Injectables Adipose Tissue. Past Present and Future.pptx

Injectable Adipose
Tissue (IAT). Past,
Present and Future
Prof. Osama B. Moawad, MSc.,
MD.
President of
Egyptian Society of Cosmetic
Surgery and Laser (ESCSL)

email address: askprof@moawadskininstitute.com 2

History
• Historically, the use of fat grafts to
correct congenital deformities and
complex traumatic wounds was
proposed in 1893 by Neuber,
Hollander in 1912, Neuhoff in
1921, and Josef in 1931.
• The liposuction technique was
introduced by Fisher in 1974,
followed by the tumescent
technique by Klein in 1985.

History
• In 1986, Ellenbogen
described the
utilization of fat
grafting in aesthetic
surgery.
• In 1987, Coleman
standardized fat
grafting.

History
• In the early nineties, I
was fascinated with Dr.
J. Fulton and how he
used fat grafting in acne
scars.
Dr. J. Fulton email address: askprof@moawadskininstitute.com 5

History
• I did the first case
of IAT to treat acne
scars (1997) at a
Security Forces
Hospital in Saudi
Arabia.

History
• Rohrich and
Pessa, in 2007,
described the
anatomy of fat
compartments of
the face.

History
• Tonnard et al.
coined the term
“Nanofat” in
2013.

Indications
• IAT is indicated
for any volume
loss in soft tissues
and/or bone, due
to congenital,
aging, weight loss,
disease or other
causes.

Indications
• A matrix classification
of small-volume versus
large-volume and
regenerative versus
non-regenerative cases
yields four distinct
indications.
The surgeon should remember that the first is not to harm

Physical
Examination
. Aging vs.
Aesthetics
• Aging of the Face is easy
to diagnose, and it is
manageable.
• Ideal aesthetics of the
face are challenging to
define and much more
difficult to achieve.

Why Aesthetics
and Anatomy?
• Knowing the anatomy of
the aging face and the
ideal aesthetics will
better inform us about
optimal injection
materials and the
required volumes in an
economized approach.

Dermal White
Adipose Tissue
(dWAT)
• Dermal white adipose
tissue (dWAT) in the papillary
dermis contains adipocytes
with phenotypical and
functional properties that
differ from those located
deeper in the subcutaneous
white adipose tissue (sWAT).

Dermal White
Adipose Tissue
(dWAT)
• dWAT adipocytes could be
involved in spatially local
crosstalk with skin cells in
aging, wound healing,
scarring, hair growth, and
inflammatory and
pigmentary skin conditions.

The Reverse of
Aging Face
• The skin
rejuvenation
paradigm shifts
neocollagenesis
to spatial
modification of
AT.
KSA. Riyadh. 2000

Dermal White
Adipose Tissue
(dWAT)
• The non and minimally
invasive aesthetic
procedures will target
dermal adipocytes
in the hypodermis
instead of
fibroblasts in the
dermis.

Why Should I
Choose IAT?
• It is autologous.
• Inexpensive.
• Easy to obtain.
• It integrates into tissues giving
long-lasting results.
• It is a dynamic tissue with
regenerative capabilities.

When Should I Not ?
• It might be expensive initially.
• Downtime afterward is at least two
weeks.
• Results are unpredictable.
• Weight fluctuations are a problem.
• Temporary filler patients should
wait at least one year.
• Semi-temporary or permanent
implant patients are not a
candidate.

When Should I Use
Synthetic Fillers?
• I use filler when I treat
patients who are not ready
for IAT.
• A younger patient who
needs minimal filling, no
downtime, cannot afford
IAT, and needs accurate
filling in hypoplastic lips or
a deep nasolabial fold.

When Should I
Not?
• Fillers are associated
with significant
complications such as
hypersensitivity and
infections.
Non-autologous filler injected at home by non-doctor
develop ?biofilm 3 years later

Autologous.
vs. Non-
autologous
• It will be years before
new generations of
fillers offer the cells and
the tissue benefits
beyond volume surgery.

