE – YEAR 2007 NUMBER 2 – GENOVA ITALY – COPYRIGHT 2007
Adipofilling®: materials and methods
Sergio Capurro
Capurro
Research Group
Capurro Research
Publications
contact@capurroresearch.org
Summary
In Adipofilling®, lobular fat obtained by means of liposuction is transformed
into a “permanent biological filler” composed of adipocytes, stromal cells and
connective material.
The rationale behind the choice of the materials and methods used in
Adipofilling® highlights the differences between this new technique and the
traditional techniques of lipofilling and Lipostructure™.
Keywords: Adipofilling®, adipocytes, connective stroma, stem cells, liposuction,
Lipostructure™.
Introduction
The adipose tissue yielded by liposuction can be transformed by means of a simple and economical mechanical procedure into a cell suspension that can be injected in large or small quantities into the subcutaneous tissue. Our experience, which dates back to January 2004, has shown that the volume reduction – from lobular fat (Fig.1) to adipocytes (Fig. 2) – enables a far higher percentage of the injected material to survive in comparison with the results of our previous lipofilling or Lipostructure™ operations. The poor survival of lobular fat injected into the subcutaneous tissue, together with the complications involved, has prompted most authors to perform only intramuscular and submuscular lipofilling (2).
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However, intramuscular and submuscular injection is inappropriate in facial esthetic procedures or in parts of the body where muscle tissue is insufficient to supply the lobules of adipose tissue with adequate nutrition.
Once the lobules of adipose tissue have been transformed into adipocytes, stromal cells and connective material (Fig. 3), Adipofilling® can be injected into the subcutaneous tissue, which is its natural site. Moreover, it does not give rise to the complications seen in lipofilling, which are described as: irregularity, hardening, calcification and total re-absorption of the grafted adipose tissue.
Fig.3) Adipofilling® smear.
On account of the “cellular” dimensions of the material in suspension,
Adipofilling® behaves like a physiological solution. The initial hardening of
the injected area rapidly gives way to a normal consistency of the tissues that
have been enhanced in volume; this effect is determined by the distribution of
the adipocytes in the interstitial spaces of the subcutaneous tissue. Indeed,
the adipocytes, unlike lobular fat, do not push aside the connective network;
rather, they are integrated into it.
Adipofilling® is used for volume enhancement of the breasts (Fig. 4), to correct
volume deficits of the face and body, and to improve trophism of the skin, not
least in pathological conditions (scars, ulcers, radiodermatitis).
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With regard to the increase in volume, we maintain that this is determined by
the adipose cells, and not by subcutaneous fibrotic phenomena. Indeed, no
fibrotic alteration has ever been revealed by echographic or radiological
examinations performed 1-3 years after additive mastoplasty involving
Adipofilling®, nor have we found any tactile alterations following Adipofilling®
procedures carried out on the subcutaneous facial tissues. |
Fig.
4) Breast enhancement with Adipofilling®. The lobules of adipose tissue taken
from the supragluteal region are transformed into a cell suspension and injected
into the subcutaneous or subglandular tissue of the breasts. Two regions of the
body are improved in a single ambulatory procedure.Materials and methods
Instructions for the patient
The patient must not take aspirin for a week prior to the Adipofilling® procedure, and must refrain from smoking or drinking alcohol for 15 days before the procedure and for a month afterwards. Following Adipofilling®, an abundant, well-balanced diet is recommended.
Anesthesia of donor areas
Adipofilling® is an outpatient procedure.
Once the donor areas have been marked out and disinfected with jodopovidone,
local anesthesia is carried out by means of a modified Klein solution (the
physiological solution is replaced by lactate Ringer solution). If the patient
wishes, a sedative may be administered.
Liposuction
To safeguard the integrity of the aspirated tissue, liposuction is performed through cannulae of 4 or more millimeters in caliber (Fig.5) even if small amounts are to be drawn. Moreover, cannulae with large apertures are preferable (Fig. 6).
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Indeed, for obvious reasons of geometry, for the same amount of aspirated
material, the larger the diameter and the apertures of the cannula are, the
fewer cells will be damaged by rubbing against the cannula wall.
