Scar Tissue Graft as a Filler for Soft Tissue Augmentation

Soft tissue augmentation with autogenous tissue has been used to correct various defects during aesthetic facial contouring and reconstructive procedures. Although dermal grafts have longer survival rates, fat grafts always have been more popular because of the simple harvesting and grafting methods used. The authors aimed to use existing scar tissue as an injectable graft and to compare its effectiveness as a soft tissue filler substance with that of dermal grafts. In this study, scar tissue was created on 24 male Wistar rats. The created scar and normal healthy skin were removed from the rat dorsal scapular donor site. After depithelialization, the harvested tissues were minced until they were thin enough to pass through a 16-gauge needle. The grafts then were injected into the recipient site between the abdominal muscles. Volumetric analyses and histologic evaluation of the grafts were performed 1, 3, and 5 months after transplantation. The first month after the injection, the amount of remaining dermis graft was more than the scar graft, and this difference was statistically significant. However, at the end of months 3 and 5, there was no marked difference between the groups. The remaining volume of injected scar tissue graft was comparable with that of the dermis graft. The scar grafts were composed mainly of dense connective tissue during all the evaluation periods. In this study, scar tissue provided results comparable with those of dermal grafts up to 5 months when used as a soft tissue filler. It seems that neovascularization of the scar graft may be inadequate for maintenance of graft viability, as compared with dermis grafts. On the other hand, the scar graft formed fibrous tissue, which may be responsible for providing adequate volume as a filler. This may have clinical implications for the patient who needs both scar revision and soft tissue augmentation procedures simultaneously.     

脂肪注射移植后皮肤质地改善的研究

目的:通过皮下脂肪注射移植,探索移植脂肪对皮肤质地的改善作用。方法:取30只裸鼠,随机分成三组,所有鼠左侧皮下移植人脂肪细胞,在另一侧10只注射硅凝胶,10仅行皮下穿刺,剩下10只无任何处置,8周取皮肤组织做HE、Masson’染色观察皮肤真皮层厚度及真皮层内胶原蛋白的含量。结果:取材时,所有裸鼠上都能看到所移植的脂肪,但体积较术前有较明显缩小。肉眼看,脂肪呈正常外观,有较多新生血管生成。组织学检测,移植脂肪外周有大量细胞外基质形成,实验侧真皮层较对照侧明显增厚,真皮内胶原含量增多。结论:移植的脂肪组织不仅仅是一种填充物,在改善轮廓的同时,还有真皮增厚、胶原含量增加等皮肤改善的效应。     

透明质酸对大鼠颗粒脂肪移植物存活影响的初步研究

目的:观察透明质酸(hyaluronic acid,HA)对大鼠自体颗粒脂肪移植物存活的影响。方法:18只Wistar大鼠(雄雌不限,体重220±5g)背部皮下分别注射自体颗粒脂肪0.3ml、透明质酸0.3ml和自体颗粒脂肪与透明质酸混合物0.3ml(颗粒脂肪0.15ml+透明质酸0.15ml),并记为Fat组、HA组、Fat+HA组,分别于第30天、第60天、第90天,检测移植物的体积并计算成活率;HE染色分析脂肪细胞的形态和移植物的炎症反应;免疫组织化学染色检测CD31表达,计数血管情况。结果:1注射Fat、HA、Fat+HA(1:1)0.3ml后,大鼠背部形成三个长条形的局部隆起,注射第15天HA组局部隆起消失,注射后第30天,第60天,第90天Fat+HA组移植物的成活率比Fat组高,具有统计学意义(P0.05);2局部取材切片(HE染色)可观察到炎症反应程度逐渐减轻,Fat+HA组诱发组织炎症反应较Fat组为轻;3注射后第30天,第60天,第90天时CD31标记组织内血管计数Fat-HA组多于Fat组,具有统计学意义(P0.05)。结论:透明质酸混合自体颗粒脂肪注射可以提高颗粒脂肪的成活率、促进移植物的再血管化、维持脂肪移植物的体积。     

