Four studies reported multiple complications, while 3 reports showed no complications and 3 reports did not mention complications at all. These complications reported in the 4 studies included donor-site hematoma (in 1 patient), mild post-operative erythema (in 2 patients), mild volumetric asymmetries (in 2 patients), chronic edema (in 2 patients), overcorrection (in 2 patients), skin irregularity (in 6 patients),[24,25] and headache or dysesthesia (in 7 patients).
Three-dimensional surface imaging devices can create a virtual 3D model of the face, breasts, and body contour in a standing patient and can simulate the post-augmentation appearance and calculate desired augmentation volumes. Studies have shown that the standard deviation of volume measurements in 3D imaging is approximately 2% compared to the real volumes.[27–29] This finding revealed good accuracy and reproducibility in volume measurements. There are several commonly used 3D surface imaging systems in the marketplace: the Axis3 (AX3 Technologies LLC, Miami, FL), the 3dMD (3dMD LLC, Atlanta, GA), and the Vectra (Canfield, Parsippany, NJ). These systems require an operator capable of clinical judgment. A not yet commercially available system called Precision Light presented by Creasman et al is able to automatically recognize anatomical landmarks. It can measure linear, contour, and volume parameters in the breasts. The reproducibility of its measurements is very high, with a reliability of 99.6%. This mechanism of combining 3D systems with automation is considered 4-dimensional technology, which can reduce operator/evaluator subjectivity and function at higher speed, thus improving the experience of clinical users.
Many factors have been considered relevant to the long-term retention of autologous fat. Studies have evaluated the impact of harvesting methods on fat graft retention rates, including hand-held syringe aspiration,[33–35] suction-assisted lipectomy,[33–36] and ultrasound-assisted lipectomy.[36,37] These studies demonstrated differences in cell survival and adipocyte functionality among in vivo animal experiments and human studies. However, no significant differences in the volume or weight of the fat grafts isolated by the different methods were observed in a study of immunocompromised mice. Surgeons now seem to agree that the actual harvesting methods are less important, as fat survival has been comparable among the different harvesting methods.
In recent years, adipocyte-derived stem cells, platelet-rich plasma (PRP), and stromal vascular fraction (SVF) have been widely used for both therapeutic and esthetic indications because of their capacity for angiogenesis and wound healing. Many studies have investigated the effects of cell-assisted fat grafting on increasing fat survival. Sasaki et al  reported a prospective study of 236 patients in 4 groups using conventional fat grafting, PRP-assisted fat grafting, SVF-assisted fat grafting, and PRP/SVF-assisted fat grafting. This study showed that PRP, SVF, and PRP/SVF cell assistance of processed fat resulted in a statistically significant mean graft retention rate (68.5%, 72.9%, and 69.7%, respectively) over their baseline control at 12 months compared to conventional fat grafting methods (38.3%).
In the last 2 years (2016–2018), 3 systematic reviews and meta-analyses have yielded statistical evidence of the effect of increasing fat grafting retention rates in cell-assisted fat grafting techniques. In Zhou et al's review, the pooled fat survival rate was significantly higher (P = 0.0096) in the CAL group (60%) than in the non-cell-assisted lipo-transfer (non-CAL) group (45%). In Laloze et al's review, the fat survival rate was significantly higher (P < 0.0001) in the CAL group (64%) than in the non-CAL group (44%), independent of injection site (breast or face). In Wang and Wu's review, the fat survival rate was significantly higher in the CAL group than in the non-CAL group, with a weighted mean difference of 25.85%, (P = 0.013). All of these studies revealed that CAL can result in superior fat survival rates compared to conventional lipo-injection.
Studies have also investigated the impact of fat-processing techniques. According to an American national consensus survey, 34% of plastic surgeons used centrifugation as a processing technique for fat grafting, 45% used gravity sedimentation, 34% used filtration, and 11% used gauze rolling.[43–46] In the latest animal studies, no significant difference was found in the structure or weight of the fat graft when comparing centrifugation, filtration, and sedimentation methods.[12,47–49] Another study showed better outcomes in terms of fullness and smoothness with centrifugation than with gravity sedimentation. Recently, in a randomized controlled trial of cotton pad filtration, centrifugation, and gravity sedimentation, the authors showed that cotton pad filtration demonstrated the highest fat graft retention rate, and this result was statistically significant. Another randomized controlled trial of filtration and gravity sedimentation showed that there was no statistically significant difference between these 2 techniques. However, there was a trend showing better performance of filtration in fat survival.
Our study has 2 primary limitations. In this updated systematic review, we concentrated on fat survival only in facial esthetic AFG measured with the 3D surface imaging technique. This was done to try to restrict bias and come to a convincing conclusion. Additionally, until now, the number of relative clinical trials and cases has not been adequate to make a strong comparison through a meta-analysis. To explore more convincing database evidence on this topic would require additional randomized controlled trials and multiple center trials with large samples to be conducted.
This article presents a systematic review of 10 studies on 3 different fat-processing techniques, wherein the fat graft retention rates were measured using 3D imaging devices. We found that there was a trend toward filtration and centrifugation techniques resulting in better retention outcomes. However, there was a wide variation with respect to the retention outcomes within each single processing technique, and we could not find a significant difference among these 3 techniques.
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
The authors report no conflict of interest.
Wang GHE: conception and design, collection and assembly of data, data analysis and interpretation, manuscript writing, manuscript revising. Zhao JF: conception, collection and assembly of data, manuscript writing, manuscript revising. Xue HY: manuscript revising, interpretation. Li D: conception and design, interpretation, provision of study.
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