ADIPOFILLING ADIPOFILLING
Capurro
Research Group
Capurro Research
Publications
contact@capurroresearch.org
We describe a simple method of mechanically fragmenting aspirated or
surgically removed adipose tissue in order to obtain “filler” consisting of
adipose cells and connective material. This “biological filler” can be injected
in order to correct both deep and extremely superficial volume deficits. The
results of the procedures carried out appear to be stable over time. Thanks to
the standardised granulometry of the fat mechanically treated by means of a
small kitchen whisk, this technique (Adipofilling) lends itself to research into
the survival of fat grafts, supplementation aimed at improving grafting of the
cells injected and methods of cell selection.
KEYWORDS: lipofilling, Lipostructure, Adipofilling
Techniques for filling localised areas of the body by means of adipose tissue
are commonly called lipofilling. In recent years, such techniques have made use
of tissue removed during liposuction, and have been implemented to counteract
shrinkage or drooping of the integument and in plastic surgery after traumatic
primary or secondary tissue loss. Secondary tissue lost is frequently caused by
protease inhibitors in AIDS treatment. Recent advances in stem cell research
have revealed that adipose tissue contains a high number of stem cells, a
finding which has considerable implications for medical practice.
Research in the field of lipofilling has mainly focused on improving the
survival of implanted adipose lobules. A further area of research focuses on
improving the use of adipose tissue as inexpensive biological “filler”.
Proposed procedures include: liposuction through small-calibre cannulas,
centrifugation and injection of tiny amounts of adipose tissue into many
separate sites (1-2), filtration of freshly-removed fat through fine-mesh gauze
in order to isolate the living tissue to be re-implanted, and the addition of
insulin (3) or beta-blockers (4) in order to modulate lipolysis in the phase
following implantation of the adipose lobules, or serum (5).
“Lobules” of adipose tissue are not as versatile as an injectable commercial
“filler”. The lobular structure of the graft makes it more difficult to achieve
uniform, superficial distribution. Moreover, the survival of injected lobular
adipose tissue is not reproducible, as it can be influenced by many factors: age,
aspiration modality, vascularisation of the implantation site preparation of the
tissue, the size of adipocytes, characteristics of the area from which the
tissue is taken, graft technique, metabolic conditions, habits such as smoking,
or pharmaceutical treatments. In our view, however, the most evident cause of
variability remains the size of the lobules injected. Indeed, it is acknowledged
that the smaller the volume that has to be nourished, the faster and surer graft
attachment will be. In a large lobule of adipose tissue, the cells in the
central portion are liable to necrosis, re-absorption or calcification. This
limits the use of lipofilling in breast enlargement procedures.
Risks such as tactile and visible alterations caused by superficial injection or
injection of excessive amounts are also well documented. These effects seem to
stem from the difficulty of nourishing the grafted lobules, owing to their
excessive size. In an attempt to obviate such difficulties, the adipose tissue
is withdrawn through a small cannula, and small quantities are grafted into
several tunnels created by means of a micro-cannula; this involves executing
repeated movements of the syringe. However, this manoeuvre is rather traumatic.
To overcome these drawbacks and to make filling by means of adipose tissue more
versatile and less traumatic, we have worked out a simple and inexpensive
procedure by which lobules of adipose tissue from liposuction, or fragments of
adipose tissue from abdominoplasty, are dissociated. The resulting cells and
connective tissue can be injected as a filler by means of an 18 G or smaller
needle.
As in traditional lipofilling, the donor areas and the areas of the face and/or body to be enriched with adipose cells and connective tissue have to be marked out and the quantity of material needed to achieve the desired effect has to be assessed. In volume-enhancement procedures, the total volume of adipose lobules taken should be three times greater than that required for the correction.
Anaesthesia is carried out by using a modified Klein’s solution (the physiological solution is replaced by lactate Ringer’s solution). Lobules of adipose tissue are removed from the donor region by means of a 60 ml syringe and a cannula of 3, 4 or 5 mm according to the quantity to be injected. Smaller-calibre cannulas should be avoided, as they are more likely to damage the aspirated tissue. This conviction is based on geometrical considerations. Using larger-diameter cannulas means that less of the aspirated material comes into direct contact with the walls of the cannula; clearly then, less of this material is subject to potential damage due to friction against the walls. Once removed, the lobules of adipose tissue are washed with the lactate Ringer’s solution in a glass container. The washing solution is aspirated from the container by means of a cannula and repeatedly replaced until it becomes colourless. Washing removes blood and lidocaine, which potentially inhibits glucose transport in adipocytes and their growth in culture (6). Adipose tissue may also be obtained from excess skin and fat removed during abdominoplasty.
Once the predetermined quantity (minimum 20 ml) of adipose tissue lobules has been obtained by means of liposuction and washed, the resulting material (up to a maximum of 100 ml) is poured into a 250 ml glass with a diameter of 6.5 cm, and 50 ml of lactate Ringer’s solution is added. The procedure used to obtain cells from adipose tissue consists of 4 or 5 steps carried out by means of a small kitchen whisk (Philips Essence), the tip of which can be sterilised in an autoclave (Fig. 1).
The blades of the whisk will need to be checked after about 25 uses and, if necessary, sharpened or replaced. The adipose cells and connective material thus obtained (Fig. 2-3) are poured into 20 ml syringes from which the plungers have been removed.
