02. Hypotrophy correction of the lower third of the face with Adipofilling®
KEYWORDS: liposuction, Adipofilling®, Adipopimer, lipofilling, Lipostructure™, hypotrophy of the face
Adipofilling consists of grafting a cell suspension of adipocytes and stromal cells. Adipofilling can be used to correct hypotrophy of the lower third of the face. Lobular fat obtained by means of liposuction is washed and then fragmented. Liposuction is carried out by means of a 4 mm or 3 mm cannula through a small incision inside the navel. The aspirated fat is washed with lactate Ringer solution until the liquid becomes clear. After washing, which removes the blood and the residues of mepivacaine and epinephrine, the lobules are fragmented until a suspension of single cells or small clumps of cells are obtained. This cell suspension is injected through an 18G needle mounted on a 2.5 ml syringe. The adipose and stromal cells are injected into the subcutaneous tissue in several planes, according to the pre-established plan. Light massage helps to distribute the cells uniformly. Local anaesthesia is only performed at the point of entry of the needle. Anesthesia utilizes mepivacaine, as lidocaine prevents glucose from entering the adipose cell. Injection of the cell suspension is not traumatic. Moreover, unlike lipostructure and lipofilling techniques, it does not require numerous injections. In Adipofilling, adipose and stromal cells are grafted. These cells are easily integrated into the receiving tissues. Whether Adipofilling is used to increase trophism or, as in this case, to enhance facial volume, the integrity of the receiving tissues is respected; indeed, as repeated insertions of the cannula are not needed, there is no untoward fibrosis, which would yield only short-lived volume enhancement. High-velocity centrifugation is always avoided, as it would irreparably damage the adipocytes; indeed, after high-velocity centrifugation, adipocytes appear vacuolated on electron microscopy. Whenever we wish to condense the cell suspension, or to extract the stromal cells, centrifugation does not exceed 500 rpm for 5 or 10 minutes. Volume enhancement in the posterior region of the face is a characteristic effect of Adipofilling rejuvenation. The posterior region of the face is a very important aesthetic element; in the young it is even and curvilinear, while in old people it is uneven and has recesses due to hypotrophy of the subcutaneous tissues. In hypotrophy of the lower third of the face, Adipofilling is also carried out on the angle of the mandible and the chin. Correction of the mandibular angle and arch will restore balance to the face of this patient. We are now moving on to the contralateral region of the face. Dividing the design into segments makes it easier to inject the right amount of the cell suspension in order to maintain symmetry. As we have already said, with Adipofilling, unlike Lipostructure and lipofilling, there is no need to create numerous tunnels. Because the adipose and stromal cells are small, they spontaneously spread into the spaces in the subcutaneous tissue. The suspension behaves like a volumetric revitalizing agent and can even be injected superficially. The operator distributes the suspension as uniformly as possible by executing slow
movements of the syringe. Once the needle has been withdrawn, the cell suspension will sometimes tend to flow out; for this reason, the entry site is pressed slightly for about 20 seconds. After this time, the suspension will no longer re-emerge from the entry site, as the adipose and stromal cells will have found their place in the tissues. Now, the shape of the chin is corrected. Adipose and stromal cells are implanted underneath the scar left by the previous chin implant. The advanced cellular suspension corrects the volume deficit in the temporal fossa, the lachrymal grooves and the lower lip. In the temporal fossa, it is advisable to aspirate before injecting the suspension or to use a disposable 21G needle cannula. For small volumetric corrections, a 1 mL Luer Lock syringe is particularly indicated. Thanks to its particular characteristics, the cell suspension can be injected into the lachrymal sulcus and the lip without any problems. Altogether, about 29 ml is implanted on each side. The total of lobular fat removed by liposuction was about 100 ml. When the lobular fat is transformed into a cell suspension, its overall volume is almost halved, the volume of the cell suspension being about 60% of that of the lipoaspirate. The result after six months demonstrates the extreme effectiveness of Adipofilling. After nine months, in