INTRODUCTION
Tonnard et al., in 20131, described the nanofat graft. The intradermal injection of the graft with 27 gauge
needles became viable through the emulsification and filtering of the liposuctioned
fat. The laboratory analysis showed complete destruction of the adipocytes and a total
loss of the volumization capacity; however, it allows the isolation of the stromal
vascular fraction of the fat, maintaining its regenerative potential intact2. The nanofat graft improves the quality of the skin in damages secondary to aging
and in the healing sequelae3-5. This work aims to present the initial results of the nanofat graft with the use
of a low-cost disposable device, proposing a standardization of its use according
to the area to be treated.
METHODS
A prospective cohort was conducted from July 2019 to March 2020. The approval of the
institutional review board of the Hospital de Clínicas de Porto Alegre was granted,
project number 2008-0058, and this research-based study was conducted following the
provisions of the Declaration of Helsinki. The inclusion criterion was patients who
underwent nanofat grafting for skin treatment. The exclusion criterion was the previous
performance of some invasive treatment of the skin. Twenty consecutive patients who
met the prerequisites were analyzed.
The results were evaluated in the 6th postoperative month. The patients answered a
questionnaire, classifying from 1 - very bad to 10 - excellent, changes in skin quality.
To remove the graft, we chose between the infraumbilical region or the inner thigh6. Infiltration is performed with saline solution and adrenaline at a concentration
of 1:300,000. Liposuction is performed with a 3mm cannula, with 1mm holes and rough
surface(1, FAGA).
The collected fat is washed and decanted7. The first part is the micrograft and is ready for use; the second is transferred
30 times by each of the three 2.4mm, 1.8mm and 1.4mm(FAGA)protractors. After transfers, the emulsified graft will be ready1. According to the need for nano graft volume, a percentage of the emulsified graft
can go to the third stage. This step consists of passing once in each of the threefilters(1, FAGA): 0.5mm, 0.3mm and 0.15mm (Figures 1 and 2).
Figure 1 - Protocol for obtaining the nanofat graft. Source: FAGA Medical | Surgical equipment
and medical-hospital products(http://www.fagamed.com.br/ index.php).
Figure 1 - Protocol for obtaining the nanofat graft. Source: FAGA Medical | Surgical equipment
and medical-hospital products(http://www.fagamed.com.br/ index.php).
Figure 2 - Nanofat graft (needle 27 gauge).
Figure 2 - Nanofat graft (needle 27 gauge).
For application, the fat is transferred from the 20ml syringe to the 3ml syringe and
coupled to the Multineedle 19 Needles System (JM Biotech Co. Ltd., Daegu, South Korea) (Figures 3 and 4). The depth to be grafted is standardized by anatomical region (Table 1 and Figure 5). The system is applied to 90 degrees concerning the skin for complete penetration
of all needles. An application of 0.3ml of nano graft per stitch is performed (0.016ml
injected by each needle) (Figure 6). After finishing the grafting, skin massage is performed with the nano graft.
Figure 3 - Multi needle System
Figure 3 - Multi needle System
Figure 4 - Photo illustrating the moment of application of the Nanofat Injector - Disposable
low cost device for fat grafting.
Figure 4 - Photo illustrating the moment of application of the Nanofat Injector - Disposable
low cost device for fat grafting.
Figure 5 - Anatomical regions for grafting.
Figure 5 - Anatomical regions for grafting.
Figure 6 - Application of multi needle system.
Figure 6 - Application of multi needle system.
Table 1 - Depth to be grafted standardized by anatomical region.
Muscle |
Number of a needles |
Size |
Frontal |
19 needles |
1mm |
Orbital |
19 needles |
1mm |
Zygomatic |
19 needles |
2mm |
Maxillary and Mandibular |
19 needles |
2mm |
Perioral |
19 needles |
1mm |
Anterior cervical |
19 needles |
1mm |
Back of hands |
19 needles |
1mm |
Skin treatment after radiotherapy |
19 needles |
2mm |
Table 1 - Depth to be grafted standardized by anatomical region.
RESULTS
The twenty patients followed did not present any postoperative complications. Edema
after application decreased between three and seven days. There was no hematoma or
infection. Patients who underwent only nanofat grafting without another associated
surgery could return to their activities after 24 hours (Figures 7 and 8).
Figure 7 - Preoperative aspect of nanofat grafting, six months after the procedure. Nano grafting:
6ml perioral and 12ml in the maxillary region.
Figure 7 - Preoperative aspect of nanofat grafting, six months after the procedure. Nano grafting:
6ml perioral and 12ml in the maxillary region.
Figure 8 - Postoperative aspect of nanofat grafting, six months after the procedure. Nano grafting:
6ml perioral and 12ml in the maxillary region.
Figure 8 - Postoperative aspect of nanofat grafting, six months after the procedure. Nano grafting:
6ml perioral and 12ml in the maxillary region.
The scores reported by patients at six months were between 7 and 10, with a mean of
8 (Table 2).
