Injectable Tissue Replacement and Regeneration: Anatomic Fat Grafting to Restore Decayed Facial Tissues

Abstract

Aging is a dynamic process that can be modeled and understood tissue by tissue and cell by cell. Numerous authors have helped us understand the anatomy of facial fat compartments and the effects of aging on our facial tissues such as skin, fat, bone and fibrous ligaments. Injectable tissue replacement and regeneration (ITR2) is a method to replace decayed tissues of the face using "like tissues" in an effort to delay or slow the rate of tissue decay seen in facial aging. Facial topography and proportion analysis are performed to diagnose individual-specific losses of facial fat. The degree of sun damage and skin thinning is noted as is the degree of loss in the superficial fat compartment. Deep compartment fat loss is evaluated as is pyriform aperture, orbital, mandibular ramus, mandibular body, and chin resorption. From this analysis, a detailed treatment plan is formulated. Using a mechanical device, 3 different fat grafts are created: 2 mm (millifat), 1 mm (microfat), and 500 microns (cell optimized, matrix rich nanofat); anatomic replacement of all areas of tissue loss is carried out. Millifat is used for deep compartment and bone losses, microfat for superficial fat losses above the facial musculature and nanofat is used intradermally and as a biological cream for topical application. The rationale behind this standardized approach is explained and the scientific foundations for the idea are presented. Reduction in tissue decay appears to be a valid observation, but awaits others confirmation.

Fig. 1.

A 33-year-old patient is shown (A) and (B) 6 years later, just before receiving full facial ITR² rejuvenation. In (B), the subtle signs of aging around the eyes, marionette basins, cheeks and pyriform region can be appreciated. At this stage, by replacing the lost volume in an anatomically precise manner that addresses all areas of deep and superficial fat loss, bone loss, skin atrophy, and photodamage, tissue mass is increased, blood supply improved, sustaining and replacing lost tissues and reducing or even reversing some elements of decay, and aging. C, Patient is shown 6 months after ITR². ITR², injectable tissue replacement and regeneration.

Fig. 2.

In these photomicrographs, aged skin (A) has been treated with mechanically dissociated, SVF-enriched fat grafts (B). Three months after treatment, regeneration of elastin and collagen can be seen with improvement in capillary density. Reprinted with permission from Plastic and Reconstr Surg. 2015;135:999–1009.

Fig. 3.

The superficial and deep fat compartments of the face.

Fig. 4.

Cadaver dissections of superficial (A) and deep (B) fat compartments of the midface. Note the deep fat compartments are below the muscles and more “pillowy,” like buccal fat, whereas the superficial fat is more tightly clustered parcels separated by increasingly arborized fascial extensions.

Fig. 5.

Arborization of the retaining ligaments through the 5 facial layers. SMAS, superficial muscular aponeurotic system.

Fig. 6.

A 54-year-old woman who presented with modest sun damage, superficial and deep compartment fat loss and mild laxity seen in the jowls and neck. Orbital expansion created a subtle appearance of pseudoptosis and “senile” enophthalmos, which according to the patient looked as if her “eyes were falling back into her skull.” The appearance of the aged orbit and periorbital tissues in some patients is analogous to a posttraumatic orbital deformity, where correction of the orbital volume enlargement corrects the pseudoptosis (A). This patient underwent ITR² fat grafting to all areas of tissue loss, including the upper eyelid sulcus beneath the orbicularis, intraorbital fat grafting in the inferior lateral aspect of the orbit, the lips and pyriform, deep and superficial fat compartments of the cheeks, upper and lower eyelids, supraorbital rims, forehead and temples as well as the inferior mandibular border and gonial angle along with “pinch” upper and lower blepharoplasties. B, Patient is shown at 1 year postoperatively. ITR², injectable tissue replacement and regeneration.

Fig. 7.

A, A 67-year-old patient is shown with fat loss in superficial and deep fat compartments, modest sun damage, and modest skin laxity. B, The ITR² treatment plan is created for each individual patient based on areas of bone and fat loss and skin thinning. The red overlays represent areas of deep fat loss to be treated with millifat, and the orange areas represent areas of bone loss to be addressed with millifat. C, The blue overlays represent areas of superficial fat loss to be treated with microfat and/or nanofat. D, Patient is shown 6 months postoperatively. ITR², injectable tissue replacement and regeneration.

Fig. 8.

The 12-holed harvesting cannula with 2.5 mm diameters hole sizes used for direct harvest of millifat.

Fig. 9.

A, A 70-year-old patient with superficial fat and deep fat loss is shown preoperatively. B, Patient is shown 6 months postoperatively after being treated with a facelift (high SMAS), Platysmaplasty, U/L Bleph, 18 ml of SVF-enriched fat grafting in 3 sizes to the upper eyelid sulcus, lips, buccal fat pad, temporal regions, forehead, perioral tissues, deep medial cheek and medial and lateral SOOF, and a dual fractional laser. SMAS, superficial muscular aponeurotic system; SOOF, suborbicularis oculi fat; SVF, stromal vascular fraction.

Fig. 10.

A, Patient is shown preoperatively with deepened nasolabial folds and fine lines around the lips. B, Patient is shown 6 years postoperatively after her perioral region was injected with SVF-enriched cells to treat nasolabial folds, lips and radial wrinkle lines of the perioral tissues that had deepened due to age. SVF, stromal vascular fraction.