The syringes are then sealed with plastic caps (Tip guardTM, Scanlan International, US) and centrifuged at low velocity (200 g) for 1 min. After centrifugation, the supernatant at the bottom of the syringe is discarded. Once this liquid has been removed, the opening of the syringe is closed by means of a finger, the plunger is inserted up to a few millimeters and the syringe is turned upside down.
After this step, the volume of fat removed should be reduced by almost half, as
the lobules are broken down into adipocytes and fragmented connective material.
Handling the adipose tissue by this procedure causes negligible breakage of
cells, as shown by the absence or minimal presence of liquid fat on the surface
of the syringes after centrifugation.
Adipocytes and connective tissue components can also be derived from the subcutaneous tissue obtained from abdominoplasty. In this case, the subcutaneous tissue must be cut into small pieces before using the whisk (Fig.4), and the 4-step procedure mentioned above must be carried out three times.
Once the adipocytes and connective material have been centrifuged, and the washing liquid has been eliminated, the adipose tissue, transformed into filler, is ready to be injected. In this phase, a supplement can be added, if needed.
When large volumes are to be injected, a 20 ml syringe is used, together with a cannula of 2 mm diameter; when small volumes are to be injected, a connecting tube is used to transfer the cell components to smaller (2.5 or 1 ml) syringes for injection with an 18 G needle. Injection can be carried out either in depth or just below dermis: during injection, the needle must be kept moving in order to avoid intravenous injection. After injection, the transplant area can be moulded and smoothed with the fingers, exactly as is done when fillers are used. Pain due to injection can be reduced by means of anaesthetic cream applied topically, or local anaesthetic: 1% lidocaine without epinephrine infiltrated into the dermis; the subcutaneous adipose tissue is not infiltrated. Alternatively, the procedure can be performed under general anaesthesia. The post-operative course is good and ecchymosis is modest.
Adipofilling can be used for several purposes: to correct breast asymmetry (Fig.
5) or enhance breast volume; to improve aesthetic appearance after the insertion
of breast prostheses (Fig. 6); to eliminate the tactile sensation of the edge of
the prosthesis (Fig. 7); to replace subcutaneous tissue loss; to improve the
aesthetic appearance of scars and the aftermath of acne; to enhance the
vermilion border of the lip (Fig.8); to fill facial areas (Fig.9, 10); after
blepharoplasty, and to restore a youthful appearance to the orbital area.
Adipofilling® has also been used to rejuvenate the skin of the nose and to obtain a more natural and symmetrical result after rhinoplasty (Fig.11) and elastic suspension face-lifting, to rectify facial asymmetry to restore a youthful appearance, to stimulate the healing of ulcers, etc,.
Since 2003, we have treated 55 patients. In the first (20%) patients treated, we underestimated the amount of tissue needed, and further surgery was performed after six months in order to obtain the volume desired. No patient needed a third operation. In general, the procedure has been seen to yield very good results, although graft success may vary from one patient to another according to age, metabolic conditions, habits such as smoking, and pharmaceutical treatment. After initial oedema due to the shock of transplantation, liquids are re-adsorbed and adipocytes shrink slightly, but regain their proper volume within about 30 days. In all of our procedures, stable results have been maintained. Echography carried out on the breast region every six months has confirmed the maintenance of volume. Mammography performed one and two years after lipofilling has never revealed calcifications. The superficial injection of adipose cells and connective material, even in very delicate areas such as the eyelids and the lip region, has never caused visible or palpable alterations in any patient. Adipofilling allows uniform superficial distribution of the injected material and has also been successfully used to improve the aesthetic appearance of cutaneous scars.
This simple technique for reducing the size of the tissue components injected opens up the possibility of using fat as a subcutaneous biological “filler”. Adipocytes can be considered highly viable, as suggested by their glucose transport capacity, which has been measured under both basal and maximally insulin-stimulated conditions (7). In this study, adipocytes were isolated from 1 g samples by collagen digestion (8-9). The cells and connective material obtained during adipofilling were injected below the dermis. Injection caused little trauma and could be carried out even with an 18 G needle. Distribution of the injected material was optimal and there was no need for repeated traumatic movements of the syringe in order to ensure uniform distribution. No visible or tactile alterations ensued even when the material was injected very superficially. Large amounts of material were injected without any complications, thereby facilitating distribution and moulding of the material. No calcification occurred, and isolated cells displayed better survival than lobular clusters. e A possible complication of adipofilling is the risk of intra-vessel injiction; this risk can be avoided by keeping the 18 G needle moving during injection. Moreover, fragmenting the adipose tissue by means of the technique described enables the granulometry of the injected material to be standardised. The results of adipofilling suggest that the questions of variable graft survival, reagent selection to improve the survival of the injected cells) and methods of cell selection should be investigated further. Finally, the technique described relies on a very simple use of a cell population that includes the stem cells contained in connective tissue, and is in line with the new concept of regenerative medicine.
Adipofilling is particularly promising in that it enables the volume of the
breasts or buttocks to be enhanced and the desired shape to be achieved. When
applied to the face, adipofilling is able to correct asymmetries and to create a
fine, complete layer of adipose cells and connective tissue under the dermis,
thereby rejuvenating the appearance. In the nasal region, adipofilling corrects
the surgical artefacts left by rhinoplasty (see fig.11), making further
traumatic and complex operations unnecessary. The present clinical
experimentation should be regarded as a starting-point for further experimental
research and clinical trials, which will become possible if, as we believe, the
technique is taken up by others.
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