Does Stromal Vascular Fraction Supplementation Improve Facial Lipotransfer?

Does Stromal Vascular Fraction Supplementation Improve Facial Lipotransfer? Gontijo-de-Amorim et al1 claim that fat enriched with the stromal vascular fraction (SVF) improves volume retention after facial lipotransfer. The authors describe a comparison of 5 patients injected with enriched fat vs 5 patients injected without SVF supplementation using computed tomography (CT). The authors report that the enriched fat group lost only 9.6% of its volume vs 24% in the untreated group.1 The authors simply centrifuge the lipoaspirate rather than separating it enzymatically using collagenase to isolate adipose-derived stem cells.1 Whether the cell pellet left at the bottom of the tube after centrifugation truly represents the SVF is open to question.2 Although box plots are included, the actual measurement data for the 10 patients are not reported. The authors provide 2 clinical examples along with their axial CT scan images. The area of fat injection is indicated by 2 linear measurements. It is not clear how volumes were calculated from these linear dimensions. Regardless, errors in these measurements beg disclosure. For the 26-year-old woman with mild Parry-Romberg syndrome injected with 65 mL of enriched fat, the linear measurement perpendicular to the 45-mm long axis is labeled “20 mm” on the preoperative image (Figure 1A). This length should be almost half the length of the 45-mm measurement. However, this length appears to be less than ¼ of the longer measurement. The Canfield 7.4.1 imaging software (Canfield Scientific, Fairfield, NJ) applies the measurement label directly onto the image, reducing the risk of error. Using this imaging software, the length of the shorter limb measures 1.06 cm (10.6 mm), not 20 mm, if the 45-mm measurement is used for calibration (note: the assumption is made that the longer measurement is the correct one). On the postoperative image (Figure 1B) this depth measurement is labeled 33 mm although the actual measurement is 1.31 cm (13.1 mm). Therefore, the postoperative increment in thickness is only 2.5 mm (1/10 inch), not 13 mm. The area increases from 4.37 cm2 to 5.15 cm2, a difference of 0.78 cm2 (18%). An area difference of 18% corresponds to a volume increment of 39% (1.18 × 1.18), assuming equal volume expansion in all 3 planes, or 0.61 cm3. Surprisingly, measurements on the contralateral untreated side reveal a decrease in area of 1.0 cm2 (14%). The reason for this reduction in unclear. A possible explanation is weight loss during the 1-year period between CT studies. Controlling for this difference on the treated side raises the area increase on the treated right side slightly, to 0.90 cm2. Figure 1. View largeDownload slide This 26-year-old woman’s axial CT images are compared. She has mild right hemifacial atrophy. She was injected with 65 mL of enriched lipoaspirate. The preoperative image (A) includes 2 measurements, a 45-mm long-axis measurement and a 20-mm short perpendicular axis measurement. The Canfield imaging software was used to measure dimensions and the computer-generated measurements are superimposed by the program. The length of the short axis is actually 1.06 cm (10.6 mm), based on a 45-mm length of the long axis. Postoperatively, the length of the short axis is labeled 33 mm (B). The true length is 1.31 cm (13.1 mm). This depth measurement increases 2.5 mm (10.6 mm to 13.1 mm) after surgery, not 13 mm. The area (shaded), calculated using the Canfield area measurement function using the 2 marked axes measures 4.37 cm2 (A). The treated area increases 0.78 cm2 1 year after lipoinjection (B). The area decreases 1.00 cm2 on the untreated left side. Adapted from Gontijo-de-Amorim et al.1 Figure 1. View largeDownload slide This 26-year-old woman’s axial CT images are compared. She has mild right hemifacial atrophy. She was injected with 65 mL of enriched lipoaspirate. The preoperative image (A) includes 2 measurements, a 45-mm long-axis measurement and a 20-mm short perpendicular axis measurement. The Canfield imaging software was used to measure dimensions and the computer-generated measurements are superimposed by the program. The length of the short axis is actually 1.06 cm (10.6 mm), based on a 45-mm length of the long axis. Postoperatively, the length of the short axis