Refinement of Rhinoplasty with Lipoinjection

Background The most common aesthetic defects after rhinoplasty are small dorsal irregularities observed mainly in patients with thin dorsal nasal skin. Many techniques have been used in attempts to prevent perceptible irregularities and sharp edges of bone and cartilage in these patients. Adipose tissue transplantation has been used widely in aesthetic surgery as a surgical method to correct surface depression or to augment soft tissue. Recently, this tissue has been considered a potential source of stem cells with regenerative capacity and other benefits. The authors present a simple procedure using lipoinjection of microfat grafts over the osseocartilaginous framework of the nasal dorsum as a routine technique in rhinoplasty. Methods Open rhinoplasty was performed for all the patients. At the start of the procedure, we aspirated 3 to 5 ml of fat and separated it using the sedimentation method. The fat deposited as sediment (2–3 ml) was injected at the beginning of the procedure, after suture of the incisions and before application of the splint, over the osseocartilaginous framework in the subcutaneous space. The fat acted as a thin layer of soft tissue to thicken the overlying skin and help camouflage minimal imperfections. Results Between February 2003 and May 2005, 78 rhinoplasties were performed, with injection of autologous fat. Of the 78 patients, 61 were primary rhinoplasties and 17 were secondary rhinoplasties with a follow-up time of 1 to 36 months. No minor irregularities were observed, and the aspect and quality of the skin improved for all the patients. Conclusions Fat injection into the nose as a refinement of rhinoplasty is a fast, easy, inexpensive procedure for obtaining regular and smooth contours on the nasal dorsum that lasts over time.     

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient’s and observers’ scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.     

Superficial skin texture: a study on full-thickness skin grafting in facial reconstruction

Usually in harvesting a full-thickness skin graft, we match color, skin thickness, and the presence of hair in the potential donor site with the recipient site to obtain as good an esthetic result as possible. Superficial skin texture is, in part, responsible for the esthetic result in facial reconstruction. Full-thickness skin grafts harvested from the supraclavicular region in 20 patients operated on for facial skin tumors and immediate reconstruction, were included in this study. The superficial skin texture was reproduced using a silicone cast technique; a polyvinylsiloxane derivative was used and it was analyzed by scanning electron microscopy (SEM) in order to detect and measure morphological features of the skin surface. The mechanism affecting superficial skin texture was studied to elucidate the importance of the superficial skin texture of the graft donor site and consequently the intraoperative orientation of the graft into the recipient area to improve the esthetic outcome. Our study shows that the forces of the recipient site are able to modify full-thickness skin graft dermis and as a result change the overlying superficial skin pattern. The graft always tends to change to the features of the recipient area after 24 months because of the environment of the new site. These findings suggest that color and thickness of the donor site still remain more important than intraoperative graft orientation in the recipient area in order to achieve good esthetic results in skin grafting.     

吻合血管腓骨移植48例报告

目的　探索吻合血管腓骨移植治疗长管骨大段骨缺损的方法与效果。方法　长管骨骨缺损６ ｃｍ 以上４８ 例,用对侧腓骨游离移植修复缺损,均携带供观察腓骨血供的“监测皮岛”或供修复皮肤软组织缺损的皮瓣。结果　１ 例失败,４４ 例于术后３ ～６ 个月、３ 例于１ 年内骨性愈合。随访３ 年以上３６ 例,移植腓骨均增粗、塑形,酷似受区长管骨。结论　吻合血管腓骨移植治疗长管骨大段骨缺损效果满意,“监测皮岛”是保证腓骨血供的有效监测手段     

Evaluation of a porcine origin acellular dermal matrix and small intestinal submucosa as dermal replacements in preventing secondary skin graft contraction

The degree to which a split thickness skin graft (STSG) contracts after application to its recipient bed is related in part to the proportion of the dermis harvested from the donor site. Harvesting thicker skin grafts may produce better cosmetic results in the recipient bed but result in increased donor site morbidity. The combination of an autologous ultra thin split thickness graft with an underlying non-autologous dermal component may reduce secondary skin graft contraction without further increasing donor site morbidity. This study was aimed at assessing the suitability of two porcine derived biomaterials (Permacol and small intestinal submucosa, SIS) for use in combination with skin grafts in a Sprague-Dawley rat model. Full thickness wounds (1 cm(2)) were created in Sprague-Dawley rats and grafted with skin in combination with Permacol or SIS either as a one-stage operation or following a 2-week-period of vascularisation of these dermal matrices before a second stage operation to cover with skin. Skin graft viability and wound area were assessed at weekly intervals until 4 weeks after graft application. Both Permacol and SIS were able to support an overlying skin graft but had no beneficial effect on skin graft contraction in this model compared to skin grafts alone.     

