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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 2
| Issue : 1 | Page : 30-33 |
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Investigation of postoperative satisfaction of facial autologous fat grafting with platelet-rich plasma
Xiangdong Qi, Jie Zhou
Department of Laser and Plastic Surgery, Guangzhou General Hospital of Guangzhou Milltary Command, Guangzhou 510010, Guangdong Province, China
| Date of Web Publication | 11-May-2016 |
Correspondence Address:
Xiangdong Qi
Department of Laser and Plastic Surgery, Guangzhou General Hospital of Guangzhou Milltary Command, No. 111 Liuhua Road, Guangzhou 510010, Guangdong Province
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2226-8561.182295
Objectives: This single-center prospective, case-controlled study investigated satisfaction and esthetic results as rated by the physician and patient, respectively, by following up thirty patients with aging face, who underwent facial autologous fat grafting with platelet-rich plasma (PRP). Materials and Methods: A retrospective review of thirty patients, who were suffering from facial sagging or partial depression and requiring autologous fat grafting between February 2012 and September 2015. Photograph was taken before and 3-month after the operation. Patient and physician satisfaction was rated using visual analog scale (VAS) ranging from 1 (least satisfied) to 10 (most satisfied) 3 months after the operation. Statistical difference between the patient and physician satisfaction scores was analyzed by SPSS 17.0 software. Results: The patients' average age was 34.5 ± 1.2 years. The average VAS score of physician satisfaction was 7.9 ± 1.0, and the average VAS score of patient satisfaction was 8.0 ± 1.2. There was no statistically significant difference between the two groups in scores (P = 0.859; P > 0.05). Conclusion: There is no evidence that different donor sites or different donor-site preparation will lead to different outcomes. Multilevel injection is recommended for autologous fat injection. The high satisfaction scores indicated a good esthetic result of facial autologous fat grafting with PRP. Autologous fat as one of the popular soft tissue fillers is durable and safe. The biggest challenge is the high variation in absorption rate. PRP may lead to higher survival rate of fat and satisfaction level. The stability of survival rate of autologous fat grafting with PRP and the connection between complications and PRP technique need further study. Keywords: Autologous fat grafting, platelet.rich plasma, satisfaction, soft tissue filler
How to cite this article:
Qi X, Zhou J. Investigation of postoperative satisfaction of facial autologous fat grafting with platelet-rich plasma. Digit Med 2016;2:30-3 |
| Background | |  |
More than 100 years ago, Nueber reported on the results of small adipose grafts transplanted from the arm for reconstruction of a soft tissue defect on the face. Then, in 1911, Brunnin was the first to inject autologous fat into subcutaneous tissue, whose result of grafts showed good absorption. In the late 1950s, reports showed that up to 50% of the free fat graft volume dissipated after transplantation, leading many individuals to question its efficacy. In 1986, Dr. Yves-Gerard Illouz first reported reinjecting viable fat that had been obtained during liposuction surgery, and Dr. Pierre Fournier presented his technique of syringe extraction and reinjection of fat.[1],[2] Today, this technique is widely used for correcting wrinkles, folds, depressions, and scars and can even be used for breast or buttock augmentation. Fat may be the best answer for those patients, who need large quantities of filler for correction, are allergic to collagen, or would like permanent results. However, autologous fat absorption rate, hardening nodules, and fibrocysts plague doctors and patients alike.
| Methods | | |
Objectives
First, to investigate satisfaction and esthetic results as rated by the physician and patient, respectively, by following up thirty patients with aging face, who underwent facial autologous fat grafting with platelet-rich plasma (PRP). Second, to evaluate whether there is a statistically significant difference between the satisfaction ratings by doctors and patients.
Patients and surgery
A retrospective review of thirty patients who were suffering from facial sagging or partial depression and requiring autologous fat grafting between February 2012 and September 2015 was conducted for the study. Thirty patients were randomly selected by random lottery. Every patient was drawn 30 ml blood preoperative for preparation of PRP. Surgery was performed under general anesthesia. Local anesthesia using 0.2% lidocaine 1:1,000,000 epinephrine was applied at the fat harvesting areas that were usually bilateral thigh or abdomen. The harvested fat was injected into forehead, temporal, lacrimal groove, cheek, and nasolabial for improving the appearance of the patients. Nearly 1 mL syringe and 16 gauge needle were used for injection.