is labeled 33 mm (B). The true length is 1.31 cm (13.1 mm). This depth measurement increases 2.5 mm (10.6 mm to 13.1 mm) after surgery, not 13 mm. The area (shaded), calculated using the Canfield area measurement function using the 2 marked axes measures 4.37 cm2 (A). The treated area increases 0.78 cm2 1 year after lipoinjection (B). The area decreases 1.00 cm2 on the untreated left side. Adapted from Gontijo-de-Amorim et al.1 These findings may be compared with the 18-year-old man with severe Parry-Romberg syndrome who was treated with a similar fat volume (70 mL) on the affected left side, but without SVF supplementation. In this patient, the labeled depth measurements are closer to the true measurements (Figure 2). This patient’s preoperative treatment area measures 4.58 cm2 (Figure 2A) and the postoperative area is 6.78 cm2 (Figure 2B), for a difference of 2.20 cm2. The difference on the right control side, 0.31 cm2, is minimal and probably lies within the margin of error. This patient demonstrates a 48% increase in area on the injected side, which equates to a 119% (1.48 × 1.48) increase in volume, or a gain of 4.84 cm3. Figure 2. View largeDownload slide This 18-year-old man’s preoperative (A) and 12-month postoperative (B) axial CT images are compared. He has severe Parry-Romberg syndrome causing left facial atrophy and deviation of the nose to the affected side. He was injected with 70 mL of nonenriched fat. Computer measurements are calibrated using the 51.0 mm length of the long axis on the right side. The lengths of the labeled perpendicular axes are similar to the computer-assigned Canfield measurements, although they are not identical. After lipoinjection, the area of the left treated side increases 2.20 cm2 vs 0.31 cm2 on the control side (B). Adapted from Gontijo-de-Amorim et al.1 Figure 2. View largeDownload slide This 18-year-old man’s preoperative (A) and 12-month postoperative (B) axial CT images are compared. He has severe Parry-Romberg syndrome causing left facial atrophy and deviation of the nose to the affected side. He was injected with 70 mL of nonenriched fat. Computer measurements are calibrated using the 51.0 mm length of the long axis on the right side. The lengths of the labeled perpendicular axes are similar to the computer-assigned Canfield measurements, although they are not identical. After lipoinjection, the area of the left treated side increases 2.20 cm2 vs 0.31 cm2 on the control side (B). Adapted from Gontijo-de-Amorim et al.1 Despite similar fat injection volumes, the patient treated without the SVF supplement shows much more improvement in area and volume based on CT measurements. However, the volume increments for both patients are still far less than the total volume of fat injected. The patient with the advanced Parry-Romberg syndrome (Figure 2) demonstrates a 7% (5 mL/70 mL) calculated volume retention at 12 months. The patient with mild hemifacial atrophy (Figure 1) injected with enriched fat has even less fat retention (1 mL/65 mL), approximately, 1.5% of the original volume. Looking at it another way, the enriched-fat patient lost 98.5% of the injected volume, vs a 93% loss for the patient treated without fat enrichment. These findings stand in stark contrast to the authors’ conclusions. It is unclear why CT was used as opposed to magnetic resonance imaging (MRI), which avoids unnecessary patient radiation and provides excellent fat imaging with T1-weighting.3 It is more difficult to differentiate fat from other soft tissues on CT images. For this reason, MRI has been used in previous studies of facial fat volume.3-5 Patients with Parry-Romberg syndrome or previous trauma may have confounding variables such as an unknown disease process causing fat absorption, or scarring that might limit soft tissue expansion. The results are unlikely to be generalizable to the cosmetic surgery population. By injecting one side, the authors have a control side available, which is useful to control for known and unknown confounders such as weight gain. In the absence of contralateral measurements, patient weights would be useful to rule out weight gain as a confounder. The authors state that their patients were randomized by order of enrollment.1 This is not an acceptable form of randomization because it is subject to selection bias and inadequate concealment.6,7 