Optimal use of negative pressure wound therapy for skin grafts

Skin grafting is a technique used for transplanting human skin (i.e. epidermal and some dermal layers) from a harvest site to a recipient site. However, advancements in bioengineered matrices have also introduced alternatives to skin grafts. The method used to secure the graft, whether skin or biomatrix, is critical in reducing graft failure. During the past several years, negative pressure wound therapy using reticulated open-cell foam (NPWT/ROCF; V.A.C.? Therapy, KCI USA, Inc., San Antonio, TX) has become a well-established method for bolstering grafts to recipient beds and is being used more frequently over biomatrices to help improve graft outcomes. This review will combine expert opinion with scientific evidence for the use of NPWT/ROCF over grafts.     

Free temporoparietal fascial flaps and full-thickness skin grafts in aesthetic restoration of the nose

Free tissue transfers have been rapidly replacing distant flaps for use in nasal reconstruction. The temporoparietal fascial flap is a thin, broad, pliable, and well-vascularized flap. It can be used to drape over the cartilaginous and bony framework of the nasal skeleton and nourish the underlying primary cartilage grafts as well as the overlying full-thickness skin graft. The thin contour of the flap is aesthetically superior to thicker skin flaps and eliminates the need for secondary defatting or touch-up procedures. A large, single sheet of full-thickness skin graft, harvested from the supraclavicular region, can be applied over the fascial flap in the same session and provide a quite acceptable color match. The authors present a case whose alar margins and atrophic nasal skin were restored in one session by primary conchal cartilage grafts, a free temporoparietal fascial flap, and a full-thickness supraclavicular skin graft.     

Long-term clinical outcomes of fat grafting by low-pressure aspiration and slow centrifugation (Lopasce technique) for different indications

Abstract

Autologous fat grafts have been used successfully for structural fat grafting in facial, lip, and hand rejuvenation, body contour improvement, and traumatic defect restoration. The purposes of this study were to define a new fat graft harvesting and processing technique, which is named the “Lopasce technique” (low-pressure aspiration and slow centrifugation technique), and to evaluate the late clinical outcomes of fat grafting by this technique for different indications. A retrospective study was performed using the medical records of 21 patients (17 women and four men). The mean injected fat volume was 33.2 ± 34 cc (range 6–125 cc). The mean follow-up period was 13.2 ± 5.6 months (range 6–26 months). Postoperative results were evaluated by subjective and objective methods. In the subjective evaluation, 19 patients stated that there had been little resorption and that it was not necessary to repeat the fat grafting, one patient reported that the fat was resorbed in part, and one patient reported that the fat was resorbed completely. In the objective evaluation, the amount of fat graft taken in the recipient sites was between 60%–80% (average 70%) when compared with preoperative and late postoperative photographs of the patients at the 6- and 26-month follow-ups. Fat grafting is a simple, effective, and reproducible technique with a high satisfaction rate and few disadvantages or complications. We consider that structural fat grafting with the lopasce technique is an easy, effective, and long-lasting treatment for correction of congenital or acquired defects associated with various medical conditions.     

Vascularized fat transfer

The use of free tissue transfers has dramatically improved the outcomes of soft tissue reconstructions of the face. This is particularly true when large volumes of soft tissue are needed or when the recipient bed has a compromised local blood supply. Although traditional fat grafting procedures often allow for satisfactory results in some patients, the use of scapular and parascapular free tissue transfers has markedly improved the predictability of these reconstructions, often in a single stage. As perforator flap reconstructions evolve over time, these types of flaps may eventually supplant the available fasciocutaneous free flaps as the flap of choice in these reconstructions primarily because of improved donor site scarring and morbidity.     

Current state and exploration of fat grafting

Fat grafting has become one of the most frequently used techniques in plastic and reconstructive surgery. Many studies have focused on optimizing procedures, such as donor site selection, harvesting, processing, and grafting. Representative basic techniques include Coleman’s and “3L3M” techniques. A new technique called compartment-based targeted fat grafting (CTFG) has gradually been established based on anatomical findings of the facial and hand compartments. CTFG achieved precise restoration of the fat volume in the anatomical state. Cell-based fat grafting has introduced new fields involving tissue repair and regeneration, including facial rejuvenation and scar improvement, among others. In this review, we summarize the timeline for the development of fat grafting.     