IAT and
The Face
• IAT represents a simple
tool for creating the
aesthetic "ideal,"
targeting site-specific
reduction,
augmentation, or
straightening facial
features in a holistic
approach.

IAT and The
Face
• Using IAT, I can
reshape the
forehead, cheeks,
nose, chin, and
mandible without
needing implants
or bone surgery.

The
Forehead
• In frontal
deficiency, IAT can
create or restore
facial harmony.

Medial Eyebrow
and Upper
Eyelid
• I can restore uniform fullness and a unified
transition between the upper eyelid and
eyebrow devoid of shadowing.

Upper
Eyelid
• I can correct the "A deformity“ of the
upper eyelid by IAT intraocularly through
a lower transconjunctival incision.

The Tail of
Eyebrow and
Lateral Upper
Eyelid
• I can correct
temporal
hollowing, brow
descent and
crowding of the
upper lid using
IAT.

The Tail of
Eyebrow and
Lateral Upper
Eyelid
• I can lift the
brow by
augmenting the
temple and
lateral forehead.

The Midface
• Rejuvenating
the midface is
focused on
restoring the
dominance of
midface volume.

The Midface
• Dominance can
be achieved by
selectively
targeting deep fat
compartments,
especially the
pyriform space.

Lower Eyelid,
Infraorbital
Rim and Tear
Trough
• When treating the
lower eyelid, tear
trough and upper
cheek, I must do it
simultaneously as
these areas overlap.

Lower Eyelid,
Infraorbital
Rim and Tear
Trough
• At the same
time, I can
improve skin color
by injecting
nanofat into the
dermis.

The
Midface
• Using IAT
transforms the whole
face into a youthful
convex platform
dominated by unified
highlights.

The
Midface
• IAT of the midface
will lessen the
appearance of the
NLF, marionette, and
jowls and straighten
the jawline.

The Nose
Region
• Augmentation
rhinoplasty using
IAT can correct
deformities in
primary or revision
cases.

The Nose
Regions
• The nasal base and
the dorsum could be
augmented for
patients with a mild
hump, short , or
saddle nose.

The Nose
Region
• The nasal tip
can be enlarged,
re-contoured, or
elevated.

The Lips • In 2001 I did lip augmentation for the first
time.
Patient is a great Teacher

The Lips
• After twenty years, I can say that the IAT should be
injected to duplicate the lips' beauty and not simply
make the mouth larger or make "sausage-shaped"
lips.
Immediate Result

LABIO-MENTAL
CREASE
• Support for the lower lip and chin interface is
achieved by restoring the volume of the labio-
mental area.

Labiomandibular
Fold/Crease
(marionette)
• Augmenting the marionette folds needs
about 2-3 ml of millifat.

I can correct age-associated volume loss,
projection, vertical height or atrophic skin of the
chin.
The Chin

The
Mandible
• IAT of the jawline benefits patients with
long faces seeking beautification.

The Mandible • Augmentation of the mandible not only
delineates the jawline but also borrows skin from
the neck, enhancing the cervical mental angle.

Complementar
y
Procedures
• In an aging face with soft tissue atrophy and
decent, IAT might be combined with facelift
surgery.

• It will effectively address the central face soft tissue
atrophy and improve the appearance of the tear
trough, cheeks, and NLF.
Complementary
Procedures

Breast Lipofilling

Breast
Lipofilling
• Breast lipofilling is almost painless compared to
submuscular implant placement, with shorter
recovery and minor morbidity.
Immediate Results
MSI

Breast
Lipofilling
• Diffuse distribution of AT is ensured by placing
fat subcutaneously in different directions.
• No fat is placed into the mammary glands or
the pectoralis muscles.
Immediate Results
2002 Riyadh, KSA

Implant Removal
and
Simultaneous
IAT
• IAT can replace
breast implants
in a patient
with capsular
contracture.