Table 2 - Satisfaction scores (0-10), age and gender of patients 6 months after surgery
|
Score 0-10 6 months P.O. |
Age |
Gender |
MEC |
7 |
54 |
F |
IT |
9 |
44 |
F |
ES |
10 |
53 |
F |
EM |
8 |
53 |
F |
JP |
8 |
50 |
F |
SM |
7 |
43 |
F |
LG |
7 |
44 |
F |
EP |
8 |
52 |
F |
LP |
9 |
67 |
F |
MG |
7 |
63 |
F |
IR |
8 |
64 |
F |
RP |
7 |
60 |
F |
FL |
7 |
61 |
F |
EB |
10 |
74 |
F |
LB |
8 |
54 |
F |
VR |
8 |
59 |
F |
LC |
9 |
58 |
F |
JM |
7 |
55 |
F |
RR |
8 |
48 |
F |
MT |
8 |
76 |
F |
Table 2 - Satisfaction scores (0-10), age and gender of patients 6 months after surgery
DISCUSSION
The indication of nanofat graft aiming at skin treatment is growing worldwide. We
did not find any article described with an unfavorable conclusion to its use. The
main advantages of the nano graft are the maintenance of stem cells derived from adipose
tissue (ADSCs), in addition to the possibility of intradermal grafting, which was
not possible before its description. The ADSCs have already been widely studied, and
their regenerative potential well documented, with several applications to plastic
surgery3-5,8. Sesé, in 20192, described that the isolation of ADSCs, when carried out by the mechanical emulsification
system, requires a quantity of fat ten times lower than the standard method, enzymatic
isolation, and produces a higher concentration of stem cells, which explains its regenerative
potential2. The process of obtaining the nano graft is summarized in three stages: micrograft,
emulsified fat and nanofat graft. Despite adding surgical time - due to preparation
in three stages - when compared to the classic graft, all stages generate grafts with
properties to treat different changes in aging, as shown in Figure 1.
In 2013, Tonnard et al. 1 described the application of the nano graft with 27 gauge needles. Still, the method
requires a long time to perform, resulting in prolonged edema due to the formation
of subdermal “fat lakes” and, mainly, the impossibility of standardizing the depth
of application. Verpaele et al., in 20199, described a new method, where they associate micro-needling with the deposit of
the nano graft; for this, 8ml and 20 minutes of micro-needling are required. The system
described in this article allows standardizing the injection depth according to the
different anatomical areas10. With standardized grafting, injections are uniformly intradermal, reducing the risk
of perforation of subdermal vascular plexus. This explains the lower potential of
ecchymosis secondary to the procedure compared to the other methods already described1.
Furthermore, the proposed technique allows the control of the injection volume of
the nano graft, and with the system of 19 needles, it is possible to graft 8ml in
2 minutes. Each application of 0.3ml requires between three and five seconds, with
an injection of 0.016ml per point, which reduces the risk of large deposits, as well
as prolonged edema1. If the surgeon’s goal is nano graft deposition and not microneedling, we believe
this is the best system currently available. It allows a fast application, low morbidity,
uniform deposit and adequate depth for the selected anatomical region. Finally, state-of-the-art
technologies are usually associated with high investment. Still, the described system
has a cost of R$ 65 per device, so it is possible to put it on the surgical budget
without derailing the surgery.
CONCLUSION
The use of the Smartneedle™ system for nanofat grafting presents results in patient satisfaction similar to
other application methods. It allows a uniform and standardized distribution of the
graft according to the anatomical region and optimizes surgical time.
REFERENCES
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basic research and clinical applications. Plast Reconstr Surg. 2013 Oct;132(4):1017-26.
2. Sesé B, Sammartin JM, Ortega B, Matas-Palau A, Llull R. Nanofat cell aggregates: a
nearly constitutive stromal cell inoculum for regenerative site-specific therapies.
Plast Reconstr Surg. 2019 Nov;144(5):1079-88.
3. Oh DS, Kim DH, Roh TS, Yun IS, Kim YS. Correction of dark coloration of the lower
eyelid skin with nanofat grafting. Arch Aesthetic Plast Surg. 2014;20:92-6.
4. Menkes S, Luca M, Soldati G, Polla L. Subcutaneous injections of nanofat adipose-derived
stem cell grafting in facial rejuvenation. Plast Reconstr Surg Glob Open. 2020 Jan;8(1):e2550.
DOI: https://doi.org/10.1097/GOX.0000000000002550
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injections rejuvenate postburn scars of face. Ann Plast Surg. 2019 Jan;82(1):28-33.
DOI: https://doi.org/10.1097/SAP.0000000000001631
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of processed lipoaspirate cells: influence of donor site on cell concentration. Plast
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7. Condé-Green A, Amorim NF, Pitanguy I. Influence of decantation, washing and centrifugation
on adipocyte and mesenchymal stem cell content of aspirated adipose tissue: a comparative
study. J Plast Reconstr Aesthet Surg. 2010 Aug;63(8):1375-81.
8. Martins JMP, Oliveira FS, Lima EOC, Dullius D, Durli ICLO, Hiraiwa E, et al. Use of
derived adipose stem cells to reduce complications of cutaneous scarring in smokers.
An experimental model in rats. Acta Cir Bras. 2019;34(6):e201900605. DOI: https://doi.org/10.1590/s0102-865020190060000005
9. Verpaele A, Tonnard P, Jeganathan C, Ramaut L. Nanofat needling: a novel method for
uniform delivery of adipose-derived stromal vascular fraction into the skin: correction.
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10. Hausauer AK, Josnes DH. PRP e microagulhamento em medicina estética. Rio de Janeiro:
Thieme Revinter Publicações; 2019.
1. Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Plástica, Porto Alegre,
RS, Brasil.
2. Clínica Privada, Clínica Privada - Porto Alegre, Porto Alegre, RS, Brasil.
Corresponding author:
João Maximiliano Rua Ramiro Barcelos, 2350, Santa Cecília, Porto Alegre, RS, Brazil. Zip Code: 90035-003.
E-mail: jmaximilianopm@gmail.com
Article received: May 07, 2020.
Article accepted: April 23, 2021.
Conflicts of interest: none
COLLABORATIONS
JM Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
MP Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
ACPO Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
EMZ Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
DWD Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
CPP Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
JLM Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing
MVMC Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Realization of operations and/or trials, Resources,
Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation,
Writing - Review & Editing