The role of recipient sites in fat-graft survival: experimental study

The survival of fat grafts depends on many factors, 1 of the major being early revascularization. Early studies showed that adipose tissue has a low tolerance to ischemia. Some methods have been described to increase the tolerance of adipose tissue to ischemia. This study was designed to compare volume maintenance of the transplanted fat graft in different recipient sites of the rabbit face. Three groups of 5 New Zealand white rabbits were studied. Fat grafts harvested from the right inguinal fat pad were transplanted to the buccomandibular area of the rabbit's face. Three different recipient sites (subcutaneous, supramuscular, and submuscular) were dissected on each side of the face, and groups were formulated based on this difference of recipient sites. Morphometric, as well as histopathologic, analyses were done, and the results revealed a statistically significant increase of fat graft survival in supramuscular layer (81.95% +/- 4.40%) than in subcutaneous (41.62% +/- 3.29%) and submuscular layer (37.31% +/- 5.77%) (P<0.05). This study demonstrates that selection of an "appropriate recipient site" should enhance ultimate fat-graft survival.     

Application of fluorescent in situ hybridization in the mouse xenograft model of human fat grafting

Background: Determining the optimal technique for autologous fat grafting requires elucidation of the engraftment process at the cellular level. The nude mouse xenograft model for autologous human fat grafting is an excellent tool to evaluate the incorporation of grafted fat into the recipient. Objectives: The authors present a murine xenograft model that uses fluorescent in situ hybridization (FISH) to differentiate between murine (host) cells and human (grafted) cells. Methods: Fat grafts were harvested from human abdominoplasty specimens, fixed, embedded in paraffin blocks, and cut into 5 μm sections. The sections were stained and used for in situ hybridization with fluorescently labeled murine and human nucleic acid reagents. A fluorescence microscope was used for photographic analysis of the grafts, allowing identification of murine and human cell populations based on the wavelength at which they stained. DAPI (4,'6-diamidino-2-phenylindole) counterstaining was also applied to confirm that the images obtained represented cell nuclei. Results: At 20× magnification, strong species-specific staining of cells was seen within the tissue sections, which allowed the authors to easily discriminate between graft-derived and host-derived cells. Using this approach, human fat xenografts were revealed to comprise a complex matrix of closely interacting graft- and host-derived structures. Conclusions: FISH has the potential to be a powerful technique for distinguishing between murine and human cells in the nude mouse xenograft model of human fat grafting. By applying this technique, it may be possible to evaluate the engraftment process at a cellular level, which may ultimately allow clinicians to obtain more predictable results with grafted fat.     

Lipofilling: kritische Punkte einer erfolgreichen Fetttransplantation

Autologous fat grafting is the method of choice for soft tissue filling in aesthetic and reconstructive surgery. However, protocols differ between physicians who are still confronted with graft resorption and variable clinical outcomes. Adipose graft survival rates vary considerably depending on the method of harvest, the method of adipose tissue processing, the method of injection, and the vascularity of the recipient site. Based on various studies and the authors’ experience, this review summarizes the critical points that may influence the quality of adipose grafts, from liposuction to adipose tissue injection. Some recommendations are provided in order to optimize the overall procedure of lipofilling and to improve long-term survival of grafted tissue. The English full-text version of this article is available at SpringerLink (under“Supplemental”).     

前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复手背缺损创面

目的 探讨前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复手背缺损创面的临床疗效.方法 应用前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复14例手背部缺损创面患者.术前进行脂肪筋膜瓣设计,脂肪筋膜瓣切取面积8 cm×6 cm~12 cm×9 cm,覆盖创面后在脂肪筋膜瓣表面加皮片移植.结果 14例脂肪筋膜瓣及移植皮片全部成活.患者均获随访,时间4～10个月.脂肪筋膜瓣色泽、质地、弹性均良好,无臃肿,无前臂骨间背侧神经损伤,患者功能恢复较满意.结论 前臂骨间背侧动脉逆行脂肪筋膜瓣联合植皮是修复手背部创面缺损的有效方法.     