Composite
Breast
Augmentation
• Alternatively, it may
be used with breast
implants to achieve
results that pass
one of them alone.
Breast

Breast
Reconstruction
• In breast
reconstruction, IAT
provides an option to
treat pectus excavatum,
irradiated breast as a
primary or secondary
procedure.

Breast
Lipofilling
• It offers more
precision and
tailored
augmentation than
those obtained with
silicone implants in
tuberous breasts.

Buttocks
Lipofilling
MSI

Buttocks
Lipofilling
• Buttock lipofilling
allows comprehensive
contouring of the entire
torso and buttock
region.

Buttocks
Lipofilling
• As with
breasts, I must
achieve an
appropriate
volume with a
beautiful shape.

Buttocks
Lipofilling
• IAT may replace
implant-based
buttocks
augmentation if
the patient has
enough fat.

Hands and
Feet Lipofilling

Hands and
Feet
Lipofilling
• Compared with synthetic fillers, IAT
works much better regarding longevity,
regenerative effect, and cost-
effectiveness.

Hands and
Feet
Lipofilling
• Immediately after
injection, the hands
appeared just
slightly overfilled.

Lipofilling of the
Dorsum of the
Foot
• Applying the same
technique, I
augmented the
feet’s dorsum
Fifteen years ago.

Lipofilling of
the Ankles
• Another case
report, was done ten
years ago, although I
do not recommend
ankle augmentation.

Body Contour Deformities and IAT

Body Contour
Deformities and IAT
• Body deformities can be
corrected by removing fat
from the excess, liposhifting
into the depressed area, or
with IAT.

Body Contour
Deformities and
Lipofilling
• Liposuction of the arm
may demand lipofilling
of the bicipital triangle
to achieve an even
distribution of the fat.

Regenerative and Reconstructive Surgery

Scars,
Fibrosis, and
Wounds
• IAT is used in
scars, fibrosis,
and wounds
based on its
ability to add
volume and
regenerative
properties.

Scars,
Fibrosis and
Wounds
• IAT has changed
my practice
intensely in
acne scars
treatment.

Scars, Fibrosis
and Wounds
• Initially, I used the Nokor
needle to subcise
adhesions and found space
to add fat.
Acne Scars

Scars, Fibrosis
and Wounds
• Nowadays, I do not
recommend using
sharp instruments or
microneedling.
Acne Scars email address: askprof@moawadskininstitute.com 71

Scars,
Fibrosis and
Wounds
• Blunt-tipped
cannulas to
make tunnels
better prepare
the recipient site
than subcision.
Acne Scars

Scars, Fibrosis
and Wounds
• I can create clean, multiple
linear tunnels to insinuate fat
parcels into a welcomed
recipient site.
Acne Scars

Scars, Fibrosis
and Wounds
• If adhesion is extensive, I use a
spatula-tipped cannula attached
to an oscillating power motor.
Acne Scars

Scars, Fibrosis
and Wounds
• I am applying the same concept to treat any
atrophic depressed scars.
Before
After
Traumatic Scar

Scars,
Fibrosis, and
Wounds
• IAT decreases the healing time, diminishing
scar thickness and allowing for more skin
flexibility due to its anti-fibrotic properties.
Burn Scar

Scars,
Fibrosis, and
Wounds
• It improves skin color.
Burn Scar
IAT+ Fractional CO2

Scars, Fibrosis,
and Wounds
• It reduces inflammation and immunoreactions
lessening pain and itchiness.
• Mixed with PRP, I used IAT in a patient with
hypersensitivity to an orthopedic fixation device.
Hypersensitivity Reactions

Scars, Fibrosis,
and Wounds
• In wounds with full-thickness soft tissue
loss, adding healthy AT can promote neo-
angiogenesis, granulation and
epithelialization of the ulceration.

• Putting together, you can achieve a result
beyond all other means.
Scars, Fibrosis, and Wounds

Dupuytren and Peyronie's Diseases
• IAT and breaking the fibrotic cord
of Dupuytren’s contracture
showed excellent results and
minimal recurrence rates.
• Would I apply the same treatment
for Peyronie's disease?

