Dermal-Subcutaneous Tissue Regeneration with Stromal Vascular Cell Enriched Fat Transfer: A New Frontier for Treatment of Perioral Aging

Goals/Purpose: Perioral aging is often neglected or under treated during facial rejuvenation procedures. In order to successfully treat perioral aging, each structure from epithelial surface to underlying subcutaneous tissue to dental and osseous support system must be analyzed and addressed. The dermal and subcutaneous tissues are have been shown to undergo marked loss of nutritional vascular network, which results in loss of basilar dermal microprojections into the epithelium, leading to tissue shearing and subsequent laxity. Moreover, loss of dermal and subcutaneous tissue thickness further contributes to the aging process. Stromal vascular cells have shown experimentally and clinically to increase angiogenesis, reduce apoptosis, increase fat graft survival and bring in scores of growth and trophic factors. Herein, we report our multimodality approach to perioral aging, which includes the first clinical applications of stromal vascular cell enriched fat to restore aged dermal-subcutaneous tissue during facial rejuvenation.

Methods/Technique: All patients presenting with facial aging are evaluated for the degree of photoaging, loss of soft tissue volume, depth of rhytids, degree of skin laxity and the status of the underlying dental osseous support system. A decision is made about the correct surgical procedure and whether or not to treat the surface stigmata of photoaging at the time of the facelift or 3 months after the procedure. In general, patients with less degrees of photoaging are treated at the time of surgery with a fractional laser (1550 nm and 1927 nm) and those with more severe photoaging are treated at 3 months after surgery with a fractional CO2 laser. At the commencement of the procedure, approximately 300 ml of fat is harvested using 60 ml Toomey syringes with a 3 mm cannula. Approximately 150 ml is placed into a device for cell processing using a proprietary, pharmaceutical grade, sterile, non-mammalian collagenase type enzyme. The remaining fat is placed into an FDA approved bi-laminar filtration bag and rinsed with lactated ringers and gravity drained until clean. Following the facelifting procedure, the stromal vascular cells are added to the filtrated fat and cell enriched fat grafting is performed for augmentation (temporal regions, brows, malar region, buccal hollows, lips, nasojugal depressions, nasolabial folds) and for dermal-subcutaneous restoration (upper lip skin, lower lip skin, vermilion-cutaneous border, marionette basins vs. lines, periorbital rhytids, acne scars when present, pogonion) with either a 3 ml syringe and finger wheel device or an automatic delivery device and disposable cannulae (18, 19, 20 gauge).

Results/Complications: Fifteen patients have been treated using dermal-subcutaneous tissue restoration with stromal cell enriched fat grafts for perioral rejuvenation. Of these patients, 5 have undergone simultaneous non-ablative, fractional laser at the time of their mini-facelift or facelift procedure. Another 5 underwent fractional CO2 laser treatment at 3 months. The remaining 5 patients have yet to have laser treatments. Reduction of wrinkle depth of radial lip lines, marionette lines and nasolabial folds was evident in all patients regardless of whether they underwent laser treatment. Subtle, but obvious improvement in skin pigmentation and texture were evident in the majority of patients. No patient required secondary surgery because of excess fat. There were no complications related spefically to dermal-subcutaneous cell enriched fat injection.

Conclusion:

Restoration of dermal-subcutaneous tissue is feasible with stromal enriched fat grafting. Improvement in wrinkle depth, 10-15% increase in lip fullness and subtle changes in skin texture and pigmentation was accomplished with or without the additive effects of laser resurfacing. Dermal-subcutaneous tissue regeneration is a viable option in perioral and facial rejuventation. The use of stromal vascular cells appears to have beneficial effects on perioral rejuvenation. Further study with histologic verification of improvements in dermal and subcutaneous micovasculature as well as possible improvement and/or reversal of aging of elastin fibers is necessary to substantiate this new approach.