Current Concepts of Fat Graft Survival: Histology of Aspirated Adipose Tissue and Review of the Literature

BACKGROUND: Controversy remains about the longevity of correction in autologous fat grafts and its relation to adipocyte survival. Reported long-term fat graft survival rates differ widely, depending on harvesting method, means of reinjection, injection site, and evaluation methods. OBJECTIVE: To demonstrate histologic findings of aspirated adipose tissue and compare the findings to the reports in the literature. METHODS: Review of the literature and the histology of transplanted fat 7 years after subcutaneous implantation and trypan blue staining to determine the vitality of defrosted adipocytes. RESULTS: Fat cells survive aspiration with a suction machine or syringe equally well. Use of a liposuction cannula or 14-gauge needle gives comparable results. Local anesthesia or tumescent local anesthesia is recommended for the donor site, preferably with addition of epinephrine. CONCLUSION: Clinical longevity of correction after autologous fat transfer is determined by the degree of augmentation resulting from the amount of fibrosis induced and the number of viable fat cells. Survival of aspirated fat cell grafts depends mainly on the anatomic site, the mobility and vascularity of the recipient tissue, or underlying causes and diseases, and less on harvesting and reinjection methods.     

Importance of mesenchymal stem cells in autologous fat grafting: a systematic review of existing studies

Autologous fat grafting (lipofilling) enables repair and augmentation of soft tissues and is increasingly used both in aesthetic and reconstructive surgery. Autologous fat has several advantages, including biocompatibility, versatility, natural appearance, and low donor site morbidity. The main limitation is unpredictable graft resorption, which ranges from 25%-80%, probably as a result of ischaemia and lack of neoangiogenesis. To obviate these disadvantages, several studies have searched for new ways of increasing the viability of the transplanted tissue. One promising approach has been to enrich the fat graft with adipose tissue-derived mesenchymal stem cells (ASC) before transplantation. We have reviewed original studies published on fat transplantation enriched with ASC. We found four murine and three human studies that investigated the subject after a sensitive search of publications. In the human studies, so-called cell assisted lipotransfer (CAL) increased the ASC concentration 2-5 times compared with non-manipulated fat grafts, which caused a questionable improvement in survival of fat grafts, compared with that of traditional lipofilling. In contrast, in two of the murine studies ASC-concentrations were increased 1250 and 6250 times, respectively, by ASC ex vivo expansion, which resulted in considerably improved fat transplant survival as well as quality. This effect of high-level enrichment with ASC is thought to have been caused by paracrine signalling, cellular differentiation, or both. The surgical and tissue handling techniques used in lipofilling are well proved, but the added effect of high-level enrichment with ex vivo expanded ASC still needs to be investigated properly in human lipofilling studies, combined with a thorough follow up and matched control groups. In conclusion, ASC-enriched lipofilling theoretically has the potential for transforming lipofilling from a relatively unpredictable intervention into one in which the resorption rate, quality of tissue, and safety can be predicted, and possibly superior to prosthetic implantation.     

The use of the ALT Flap and Lateral Femoral Cutaneous Nerve for the Reconstruction of Carpal Soft Tissue and Ulnar Nerve Defects: a Case Report

The anterolateral thigh (ALT) flap has become one of the workhorse flaps, with indications including diverse reconstructive problems. The lateral thigh area is also a useful donor site for nerve grafts. The lateral femoral cutaneous (LFC) nerve can be dissected along with the ALT flap for a substantial length, depending on the requirements of the recipient site. The LFC nerve can be used as a vascularized or non-vascularized nerve graft. The technique offers advantages and it can find clinical applications, satisfying the functional and aesthetic reconstructive requirements of a complex defect. We report the case of a patient who presented with traumatic soft tissue defect of the volar aspect of the wrist and ulnar nerve defect as a complication of a fracture of distal radius. An ALT flap was used to reconstruct the soft tissue defect. The ulnar nerve was resected due to necrosis and the gap was repaired with non-vascularized grafts of the anterior branch of the LFC nerve. The soft tissues were resurfaced successfully without complications. Functional recovery was good for the superficial branch of the ulnar nerve, whereas it was variable for the deep branch of the ulnar nerve. The anterolateral thigh area offers significant advantages as donor site in the reconstruction of complex soft tissue defects being a large source of vascularized skin, fat, fascia, muscle and nerve. This availability allows for single donor site dissection, minimizing the operating time and the associated morbidity.