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AAMSSA Recommendations Use of Fat for Regenerative Purposes in Aesthetic Medicine Issued 2 September 2020

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AAMSSA Recommendations Use of Fat for Regenerative Purposes in Aesthetic Medicine Issued 2 September 2020 AAMSSA Recommendations Use of Fat for regenerative purposes in Aesthetic Medicine Issued 2 September 2020 Introduction Autologous fat cell grafting is becoming more accessible as a popular, effective, and reproducible technique in many fields of medicine. The regenerative potential of fat has been used in many fields of medicine such as Plastic Surgery, Orthopedic Surgery and Gynaecology, and is touted as the future of Regenerative and Aesthetic Medicine. The rapid growth of the use of Nanofat and Stromal Vascular Fraction (SVF) in the non-surgical fields has revolutionized the use of fat for its cellular and regenerative properties. The more recent development of simple syringe systems for harvesting fat has brought the use of fat regeneration within the scope of the Dermatologist and Aesthetic Practitioner. However there is a lot of misunderstanding about the different forms of fat harvesting and processing as well as confusion over terms. There is also little regulation over scope of practice regarding which doctors can safely perform these procedures. This guideline explains and clarifies the terminology used in regenerative medicine and outlines the AAMSSA recommendations for Aesthetic GP’s when working with fat. GP’s with a special interest in Aesthetic Medicine need to clearly understand their scope of practice and work within safe boundaries. Terminology It is important that Aesthetic Practitioners understand the different types of fat grafting and forms of fat used, as well as the different means of harvesting and processing fat. There are three forms of fat used in autologous fat transfer. Nanofat which is used for cellular rejuvenation purposes is to be differentiated from Microfat and Macrofat which are used in lipo-filling for volume enhancement. Macrofat • Large fat globules are 1200-2000µm in diameter • Fat is harvested through traditional lipo-suction aspirate with standard Coleman 3 mm cannula • Fat globules undergo various processing methods including rinsing, filtering, cotton gauze sieving and centrifugation • Macrofat is appropriate for large volume fat harvesting and grafting for body sculpting e.g. breast reconstruction • The viability of harvested fat is reduced due to fat cluster size and processing • There are unpredictable resorption rates, with over 50 % graft loss and inconsistency in results • Macrofat grafting should be performed in a sterile environment in theatre by a surgeon equipped and trained to handle any adverse effects [email protected] www.aestheticdoctors.co.za Microfat • Microfat globules are < 900µm (0.9 mm) in diameter • Microfat is harvested with a multi-port small hole cannula • Less processing is required • Microfat is reinjected through a blunt cannula between 0.7 and 0.9 mm in diameter • There is better uptake and viability compared to Macrofat globules, although up to 50 % graft loss is expected • Microfat is suitable for performing small volume lipo-filling and tissue regeneration of the face and delicate areas such as periorbital area and lips. • Microfat grafting should be performed in a sterile environment in theatre by a surgeon equipped and trained to handle any adverse effects Nanofat (Processed Microfat) • Nanofat is Microfat that has been mechanically emulsified into a liquid form • Fat is passed back and forth through 2 syringes connected with a two way-connector, until fat becomes liquid with a whitish appearance • Emulsified fat is then filtered to remove connective tissue remnants • Nanofat is not a true fat grafting procedure as no viable adipocytes remain, but it is rich in Stromal Vascular Fraction (SVF) containing Adipose Derived Stem Cells • Apoptotic fat cells in Nanofat have the additional benefit of releasing cytokines, attracting macrophages and growth factors • Nanofat is indicated for tissue regeneration • The volumetric effect is very limited • Results are seen in 4-6 months • Nanofat is administered much like a “skin booster” e.g. manually injected using a 27 G needle or fanning using a cannula or via a Mesogun. Nanofat can also be infused into the dermis using a micro-needling device. • Use of Nanofat falls within the scope of an Aesthetic GP. Enhancing Nanofat with PRP Platelet-Rich Plasma (PRP) can be combined with Nanofat. PRP provides a high concentration of Growth Factors to the Nanofat providing important trophic effects early in the healing process Adipose-Derived Mesenchymal Stem Cells The richest location of stem cells in the human body is in the fat layer. Over 2.5% of the cells in fat are stem cells and regenerative cells, while less than 0.003% of bone marrow cells are stem