(PARRY–
ROMBERG
SYNDROME)
• IAT is the best
option for those
suffering from
hemifacial
atrophy.

Craniofacial Deformities
• In other maxillofacial syndromes, IAT is necessary as the primary
step or as a secondary procedure.

Autoimmune
Diseases
• It has the same effect on
“en coup de sabre” of
scleroderma.
• The addition of a stem
cell’s fraction of AT has
been proposed to treat
the symptoms of the hand
in systemic sclerosis and
rheumatoid arthritis.

Complication
s and
Management

Complications and
Management
• Although IAT is considered a safe
procedure, there are reports of
associated morbidity.
• The mild ones are the most common,
such as edema, ecchymosis, and
asymmetries due to hypo- or hyper-
correction, hypertrophy, reabsorption, or
displacement.

FAT EMBOLISM
AND VASCULAR
OCCLUSION
• Damage to the underlying
structures can occur in
reconstructive surgery
because surgeons use
sharp instruments in
deeper planes.
• It is never reported using a
blunt cannula.

Complications.
(Liposuction)
• The best way to treat
complications is to avoid
them.
• In large-volume lipofilling,
physicians should limit the
lipoaspirate to less than 5%
of the body weight and treat
less than 30% of the body
surface in one session.

Complications
and
Management
• Beware of the harms of
pervasive industry influence
on research, practice, and
education in healthcare.
• Surgeons should take the
time to learn the procedure
correctly and introduce it
into their practice gradually
and conservatively.

Evidence-Based Medicine and
Practice

Evidence Based
Medicine
• I retrospectively
reviewed patients' charts
and photos who
underwent body
contouring and IAT
procedures in KSA and
Egypt between 2002 and
2022.

Evidence Based
Medicine
• I assembled my clinical
practice, journal
publications, and books
read to provide unbiased,
evidence-based medicine
and practice data,
concerning IAT's benefits
and harms.

Evidence-based
Medicine
• The most crucial
consideration for IAT
is to respect and
maintain the tissue
architecture of living
adipocytes.

Evidence-based
Medicine
• There is no evidence to
support the superiority
of one processing
technique over another.
• New closed systems
have not been an
advantage over regular
"open“ systems.

SURVIVAL OF
THE IAT
• In reviewing the literature, whether IAT is
enriched or not, reabsorption of graft is
around 40–50 % of the injected volume.
• The Donor-site selection seems unimportant
from a cell survival standpoint.
6m 12m 24m
First session Second Session Third Session

Evidence-based
Practice
• Lipoextraction should be the same whether you are
extracting large or small volumes.
• Using machine suction or energy-dependent liposuction is
damaging to the delicate architecture of adipose tissue.
• In regenerative surgery, the hypodermis is a better plane
for harvesting.

Evidence-
Based Practice
• Processing AT should be the same
whether you inject large or small
volumes.
• In large volumes, I need more help to
re-inject the AT as soon as possible.
• I choose the lower third of the fatty
layer as it contains more stem cells in
regenerative surgery.

Evidence-Based
Practice
• Adipose tissue should be
replaced with adipose
tissue.
• Adipose tissue should be
placed where adipose
tissue is, and not into
the surrounding
muscles.
MSI

Research and The Future
• We need to understand better the
mechanism of how AT survives.
• We need studies specifically designed to
elucidate the role of adipose-derived
stem cells.
• Future studies will be needed to
understand the role of AT in facial aging
and how to fight skin aging the best.

Conclusion
• Based on clinical studies, IAT is an effective and safe
operation.
• It can be usedas a stand-alone treatment.
• It is combined with other procedures to achieve
results that exceed the core surgery alone.
• Regenerative medicine is heading towards using
autologous materials versus allogenic biological
products.

The Take Home
Message
We are injecting adipose tissue,
knowing little about it.
email address:
askprof@moawadskininstitute.com
102

Injectables Adipose Tissue. Past Present and Future.pptx

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