The authors do not state how they randomly chose patients for CT studies.1 The two featured patients differ greatly in the degree of hemifacial atrophy, favoring the enriched-fat patient. Selection bias likely affects the photographic evaluations. Separating fat fractions, whether mechanically or enzymatically, adds time, cost, and resources to the treatment. This article does not provide the needed level of scientific rigor to justify adopting this method. Disclosures Dr Swanson receives royalties from Springer Nature (New York, NY) but declared no conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Gontijo-de-Amorim NF, Charles-de-Sá L, Rigotti G. Mechanical supplementation with the stromal vascular fraction yields improved volume retention in facial lipotransfer: a 1-year comparative study. Aesthet Surg J . 2017; 37( 9): 975- 985. Google Scholar CrossRef Search ADS PubMed  2. Pallua N, Kim BS. Commentary on: Mechanical supplementation with the stromal vascular fraction yields improved volume retention in facial lipotransfer: a 1-year comparative study. Aesthet Surg J . 2017; 37( 9): 986- 987. Google Scholar CrossRef Search ADS PubMed  3. Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after face lift and fat injection. Plast Reconstr Surg . 2011; 127( 5): 2057- 2065. Google Scholar CrossRef Search ADS PubMed  4. Gosain AK, Amarante MT, Hyde JS, Yousif NJ. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg . 1996; 98( 4): 622- 636. Google Scholar CrossRef Search ADS PubMed  5. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg . 2005; 115( 4): 1143- 1152; discussion 1153-1155. Google Scholar CrossRef Search ADS PubMed  6. Swanson E. Levels of evidence in cosmetic surgery: analysis and recommendations using a new CLEAR classification. Plast Reconstr Surg Glob Open . 2013; 1( 8): e66. Google Scholar CrossRef Search ADS PubMed  7. Sackett DL, Straus SE, Richardson WSet al.   Therapy. In: Evidence-based Medicine . 2nd ed. Toronto, ON: Churchill Livingstone; 2000: 105- 153. © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Does Stromal Vascular Fraction Supplementation Improve Facial Lipotransfer?

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© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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10.1093/asj/sjx201
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Abstract

Gontijo-de-Amorim et al1 claim that fat enriched with the stromal vascular fraction (SVF) improves volume retention after facial lipotransfer. The authors describe a comparison of 5 patients injected with enriched fat vs 5 patients injected without SVF supplementation using computed tomography (CT). The authors report that the enriched fat group lost only 9.6% of its volume vs 24% in the untreated group.1 The authors simply centrifuge the lipoaspirate rather than separating it enzymatically using collagenase to isolate adipose-derived stem cells.1 Whether the cell pellet left at the bottom of the tube after centrifugation truly represents the SVF is open to question.2 Although box plots are included, the actual measurement data for the 10 patients are not reported. The authors provide 2 clinical examples along with their axial CT scan images. The area of fat injection is indicated by 2 linear measurements. It is not clear how volumes were calculated from these linear dimensions. Regardless, errors in these measurements beg disclosure. For the 26-year-old woman with mild Parry-Romberg syndrome injected with 65 mL of enriched fat, the linear measurement perpendicular to the 45-mm long axis is labeled “20 mm” on the preoperative image (Figure 1A). This length should be almost half the length of the 45-mm measurement. However, this length appears to be less than ¼ of the longer measurement. The Canfield 7.4.1 imaging software (Canfield Scientific, Fairfield, NJ) applies the measurement label directly onto the image, reducing the risk of error. Using this imaging software, the length of the shorter limb measures 1.06 cm (10.6 mm), not 20 mm, if the 45-mm measurement is used for calibration (note: the assumption is made that the longer measurement is the correct one). On the postoperative image (Figure 1B) this depth measurement is labeled 33 mm although the actual measurement is 1.31 cm (13.1 mm). Therefore, the postoperative increment in thickness is only 