Fat preparation
The harvested fat was processed and purified by washing and cleaning, decanting, and centrifugation. Then, the preactivated PRP was mixed at a ratio of 1:20 with the purified fat that was now without blood, local anesthetic liquid, and lipid droplets.
Data acquisition and processing: The patients were verbally informed about the sample to be taken. All patients took standard photography preoperatively and postoperatively at three-time points (7 days, 1 month, and 3 months postoperation, respectively). Patient satisfaction of the surgery was evaluated using a visual analog scale (VAS) ranging from 1 (least satisfied) to 10 (most satisfied) 3 months after surgery.[3] Physician satisfaction of the effect of surgery on patients was rated by two doctors using the same method (VAS), by comparing photos taken before and 3 months after surgery. Data obtained from the two groups were calculated to evaluate the level of satisfaction, and statistical analysis was performed using SPSS 17.0 software (SPSS Inc., Chicago, USA). SPSS 17.0 software was also used to analyze the differences. An alpha value of 0.05 was set to denote statistical significance. The satisfaction score was also compared using independent samples t-tests.
| Results | | |
The study included thirty patients (female: 28, male: 2) who completed follow-up. The scores of their morphological changes of the face were evaluated by standard photos taken before and after surgery in [Table 1]. The patients' average age was 34.5 ± 1.2 years. Nine patients were followed up for 6 months, and the rest patients were followed up for 3 months. Four patients developed bruising and swelling postoperatively that disappeared <7 days later. There was no feedback of serious complications from patients. Autologous fat injection for cosmetic facial augmentation is considered safer than other filler materials. However, retinal artery occlusion after autologous fat injections has been reported. The average VAS score of physician satisfaction was 7.9 ± 1.0, and the average VAS score of patient satisfaction was 8.0 ± 1.2. There was no statistically significant difference between the two groups in scores (P = 0.859; P > 0.05), indicating the results were objective and credible. High satisfaction scores of patient and physician indicated good esthetic correction outcomes of autologous fat grafting with PRP [Figure 1]. Further, investigation of patients with scores <7 showed the main reason of low patient satisfaction was that the improvement of facial depression did not meet the requirements of the patient, and fat absorption led to unsatisfactory filling, too. The dissatisfaction of most patients is focused on that the young and beautiful face with round full cheeks depressed gradually after the surgery, which needs a second surgery. | Table 1: Patient's basic information and satisfaction visual analog scale score of patient and physician
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 | Figure 1: A 29-year-old female patient with cheek and temporal depression preoperative (a) became plump and beautiful three months postoperation (b)
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| Discussion | | |
A variety of fillers could be used for soft tissue augmentation such as hyaluronic acid, collagen, and autologous fat. Fat grafting is considered an ideal material to correct facial deformities and depression as it is autologous material with rich storage and permits long-term clinical follow-up. Moreover, it can avoid other conventional reconstructive procedures with less morbidity for the patients and less cost for the society.[4] For now, unpredictable fat survival rate caused by irregular absorption is the most pending issue. Autologous fat filling technology includes three steps: (1) Harvesting fat from the donor sites, (2) washing the harvested fat, and (3) reinjecting the purified fat into surgery area. Harvest location and centrifugation and injection method are considered significant factors in terms of lipocyte viability. Research presented by Rohrich et al. showed that fat tissue transferred from different donor sites might be considered equal, and centrifugation did not appear to enhance immediate fat tissue viability before implantation.[5]
Donor sites
Fat can be harvested from several donor sites. Abdomen, buttocks, hips, lateral thighs, inner thighs, knees, or flanks can be used for harvesting. Most people prefer harvest fat from abdomen and thigh that lead to beautiful shape of abdomen and thigh. Pinski and Roenigk reported that adipose tissue from the thigh lasted longer than that from the buttock or abdomen.[6] Strong et al. reported no significant difference in the outcomes of grafted fat obtained from different donor sites or different donor-site preparation, when tumescent solution was used.[7]
Fat processing
Adipose tissue processing techniques include centrifugation, decanting, washing, and cleaning. Fat harvested from liposuction is mixed with blood, local anesthetic liquid, and lipid droplets that turn out to be one possible reason of vascular occlusion during facial autologous fat grafting. We received a case of vascular occlusion after autologous fat grafting and found out in the fundus fluorescein angiography that showed clusters of lipid droplets clogging branch retinal artery, indicating lipid droplets could lead to fat embolism.