For liposuction, a 60 ml syringe is used (Fig. 7). The fact that the
syringe has two “arrest” positions enables the operator to graduate the force of
aspiration (Fig. 8). If the negative pressure is too high, the vitality of the
adipocytes may be compromised. The amount of adipose tissue aspirated must
be a little more than double the volume estimated for correction.
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Washing the fat lobules
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If a small amount of aspirated material is required, it can be worked inside the syringe itself; if a medium-sized volume is needed for Adipofilling®, a 250 ml glass beaker is used, while for the large volumes needed for additive mastoplasty, a glass jar is used. In this case, washing is carried out manually by means of an agitator (Fig. 9). A cannula is inserted into the glass jar and the lobules of adipose tissue are mixed by means of a slow movement, which does not damage the adipocytes. The lactate Ringer solution used in washing is aspirated and replaced until it becomes transparent. Once the last of the washing liquid has been aspirated, the lobules of adipose tissue are ready for mechanical fragmentation. The purpose of washing is to eliminate blood and to dilute the lidocaine absorbed by the adipose tissue. |
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Mechanical fragmentation
The adipose lobules are fragmented in a graduated 250 ml glass beaker (Fig. 10). The beaker can contain from 20 to 150 ml of lipo-aspirate, to which 30-50 ml of lactate Ringer solution is added in order to facilitate the action of the tip of the whisk used in fragmentation.
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Fig. 13) The adipose lobules are transformed into adipocytes, stromal cells and
connective material (Adipofilling®) by means of 5 movements from the top
downwards.
Mechanical fragmentation is carried out by means of a common small kitchen whisk (Fig.11), the tip of which is made of heat-resistant material and can be sterilized in the autoclave (Fig. 12).
The tip of the whisk can be sterilized 5-10 times before being replaced. Some
models have blades that can be re-sharpened; however, given the low cost of this
equipment, it is preferable to replace the tip, which is easily available
commercially. The tip must be able to fit into the graduated glass beaker, which
has a diameter of about 6.5 cm.
To transform the fat into a cell suspension, the cutting action of the blades is
essential. If the blades are not sharp, the lobules will not be correctly
fragmented and the cells may be damaged.
In some models, the tip is activated and moved slowly downwards inside the
beaker. In this case, five movements are carried out (Fig. 13).
IIn other, faster models, the tip is placed on the bottom of the beaker and the lipo-aspirate is fragmented in about 3 seconds as it passes through the holes in the cup of the tip. The uniformity of the Adipofilling® thus obtained is assessed visually when the 20 ml syringes are filled. If any cellular aggregates are seen, a new whisk tip with sharp blades should be mounted and further fragmentation carried out. The granular dimension produced by the mini-whisk is larger than that of the adipose and stromal cells, which therefore remain almost entirely undamaged. This procedure enables us to obtain, economically and in a few seconds, the large amounts of material needed for the volume enhancement of the breasts or buttocks. The volume of Adipofilling® obtained by means of mechanical fragmentation is about half of the lobular volume yielded by liposuction.
Preparing the syringes for centrifugation
We use 20 ml siliconated syringes. After removal of the plunger, the syringes are capped with the sterilizable plastic caps (Tip guard™, Scanlan International, US) normally used to protect surgical instruments (Fig.14).14 These small caps are sterilized inside a tea ball Fig.15).
 Fig.14) The required number of syringes are prepared for centrifugation. The syringes are capped after removal of the plunger. |
 Fig.15) The small plastic caps are sterilized in the autoclave inside a tea ball. |
The syringes are filled to the brim and fitted into the adapters (Fig.16), which have previously been sterilized in the autoclave, and placed inside the centrifuge (Fig.17).
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Centrifugation
Centrifugation serves to separate the water from the biological material and
to achieve uniform density of the processed biological material. A small
percentage of water remains, and facilitates injection into the tissues.
Centrifugation must be carried out at low velocity; too high a velocity (3000
rpm) may cause the death of the adipocytes, an eventuality that is manifested
visually by the large quantity of oil in the supernatant. Indeed, electron
microscopy studies conducted by M.Galiè (University of Verona) on adipocytes
after centrifugation at 3000 rpm have shown that those which are still intact
are structurally compromised or degenerated or display evident signs of damage.