2.5 mm (1/10 inch), not 13 mm. The area increases from 4.37 cm2 to 5.15 cm2, a difference of 0.78 cm2 (18%). An area difference of 18% corresponds to a volume increment of 39% (1.18 × 1.18), assuming equal volume expansion in all 3 planes, or 0.61 cm3. Surprisingly, measurements on the contralateral untreated side reveal a decrease in area of 1.0 cm2 (14%). The reason for this reduction in unclear. A possible explanation is weight loss during the 1-year period between CT studies. Controlling for this difference on the treated side raises the area increase on the treated right side slightly, to 0.90 cm2. Figure 1. View largeDownload slide This 26-year-old woman’s axial CT images are compared. She has mild right hemifacial atrophy. She was injected with 65 mL of enriched lipoaspirate. The preoperative image (A) includes 2 measurements, a 45-mm long-axis measurement and a 20-mm short perpendicular axis measurement. The Canfield imaging software was used to measure dimensions and the computer-generated measurements are superimposed by the program. The length of the short axis is actually 1.06 cm (10.6 mm), based on a 45-mm length of the long axis. Postoperatively, the length of the short axis is labeled 33 mm (B). The true length is 1.31 cm (13.1 mm). This depth measurement increases 2.5 mm (10.6 mm to 13.1 mm) after surgery, not 13 mm. The area (shaded), calculated using the Canfield area measurement function using the 2 marked axes measures 4.37 cm2 (A). The treated area increases 0.78 cm2 1 year after lipoinjection (B). The area decreases 1.00 cm2 on the untreated left side. Adapted from Gontijo-de-Amorim et al.1 Figure 1. View largeDownload slide This 26-year-old woman’s axial CT images are compared. She has mild right hemifacial atrophy. She was injected with 65 mL of enriched lipoaspirate. The preoperative image (A) includes 2 measurements, a 45-mm long-axis measurement and a 20-mm short perpendicular axis measurement. The Canfield imaging software was used to measure dimensions and the computer-generated measurements are superimposed by the program. The length of the short axis is actually 1.06 cm (10.6 mm), based on a 45-mm length of the long axis. Postoperatively, the length of the short axis is labeled 33 mm (B). The true length is 1.31 cm (13.1 mm). This depth measurement increases 2.5 mm (10.6 mm to 13.1 mm) after surgery, not 13 mm. The area (shaded), calculated using the Canfield area measurement function using the 2 marked axes measures 4.37 cm2 (A). The treated area increases 0.78 cm2 1 year after lipoinjection (B). The area decreases 1.00 cm2 on the untreated left side. Adapted from Gontijo-de-Amorim et al.1 These findings may be compared with the 18-year-old man with severe Parry-Romberg syndrome who was treated with a similar fat volume (70 mL) on the affected left side, but without SVF supplementation. In this patient, the labeled depth measurements are closer to the true measurements (Figure 2). This patient’s preoperative treatment area measures 4.58 cm2 (Figure 2A) and the postoperative area is 6.78 cm2 (Figure 2B), for a difference of 2.20 cm2. The difference on the right control side, 0.31 cm2, is minimal and probably lies within the margin of error. This patient demonstrates a 48% increase in area on the injected side, which equates to a 119% (1.48 × 1.48) increase in volume, or a gain of 4.84 cm3. Figure 2. View largeDownload slide This 18-year-old man’s preoperative (A) and 12-month postoperative (B) axial CT images are compared. He has severe Parry-Romberg syndrome causing left facial atrophy and deviation of the nose to the affected side. He was injected with 70 mL of nonenriched fat. Computer measurements are calibrated using the 51.0 mm length of the long axis on the right side. The lengths of the labeled perpendicular axes are similar to the computer-assigned Canfield measurements, although they are not identical. After lipoinjection, the area of the left treated side increases 2.20 cm2 vs 0.31 cm2 on the control side (B). Adapted from Gontijo-de-Amorim et al.1 Figure 2. View largeDownload slide This 18-year-old man’s preoperative (A) and 12-month postoperative (B) axial CT images are compared. He has severe Parry-Romberg syndrome causing left facial atrophy and deviation of the nose to the affected side. He was injected with 70 mL of nonenriched fat. Computer