11. Treatment of acne scars with subcutaneous and intradermal Adipofilling
KEYWORDS: atrophic acne scars, cystic acne, intradermal cellular Adipofilling, Adipopimer, fat storage
The treatment of facial acne scars is carried out by means of several techniques. Today, a new, regenerative biological technique is available: Adipofilling.
This technique has been made possible by the invention of an economical, disposable, patented device: the Adipopimer.
Local anesthesia of the area from which the fat is to be taken is carried out by means of a tumescent solution of mepivacaine and epinephrine. Liposuction is performed through a 4 mm diameter cannula.
The lipoaspirated lobular fat is washed with lactate Ringer or physiological solution in a beaker equipped with a tap. Washing continues until the liquid becomes clear and transparent.
The washed lipoaspirate is transferred to a beaker. An additional small amount of liquid is then added, in order to create the aspiration vortex that will separate the biological material without damaging it. Normally, 20 mL of 5% glucosate solution and 50 IU of rapid insulin are added to the working liquid.
The Adipopimer is immersed in the liquid and fragments the lobules of fat in a few seconds.
On inclining the beaker, the small lobular fragments are visible on the glass.
When injected into the subcutaneous tissue, the small lobular fragments created by the Adipopimer correct the volumes and the trophism of the hypodermis that has been damaged by the inflammatory manifestations of cystic acne.
Half of the suspension of lobular fragments is poured into another beaker. The Adipopimer is then activated for about 15-20 seconds. This maneuver creates a suspension of single, living adipose and stromal cells, which, when injected into the dermis, regenerate the atrophic cutaneous scar tissue. On inclining the beaker, the cells form a continuous, uniform layer on the glass.
By way of supplementation, a small amount of the cellular suspension is always poured into the beaker containing the volumetric suspension of lobular fragments. The single cells, once free from the inhibition of contact, secrete numerous substances that promote rooting.
The volumetric suspension and the cellular suspension are poured into 20 ml Luer lock syringes equipped with caps of different colors. The syringes are then placed to stand vertically, in order to separate the water from the biological material. After about 10-15 minutes, the lobular fragments and the cells, which are less dense than the water, rise to the surface. The lactate Ringer and the glucosate solution containing insulin are eliminated. The 2.5 mL Luer lock syringes used for the subcutaneous injection of the lobular fragments can now be prepared.
The solution of mepivacaine and epinephrine is used to create a tumescence, and an 18 G needle is inserted. The needle is then extracted and an 18 G or 21 G cannula is used to inject the suspension of lobular fragments beneath the skin. We inject all the areas of volumetric deficit and acne scars, which have previously been marked out. Adipofilling with small lobular fragments enhances the volumes, distends the skin, and exerts a trophic action on the hypodermis.
In severe cases of cystic acne, hypodermic damage is frequent, owing to infection and the formation of abscesses.
In this patient, the volume deficits caused by acne are clearly visible and require correction.
The volumetric suspension is injected into the subcutaneous tissue by means of the cannula. This is always done before the intradermal injection of living adipose and stromal cells into the overlying skin. Despite thorough washing, the suspensions still exert a certain anesthetic effect. It is therefore advisable to inject the dermis after having corrected the volume of the hypodermis.
To regenerate skin with atrophic scars, living adipose and stromal cells have to be injected into the dermis. For this purpose, we use a 1 mL Luer lock syringe and a 21 G or 25 G needle.
Injecting adipocytes and stromal cells into the dermis does not have a volumetric effect, but it does exert a potent regenerative action.
The cellular suspension is injected into the dermis of the entire area of atrophic scarring, not only into the individual scars. To obtain the best regenerative effect, it is advisable to inject the cellular suspension also around the area of scarring, at a distance of 1 cm.
The skin is anesthetized by the previous injection of the suspension of small lobular fragments into the subcutaneous tissue. If the patient feels any pain, the operator can carry out anesthesia with mepivacaine and epinephrine around the area to be treated.
If intradermal injections are carried out in areas of skin scarring that have not previously been injected by means of the cannula, the operator may carry out local barrier and subcutaneous anesthesia.
The injection of adipose and stromal cells into the dermis causes momentary whitening of the skin.
Once treatment of the right-hand side is complete, the volumes on the left are corrected. The cannula is used to inject the suspension of small lobular fragments into the depressed area marked out before the procedure. The lobular fragments, mixed with a small amount of cellular suspension, not only correct the depressed areas of the cheeks, but also improve the trophism of the subcutaneous tissue.