In Adipofilling®, in order to safeguard the integrity of the adipocytes, the
centrifuge is set to 100-200 atmospheres for 1 or 2 minutes (Fig. 18). The
centrifuge must be accelerated gradually up to the set velocity. If
Adipofilling® is to be used for additive mastoplasty, it is advisable to use a
large capacity centrifuge. For facial rejuvenation, a centrifuge that can hold
four 20 ml syringes is sufficient.
Preparing the syringes
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Following centrifugation, the syringes are removed from the centrifuge. The centrifuged material will be stratified according to its density; the thin layer of stromal material, which contains the progenitor and stem cells, is at the bottom (Fig. 19). Above this, the intact adipocytes are located, while on the surface there is a thin layer of cell fragments and oil released by broken adipocytes; this thin layer is often invisible to the naked eye. Adipocyte breakage may be caused by the liposuction procedure, by fragmentation with a blunt blade, or by an intrinsic weakness of the cell wall, which is often due to the advanced age or metabolic conditions of the patient. If the oil is visible, it can be splashed off the surface with a flick of the wrist. Next, the plastic cap is removed in order to eliminate the lactate Ringer solution previously added for fragmentation. This syringe is then closed with a fingertip, the plunger is inserted up to a few millimeters and the syringe turned upside down. The cellular material slides to the bottom of the syringe. The plunger is then pressed in order to eliminate the air (Fig. 20). |
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For volume enhancement of the breasts, 20 ml syringes are again used. In order to achieve uniform distribution of the stromal component, a connecting tube (Fig. 21) and an empty 20 ml syringe are used.
If the above-mentioned oily surface layer has not been removed, the supernatant can be eliminated before redistribution of the stromal component. In this case, the vital component of the Adipofilling® will be transferred into the empty syringe, leaving behind the thin layer of oil in the first syringe; this layer it is then eliminated.
Injection into the subcutaneous tissue of the breasts is performed by means of an 18 G needle or a 2 mm cannula (Fig.22). If facial volumes are to be enhanced, the adipocytes and the stromal component are transferred to a 1 ml syringe, and a needle of 18 G or less is used for injection.
Preparation of the receiving area
Once the receiving areas have been drawn out and thoroughly disinfected, local anesthesia is applied at the predetermined sites of entry of the needle or micro-cannula. Adipofilling® does not require general anesthesia. The receiving area must not be infiltrated by local anesthetic, as lidocaine has a toxic effect on the adipocytes (3). In any case, the injection of Adipofilling® causes little pain.
Injecting Adipofilling®
Adipofilling® can be injected either superficially or in depth. When
injection is superficial, the needle or cannula must always be kept moving in
order to distribute the biological material and to avoid intravascular injection,
which could have serious consequences. The repeated, traumatic movements typical
of Lipostructure™ are not necessary. In the deep adipose compartments of the
face ( 4 ) aspiration and injection can be performed while keeping the needle
immobile; the adipocytes are distributed in the same way as a physiological
solution.
Volume enhancement of 30% is advisable.
If the patient requires facial rejuvenation treatment without modifying facial
volumes, Adipofilling® is injected beneath the dermis to create a dense network
extending to the entire face.
Conclusion
The importance of the materials and methods used in Adipofilling® procedures is emphasized. Standardization of the operating procedure forms the basis for future applications and studies.
Acknowledgements
We wish to thank Prof. Mirco Galiè of the University of Verona for providing the data regarding the electron microscopy of lobular flat after high-velocity (3000 RPM) centrifugation (3000 RPM).
References
1) Capurro S.: Adipofilling; www.adipofilling.com; Capurro Research Publications ISSN 1971 www.crpub.org; Edition D’Arsonval on Line; year 2007 number 1 Genova Italy
2) Guerrerosantos J., Gonzalez 1)Mendoza A., Masmela Y. Long term survival of free fat grafts in muscle: an experimental study in rats. Aesth. Plast. Surg. 20:403-408, 1996.3) Moore JH, Kolaczynski JW, Morales LM, et al. Viability of fat obtained by syringe suction lipotomy: Effect of local anesthesia with lidocaine. Aesth Plast Surg 19:335-339,1995