Injection technique
Multilevel injection, including subcutaneous layer and muscle layer, is recommended. Autologous fat has been used in both face and nonfacial areas for rejuvenation of the hand, for improvement of body-contour defects, for breast augmentation, as well as for improvement of depressions caused by liposuction or trauma. If there is scarring, sometimes subcision must be done before the fat transfer to lift the skin off the underlying muscle to which it has adhered. Survival rate of fat in various parts differs. Most physicians believed that survival of fat in recipient sites with fewer activities is higher.
Facial autologous fat grafting with PRP is widely used in China. A variety of growth factors is rich in PRP that may promote wound healing and increase fat survival. It is also nonimmunogenic and does not cause cross-infection.[8] Higher survival rate means better postoperative esthetic results, thus increasing surgery satisfaction. Method of producing PRP is: (1) centrifuge patient's blood under strict sterile environment, and (2) use the lower end portion of the separated plasma that is the PRP. The conventional production method of PRP has been simplified. Different methods of preparation lead to different concentration and activity of PRP.[9] The use of stromal vascular fraction (SVF) has been suggested to enhance fat graft survival. The use of either PRP or SVF alone results in almost equal outcomes.[8] When recovery time of surgery, fat absorption, and other factors is taken into consideration for the investigation, it requires a long time for information collection. The data collection of satisfaction is relatively easy. Autologous fat grafting as a powerful tool to improve facial esthetics has relatively high patient satisfaction as reported.[3] VAS scoring is a simple and feasible method for patient self-assessment. In this investigation, the high satisfaction scores of patient and physician (VAS scores were 8.0 and 7.9) are close to the recent findings of foreign research (VAS score of 8.2),[3] indicating that autologous fat as facial fillers has high acceptance and satisfaction. Among numerous methods of satisfaction survey, VAS is suitable for patient self-assessment, but its accuracy and objectivity are much lower than three-dimensional measurement, which we will investigate in the further research. In addition, the safety of fat grafting is not covered in this investigation. More and more cases of vascular occlusion caused by autologous fat injection indicate that autologous fat grafting is not as secure as we thought.[10],[11],[12],[13] The analysis of the reported cases points to that incomplete washing of harvested fat, lack of anatomical knowledge and so on could be related to the accidents. Therefore, clinicians must be careful with fat injection, even other soft tissue filler injections. Further studies need to focus on how to improve safety and efficiency during the procedure of autologous fat grafting. Wide application of SVF and PRP, and the discovery and research of adipose-derived stem cells will provide more approaches to improve the survival rate of fat tissue.[8],[14],[15]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Fournier PF. Facial recontouring with fat grafting. Dermatol Clin 1990;8:523-37.  |
| 2. | Fournier PF. Collagen Autologue: Liposculpture Ma Technique. Paris: Arnette; 1989. p. 277-9. |
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| 6. | Pinski KS, Roenigk HH Jr. Autologous fat transplantation. Long-term follow-up. J Dermatol Surg Oncol 1992;18:179-84. |
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| 10. | Lee CM, Hong IH, Park SP. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol 2011;25:358-61. |
| 11. | Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and small case series: Ocular and cerebral ischemia following facial injection of autologous fat. Arch Ophthalmol 2001;119:777-8. |
| 12. | Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol 2008;2:679-83. |
| 13. | Feinendegen DL, Baumgartner RW, Vuadens P, Schroth G, Mattle HP, Regli F, et al. Autologous fat injection for soft tissue augmentation in the face: A safe procedure? Aesthetic Plast Surg 1998;22:163-7. |
| 14. | Aust L, Devlin B, Foster SJ, Halvorsen YD, Hicok K, du Laney T, et al. Yield of human adipose-derived adult stem cells from liposuction aspirates. Cytotherapy 2004;6:7-14. |
| 15. | Strem BM, Hicok KC, Zhu M, Wulur I, Alfonso Z, Schreiber RE, et al. Multipotential differentiation of adipose tissue-derived stem cells. Keio J Med 2005;54:132-41. |
[Figure 1]
[Table 1]
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