view of the excellent results, the patient requested a second Adipofilling procedure in order to enhance the volume of the inferior third of the face and to implant adipose and stromal cells into a previously untreated area: the forehead. Once the lobular fat has been harvested, washed and transformed into a cell suspension, we begin by correcting the lachrymal sulcus on each side. Now, the suspension is injected into the temporal fossa. Because of their small size, single cells or small clumps of cells take root much more effectively than lobules. In an adipose lobule, the outer cells may well survive while the inner cells become necrotic; in this case, the inner necrotic cells are likely to calcify. Indeed, when lipofilling is injected immediately beneath the skin, hardening of the lobules or visible irregularities are not rare phenomena. Moreover, in terms of survival of the lipoaspirate, the use of a small-caliber cannula should be avoided, as much of the lipoaspirate will be damaged by rubbing against the wall of the cannula. This damage to the adipose cells can easily be quantified by centrifuging the lipoaspirate at 500 rpm for 10 minutes and then measuring the thickness of the supernatant layer of oil. In the posterior region of the face, 2 mL of cell suspension is injected. The needle has been slightly bent in order to facilitate injection. The suspension is now injected. During injection, the needle is kept moving slowly. These injections are well tolerated. Anesthesia has only been carried out at the point of entry of the needle. As can be seen, there is practically no oil in the syringes. Fragmentation causes little damage to the cells, and the adipose tissue of this patient is in very good condition. Fragmentation is very rapid and economical, and causes little damage to the cells – just how little can easily be seen when we centrifuge the cell suspension at 500 rpm for 10 minutes, to separate the stromal cells. After centrifugation, only a very thin layer of supernatant oil will be visible, if at all. Nevertheless, any oil will be eliminated together with the most superficial adipocytes when the adipocytes and stromal cells are once again mixed by means of two syringes and a connecting tube. Indeed, the stromal cells need to be redistributed in the adipocytes in order to ensure effective rooting. On account of its versatility, absence of complications and excellent results, Adipofilling constitutes the gold standard for fat transfer. We finish by enhancing the upper and lower lips and the receding forehead. On account of their vitality, lightness and transparency, adipose cells are particularly suited to the filling of important areas, such as the vermilion border. The patient is gently cleaned and can now return home. Two years later, the patient returns so that we can assess the result. The patient’s satisfaction is immediately clear. Result of the second Adipofilling procedure.
Capurro S. (2015): Hypotrophy correction of the lower third of the face with Adipofilling: Adipofilling. CRPUB Medical Video Journal. Adipofilling section. http://www.crpub.org
Can facial atrophy (PRS) also be treated with Adipofilling?
Yes, and the results are very good.
What other pathologies have been treated with Adipofilling?
We have treated cases of radio-dermatitis, even with exposure of the bone; in elderly patients, we have prepared the scalp for the trouble-free creation of the skin flaps needed for reconstruction following destruction by cancer; we have injected Adipofilling immediately beneath the scars left by extensive burns; we have used it in the rectum, labia majora and vagina, in the lips of patients with scleroderma, in the sequelae of poliomyelitis, in scoliosis, etc.
What are the most common aesthetic applications?
Volumetric enhancement of the lips and of the face in general, including the forehead; in the hands; in the breasts, sometimes after breast coning by means of the elastic thread (Elasticum® Korpo, Genova, Italy); in all forms of subcutaneous and muscular tissue loss; beneath stretch marks, owing to its potent biological action; in the nasal pyramid, where it eliminates the appearance of the “remodeled nose”; on the face and body in general, including the scalp.
Is Adipofilling performed by means of a disposable instrument?
The instrument is extremely economical. Moreover, using a disposable instrument ensures proper preparation of the lipoaspirate, sterility and the absence of cross-contamination.
Does performing Lipostructure still make sense?
To be honest, in my opinion, it has never made sense.
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