The cellular suspension is now injected into the dermis of the area of atrophic scarring. Injection must be carried out in the entire area marked out. In this way, the regenerative capacity of the suspension is fully exploited.
The result starts to become visible within a few weeks. Once the result has become stable, after 3 or 6 months, a further session of intradermal cellular Adipofilling is carried out; this second session uses the 1 mL Luer lock syringes left over from the previous session, which have been conserved at -32°C.
The suspensions created by the Adipopimer acquire the property of not freezing, and can be conserved in a normal laboratory freezer. This means that several Adipofilling sessions can be carried out after only one session of liposuction and one session of processing the lipoaspirate with the Adipopimer.
Six months later, the second Adipofilling procedure is performed with the conserved adipose and stromal cells.
The suspension of living adipose and stromal cells is injected through a 21 G or 23 G needle into the dermis of the areas that need to be further regenerated.
The cellular suspension is also injected into the margins of excision of a deep wrinkle in the atrophic scar tissue of the right cheek. Surgical excision combined with Adipofilling is the ideal treatment for these atrophic wrinkles in a region of the face that is subjected to movements due to facial expression. The regenerative action of the adipose and stromal cells will make the surgical scar practically invisible.
In conclusion, treating acne scars with Adipofilling is efficacious and minimally invasive.
The possibility to repeat the treatment, as if the fat obtained were a cost-free filler, is extremely advantageous. Another advantage is that the excision of the deepest scars, especially in the folds, can be combined simultaneously with intradermal injection of the most potent regenerative biological material that we possess.
Capurro S. (2020): Treatment of acne scars with subcutaneous and intradermal Adipofilling. Adipofilling section. www.crpub.org
In the treatment of skin scars caused by acne, is it always necessary to create a suspension of small adipose fragments?
No. If there are no subcutaneous tissue deficits, only the cellular suspension is made; this will be injected into the dermis. It is advisable to draw off an abundant amount of fat, as the suspensions created by the Adipopimer can be conserved in 2.5 mL or 1 mL Luer lock syringes in a normal laboratory freezer.
Is supplementation with glucosate solution and insulin always used?
Yes. This procedure has become part of our protocol because we have observed that it promotes rooting and facilitates conservation of the suspensions at -32°C.
We have seen the interesting slides of the Adipofilling suspensions, but we have never seen a slide of ultramicrofat, etc. Why do you think that is?
Well, I'm sorry to say that I, too, have never seen a slide of the material injected by those who present these methods at congresses and in publications. It's easy enough to prepare a slide stained with EE, and it's the first thing that should be done. But then, I'm not really surprised. The methods of preparation utilized today – liposuction with micro-cannulas with tiny holes and filtration with filters that are ever finer, etc – damage the biological material and reduce to a minimum, or even destroy, all the adipocytes. In short, these techniques are destructive and inefficacious. Moreover, these methods are unable to process biological material in large quantities and rapidly while maintaining the maximum cell vitality, which is exactly what Adipofilling does. The histology of the various nanofats, microfats and so on has never been presented because you wouldn't see anything in the smear.
Has the addition of insulin to the separation liquid of the lipoaspirate processed with the Adipopimer ever elicited phenomena of hypoglycemia?
We have only had one case of mild hypoglycemia; that was during Adipofilling of the breasts, when we added 80 IU of insulin to the separation liquid. The symptoms immediately resolved with the administration of two sachets of sugar.
Why do you use mepivacaine and not lidocaine?
Lidocaine has a marked toxic effect on pre-adipocytes, while mepivacaine only has modest toxic effects. This explains why its use is advantageous and why prolonged washing of the lipoaspirate is important.
We sometimes hear about "closed systems" of processing fat. What do you think of them?
In Adipofilling, the biological material is always in a liquid medium (Ringer or physiological solution); it is never exposed to the air. Moreover, the adipocytes secrete cathelicidin, a potent antimicrobial. We have performed hundreds of Adipofilling procedures, and we have never had any infections. The biological material, especially of small dimensions, is not subject to infection. In short, closed systems are of no use.
What other treatments can be associated to intradermal Adipofilling in the treatment of atrophic scars due to acne?
Several: micro-excision of the deepest scars; peeling with acids and mixed peeling with resorcin (Electroporo-Cosmesis); needling; smoothing with high-frequency currents; dermo-abrasion. Naturally, potent biological methods like Adipofilling are the first choice; let's remember that each Adipofilling session is followed by a visible improvement. Every day, at home, the patient can also apply bionic serums of melatonin and ultra-micronized andrographolide (Korpocare) and mild peeling (glycolic acid, mandelic acid, etc.).
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