measurements are calibrated using the 51.0 mm length of the long axis on the right side. The lengths of the labeled perpendicular axes are similar to the computer-assigned Canfield measurements, although they are not identical. After lipoinjection, the area of the left treated side increases 2.20 cm2 vs 0.31 cm2 on the control side (B). Adapted from Gontijo-de-Amorim et al.1 Despite similar fat injection volumes, the patient treated without the SVF supplement shows much more improvement in area and volume based on CT measurements. However, the volume increments for both patients are still far less than the total volume of fat injected. The patient with the advanced Parry-Romberg syndrome (Figure 2) demonstrates a 7% (5 mL/70 mL) calculated volume retention at 12 months. The patient with mild hemifacial atrophy (Figure 1) injected with enriched fat has even less fat retention (1 mL/65 mL), approximately, 1.5% of the original volume. Looking at it another way, the enriched-fat patient lost 98.5% of the injected volume, vs a 93% loss for the patient treated without fat enrichment. These findings stand in stark contrast to the authors’ conclusions. It is unclear why CT was used as opposed to magnetic resonance imaging (MRI), which avoids unnecessary patient radiation and provides excellent fat imaging with T1-weighting.3 It is more difficult to differentiate fat from other soft tissues on CT images. For this reason, MRI has been used in previous studies of facial fat volume.3-5 Patients with Parry-Romberg syndrome or previous trauma may have confounding variables such as an unknown disease process causing fat absorption, or scarring that might limit soft tissue expansion. The results are unlikely to be generalizable to the cosmetic surgery population. By injecting one side, the authors have a control side available, which is useful to control for known and unknown confounders such as weight gain. In the absence of contralateral measurements, patient weights would be useful to rule out weight gain as a confounder. The authors state that their patients were randomized by order of enrollment.1 This is not an acceptable form of randomization because it is subject to selection bias and inadequate concealment.6,7 The authors do not state how they randomly chose patients for CT studies.1 The two featured patients differ greatly in the degree of hemifacial atrophy, favoring the enriched-fat patient. Selection bias likely affects the photographic evaluations. Separating fat fractions, whether mechanically or enzymatically, adds time, cost, and resources to the treatment. This article does not provide the needed level of scientific rigor to justify adopting this method. Disclosures Dr Swanson receives royalties from Springer Nature (New York, NY) but declared no conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Gontijo-de-Amorim NF, Charles-de-Sá L, Rigotti G. Mechanical supplementation with the stromal vascular fraction yields improved volume retention in facial lipotransfer: a 1-year comparative study. Aesthet Surg J . 2017; 37( 9): 975- 985. Google Scholar CrossRef Search ADS PubMed  2. Pallua N, Kim BS. Commentary on: Mechanical supplementation with the stromal vascular fraction yields improved volume retention in facial lipotransfer: a 1-year comparative study. Aesthet Surg J . 2017; 37( 9): 986- 987. Google Scholar CrossRef Search ADS PubMed  3. Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after face lift and fat injection. Plast Reconstr Surg . 2011; 127( 5): 2057- 2065. Google Scholar CrossRef Search ADS PubMed  4. Gosain AK, Amarante MT, Hyde JS, Yousif NJ. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg . 1996; 98( 4): 622- 636. Google Scholar CrossRef Search ADS PubMed  5. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg . 2005; 115( 4): 1143- 1152; discussion 1153-1155. Google Scholar CrossRef Search ADS PubMed  6. Swanson E. Levels of evidence in cosmetic surgery: analysis and recommendations using a new CLEAR classification. Plast Reconstr Surg Glob Open . 2013; 1( 8): e66. Google Scholar CrossRef Search ADS PubMed  7. Sackett DL, Straus SE, Richardson WSet al.   Therapy. In: Evidence-based Medicine . 2nd ed. Toronto, ON: Churchill Livingstone; 2000: 105- 153. © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Feb 1, 2018

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