A systematic review on extracellular vesicles-enriched fat grafting : a shifting paradigm

Background: Recent evidence confirms that mesenchymal stem cells (MSCs) facilitate angiogenesis mainly through paracrine function. Extracellular vesicles (EVs) are regarded as key components of the cell secretome, possessing functional properties of their source cells. Subsequently, MSC-EVs have emerged as a novel cell-free approach to improve fat graft retention rate. Objectives: To provide a systematic review of all studies reporting the use of MSC-EVs to improve graft retention rate. Methods: A systematic search was undertaken using the Embase, PubMed and the Cochrane Central Register of Controlled Trials databases. Outcome measures included donor/receptor organism of the fat graft, study model, intervention groups, evaluation intervals, EV research data, in vitro and in vivo results. Results: Of the total 1717 articles, 62 full-texts were screened. Seven studies reporting on 294mice were included. Overall, EV treated groups showed higher graft retention rates compared to untreated groups. Notably, retention rate was similar following EV- and MSC-treatment. In addition to reduced inflammation, graft enrichment with EVs resulted in early revascularization and better graft integrity. Interestingly, hypoxic preconditioning of MSCs improved their beneficial paracrine effects and led to a more proangiogenic EV population, as observed by both in vitro and in vivo results. Conclusions: MSC-EVs appear to offer an interesting cell-free alternative to improve fat graft survival. While their clinical relevance remains to be determined, it is clear that not the cells, but their secretome is essential for graft survival. Thus, a paradigm shift from cell-assisted lipotransfer towards ‘secretome-assisted lipotransfer’ is well on its way

Lower Third of the Face: Indications and Limitations of the Minimal Access Cranial Suspension Lift

The MACS-lift technique, in the simple or extended variation, delivers a reproducible and natural rejuvenation of the face and neck with minimal morbidity and a swift recovery. Retro-auricular extension of the surgery is avoided by pure vertical redraping of the facial skin. In patients with an exceptionally bad skin quality, any vertical pleats below the lobule that may appear can easily be corrected with a limited posterior cervicoplasty

Aging of the upper lip : part II : evidence-based rejuvenation of the upper lip : a review of 500 consecutive cases

Background: Findings from photometric analysis of soft tissue on cranial magnetic resonance imaging demonstrate that the aging upper lip shows significant lengthening, thinning, volume loss, and deepening of the nasolabial folds. In this study, these findings are implemented in a review of 500 cases of upper lip rejuvenation to propose an evidence-based strategy for surgical rejuvenation of the upper lip. Methods: The charts of 500 consecutive surgical perioral rejuvenation patients treated by the senior authors (P. L. T. and A. M. V.) from 2014 until 2018 were reviewed. The surgical methods of lip lift and fat grafting were described in relation to the cases and the metric data. Results: Of the 500 patients, 51 had an isolated procedure such as a lip lift (3 percent), lip augmentation (3 percent), augmentation of the nasolabial folds (2 percent), or skin resurfacing (2 percent). The remaining 449 patients underwent combinations of lip lift, augmentation of the lip and nasolabial fold (32 percent), lip lift with augmentation of the lip and nasolabial fold with resurfacing (30 percent), lip augmentation and resurfacing (14 percent), or lip lift and resurfacing (14 percent). Conclusions: Rejuvenating the upper lip needs to address both lengthening and volume loss. This requires a combination of surgical shortening of the upper lip by a precisely designed lip lift and a differential filling of certain upper lip regions by microfat grafting. The combination of these two modalities works synergistically

Aging of the upper lip, part I : a retrospective analysis of metric changes in soft tissue on magnetic resonance imaging

Background: In scientific literature, numerous theories on the mechanism of facial aging can be found. The debate about facial sagging versus deflation is still ongoing. In this study, the metric changes in perioral soft tissue were demonstrated. These data can contribute to a better understanding of physical changes in the aging perioral area. Methods: Upper lip measurements were performed on cranial magnetic resonance images of 200 Caucasian subjects (100 men and 100 women). The study population was aged between 20 to 30 and 65 to 80 years. The upper lip length and soft-tissue thickness were measured on sagittal and parasagittal section. Cross-section surface area of the upper lip was measured in the sagittal section to represent volume. The data were analyzed with a t test and results were considered significant at p < 0.01. Results: The upper lip in the old age group differed significantly in length (19.24 percent in women and 18.24 percent in men), thickness (up to -40.55 percent in women and -32.74 percent in men), and volume (-20.89 percent in women and -17.40 percent in men). Soft-tissue thickness at the alar nasolabial fold was significantly thinner in the old age group (-25 percent in women and -25.7 percent in men) and showed significantly greater tissue loss than elsewhere in the upper lip (p < 0.001). Conclusions: These results suggest that the aging perioral area is affected with a combination of soft-tissue lengthening, thinning, and volume loss. The clinical implications of this study on perioral rejuvenating strategies will be explained in part II

The role of microfat grafting in facial contouring

BACKGROUND: Congenital hypoplasia of facial bones has traditionally been treated by orthognathic surgery. However, the inherent invasiveness of orthognathic surgery often leads to a high complication rate. Facial fat grafting could be a less invasive method to correct facial deformities. OBJECTIVES: The aim of this study was to evaluate the results of microfat grafting for facial contouring. METHODS: This retrospective chart review evaluated 166 patients who were treated with microfat grafting for maxillary and/or mandibular hypoplasia. Pretreatment and posttreatment photographs were compared regarding improvement of facial contour, and complications were recorded. RESULTS: The follow-up period ranged from 4 months to 10 years (mean, 2 years 7 months). Thirty-eight percent of the patients had a refill procedure 6 or more months after the first procedure. A majority of the evaluated patients stated that they benefited from the microfat grafting, with ratings of excellent (50%), sufficient (48%), and poor (2%). Complications included visible fat lobules under the lower eyelid skin (7%), which was seen during the first 4 years and was resolved by changing the injection cannulae and technique, and fat resorption, which was seen in all patients, with a clinical range from ±15% in the immobile malar area and chin region to ±50% in the mobile lip area. CONCLUSIONS: Facial microfat grafting is a valuable alternative to more complicated advancement osetotomies being performed in patients solely for aesthetic reasons. The low morbidity and rapid recovery make facial microfat grafting a welcome tool in the armamentarium of the modern facial aesthetic surgeon

Mini face lift with suspension sutures: historical analysis of development and morphic resonance: reply

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Septum-based mammaplasty: a surgical technique based on Würinger's septum for breast reduction

Background: During the past 7 years, the senior author (M. H.) has been performing septum-based mammaplasty. The aim of this article is to report the safety and ease of breast shaping by using this technique. Methods: A series of 110 consecutive patients underwent septum-based breast reduction performed by a single surgeon. This technique uses a lateral or medial pedicle based on Wuringer's horizontal septum, which carries the main nerve supply to the nipple in addition to intercostal perforators. Results: Mean nipple-to-sternal notch distance was 33 cm (range, 22 to 45 cm). Mean resection was 658 g (range, 160 to 1980 g). Nipple elevation was 9 cm on average (range, 3 to 17 cm). A retroareolar hematoma occurred in three breasts. Total areola necrosis occurred in one breast (0.5 percent) as a result of an infection in a diabetic patient. Limited wound dehiscence occurred in 15 breasts (7.7 percent). A secondary scar revision was needed in 10 patients (9 percent). One patient required a revision. Conclusions: Based on a well-vascularized and constant anatomical septum, a septum-based pedicle is safe, even in large breasts. This technique is safe and demonstrates ease of pedicle shaping and breast remodeling in patients undergoing reduction mammaplasty