Stromal Enriched Lipograft for Rhinoplasty Refinement

Recently, minimally invasive procedures for aesthetic medicine have become widely popular, and facial soft tissue augmentation is one of the most common of these procedures. We have seen an increasing trend toward nonsurgical nasal reshaping with autologous fat grafting, mainly for patients who refuse surgical treatments. For these patients, the ability to fix a deformity with local anesthesia, lower financial expense, and less downtime are appealing. Although good results can be achieved using autologous fat grafting, they may not be comparable with those obtained by surgical rhinoplasty, and this is an important issue to discuss with prospective patients. Patients with an initially satisfactory rhinoplasty outcome or only slight asymmetries, depressions, and/or contour irregularities may present years after the initial surgery,1 when discreet volumetric changes in the frontonasal angle, nasal dorsum, and nasolabial angle may have led to significant differences in the perception of the nasal aesthetic.2 A 47-year-old woman presented to our department for correction of her nasal tip 2 years after undergoing primary rhinoplasty (Figure 1). Although she was offered a secondary surgical rhinoplasty, she chose to undergo nasal refinement with stromal cell–enriched lipografting. To harvest the fat, a 3-mm, hollow, blunt-tipped metal cannula attached to a 20-mL syringe was introduced into the abdominal area through a small skin incision. First, two-thirds of the aspirated fat was processed to isolate the stromal vascular fraction (SVF). Digestion was performed with 0.075% collagenase (Sigma, St Louis, Missouri) in buffered saline and agitated for 30 minutes at 37°C. The SVF containing adipose-derived stem cells (ADSC) was separated by centrifugation at 1200 g for 5 minutes with the Lipokit Centrifuge (Medi-Khan, Los Angeles, California). The SVF was located in the pellet derived from the centrifuged fat at the bottom of the lipoaspirate. The remaining one-third of the aspirated fat was treated as follows: With the syringe held vertically with the open end down, the fat and fluid were separated; isotonic saline was added to the syringe, the fat and saline were separated, and the exudate was discarded. The procedure was repeated until the fat became yellow in color and free of blood and other contaminants. Finally, SVF containing ADSC and the purified fat were mixed.3,4 In previous animal studies, this type of treatment (endogenous stem cell mobilization by lipoaspirate centrifugation) has been shown to enhance low-density fat neovascularization by increasing vasculogenic cytokine expression and improving fat graft survival.5 (A, C) This 47-year-old woman had previously undergone primary rhinoplasty and presented for correction of her nasal tip. (B, D) Seventeen months after tip refinement with stromal cell–enriched lipografting (1.6 mL total volume). The harvested fat was injected in a retrograde fashion with a 1-mm cannula connected to a 1-mL syringe. Small, droplet-like injections of fat (no thicker than 2 mm) were placed in the radix, dorsum sides, and supratip region. In our clinic, the total volume for fat injection is determined on a case-by-case basis; in the patient discussed here (Figure 1), total injection volume was 1.6 mL. It is essential to understand that true nasal remodeling is obtained by improving the underlying architectural elements of bone and cartilage; soft tissue draping adapts to these changes to render the final result.6 With nonsurgical nasal liposculpture, the fat acts as a layer of soft tissue to thicken the overlying skin and help camouflage structural imperfections. The use of autologous fat grafting removes certain filler-related side effects such as the need for repeat treatments over the long term, intolerance or rejection of foreign material, or difficult preoperative planning in the event that a patient eventually needs or wants a surgical rhinoplasty. A drawback of this technique is the fact that the surgeon cannot guarantee how much fat graft will survive in each case. It is also very difficult to guarantee that the injected fat will not spread into unwanted areas. Surgical rhinoplasty remains the primary approach for accurate shaping of the nasal framework in patients seeking aesthetic improvement of the nose, but autologous fat grafting appears to be a nonsurgical alternative that is an effective adjunct for modeling the nasal shape and profile in secondary rhinoplasty patients who refuse additional surgical intervention and accept limitations in the results. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.