cells. Adipose- derived stem cells have a multipotent proliferative capacity with the ability to differentiate into a variety of cell types including osteoblasts, chondrocytes, myocytes, fibroblasts and adipocytes. Adipose tissue is the largest microvascular organ in the body, and is an easily accessible, abundant, autologous source of stem cells. However in Regenerative Medicine adipose cells are not the most important cell group. It is the complex group of stromal and stem cells in the Stromal Vascular Fraction (SVF) that replace apoptotic adipocytes during grafting procedures that are most valuable. [email protected] www.aestheticdoctors.co.za Stromal Vascular Fraction (SVF) SVF is the heterogeneous cell population within adipose tissue. SVF contains stromal cells, bioactive scaffolding (extracellular matrix) and the microvascular environment of adipose tissue. Stromal cells consist of endothelial cells, smooth muscle cells, macrophages, fibroblasts, pre-adipocytes, and stem cells. The vascular component includes perivascular and endothelial cells necessary for neovascularization of the grafted adipocytes, improving graft retention. Liposuction Fat is traditionally harvested in a sterile environment in a theatre through various forms of liposuction. Classic liposuction techniques and large volume fat grafting or lipo-filling fall within the scope of surgery and should be performed by a plastic and reconstructive surgeon in theatre. Different forms of liposuction include: • SAL (Standard/Suction Assisted Liposuction) • PAL (Power Assisted Liposuction) • UAL (Ultrasonic Assisted Liposuction) • LAL (Laser Assisted Lipolysis) • WAL (Water Assisted Liposuction) Lipo-Aspiration Although technically lipo-aspiration is simply another form of liposuction, lipo-aspiration syringe systems or devices are designed for use by the Aesthetic Practitioner or Dermatologist in their consulting rooms. • Sterile disposable closed syringe systems are used to harvest the small volume of fat required to produce Nanofat. • Small volumes of tumescent solution is used • Simple filtration and purification systems using centrifugation or gravity separate aspirate into layers of tumescent fluid, fat cells and a very fine SVF layer • Lipo-aspiration systems are designed for harvesting SVF for the stem cells. No viable fat cells remain after processing. Understanding the risks of Liposuction and Lipo-aspiration There are valid reasons that liposuction in the doctor’s rooms is not accepted practice by the HPCSA. Harvesting from an extremity in an unsterile environment can lead to infection, cellulitis and necrotizing fasciitis. With an inadequately qualified practitioner perforations of vessels and bowels are also a reality. Other common adverse effects include oedema, ecchymosis, hematoma, seroma, hyperaesthesia and paraesthesia. Serious complications include cardiac arrest and fat embolism. There have been far more cases of blindness due to fat filling than blindness due to HA fillers. Extremely dangerous practices include the “Brazilian Butt lift” and breast augmentation which have resulted in serious and even fatal complications. Harvesting fat, no matter what technique used, is still a form of liposuction. Any cannula that is placed under the skin carries the same risk whether a doctor is removing 10 cc or 1000cc of fat. [email protected] www.aestheticdoctors.co.za Comparing Nanofat to a traditional HA “skin booster” Nanofat has excellent regenerative capacity in the skin, and if injected in a safe subdermal plane, has a definite place in Aesthetic Medicine. However the Aesthetic Practitioner needs to weigh up the benefits of Nanofat compared to the time required, equipment needed, cost of harvesting, risks involved and recovery time. Injecting a skin booster gives predictable results at far less risk and cost. Modern skin boosters contain not only hyaluronic acid but bio-revitalizing and dermal restructuring complexes such as amino acids, antioxidants, minerals and vitamins. Comparing Microfat to Dermal fillers It is important for the Aesthetic Practitioner to understand that in order to get the same effect as 3 vials (3ml) of dermal filler one needs to inject at least 50 ml of processed fat to get the same lifting capacity. 50 % graft loss is expected with the risk of inconsistent results, asymmetrical outcomes and disappointed clients. Expectations of success are often unrealistic. Aesthetic Medical doctors like to reassure patients that aesthetic treatments are by nature temporary and reversible. However fat grafting is permanent. Fillers can be easily removed, however incorrectly placed fat will be visible forever. Consistency of Microfat survival is unpredictable with many variables including harvesting and processing methods and techniques. Dermal fillers are highly predictable with consistent results. The risks and complications relating to fat grafting
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