Gerhard Sattler

Current Concepts of Fat Graft Survival: Histology of Aspirated Adipose Tissue and Review of the Literature

Background. Controversy remains about the longevity of correction in autologous fat grafts and its relation to adipocyte survival. Reported long‐term fat graft survival rates differ widely, depending on harvesting method, means of reinjection, injection site, and evaluation methods. Objective. To demonstrate histologic findings of aspirated adipose tissue and compare the findings to the reports in the literature. Methods. Review of the literature and the histology of transplanted fat 7 years after subcutaneous implantation and trypan blue staining to determine the vitality of defrosted adipocytes. Results. Fat cells survive aspiration with a suction machine or syringe equally well. Use of a liposuction cannula or 14‐gauge needle gives comparable results. Local anesthesia or tumescent local anesthesia is recommended for the donor site, preferably with addition of epinephrine. Conclusion. Clinical longevity of correction after autologous fat transfer is determined by the degree of augmentation resulting from the amount of fibrosis induced and the number of viable fat cells. Survival of aspirated fat cell grafts depends mainly on the anatomic site, the mobility and vascularity of the recipient tissue, or underlying causes and diseases, and less on harvesting and reinjection methods.

Noninferiority of IncobotulinumtoxinA, Free from Complexing Proteins, Compared with Another Botulinum Toxin Type A in the Treatment of Glabellar Frown Lines

BACKGROUND Use of botulinum toxin for esthetic purposes has rapidly expanded over the last 20 years. IncobotulinumtoxinA, also known as NT 201, is a new botulinum toxin type A (150 kDa) that is free from complexing proteins. OBJECTIVES A prospective, multicenter, randomized, rater‐ and patient‐blind, international Phase III trial to investigate the noninferiority of incobotulinumtoxinA to another botulinum toxin type A, onabotulinumtoxinA, in the treatment of glabellar frown lines. METHODS A total of 381 patients were randomized in a 3:1 (incobotulinumtoxinA:onabotulinumtoxinA) ratio to receive 24 U incobotulinumtoxinA of or onabotulinumtoxinA. Efficacy end points included the percentage of responders (patients with an improvement of ≥1 point on a 4‐point facial wrinkle scale) at maximum frown at weeks 4 and 12 as assessed by the investigators, and a panel of independent raters based on standardized digital photographs. RESULTS Four weeks after injection, response rates at maximum frown were 96.4% in the incobotulinumtoxinA group and 95.7% in the onabotulinumtoxinA group as assessed by independent raters. Analysis of the data confirmed the noninferiority of incobotulinumtoxinA. Response rates at rest were lower for both products. The rate of adverse events was low. CONCLUSION IncobotulinumtoxinA is equally as effective as onabotulinumtoxinA in the treatment of glabellar frown lines. Both preparations were well tolerated. This study was funded by Merz Pharmaceuticals GmbH. Editorial assistance was provided by Ogilvy 4D, Oxford, UK.

Validated Assessment Scales for the Lower Face

Background Aging in the lower face leads to lines, wrinkles, depression of the corners of the mouth, and changes in lip volume and lip shape, with increased sagging of the skin of the jawline. Refined, easy‐to‐use, validated, objective standards assessing the severity of these changes are required in clinical research and practice. Objective To establish the reliability of eight lower face scales assessing nasolabial folds, marionette lines, upper and lower lip fullness, lip wrinkles (at rest and dynamic), the oral commissure and jawline, aesthetic areas, and the lower face unit. Methods and Materials Four 5‐point rating scales were developed to objectively assess upper and lower lip wrinkles, oral commissures, and the jawline. Twelve experts rated identical lower face photographs of 50 subjects in two separate rating cycles using eight 5‐point scales. Inter‐ and intrarater reliability of responses was assessed. Results Interrater reliability was substantial or almost perfect for all lower face scales, aesthetic areas, and the lower face unit. Intrarater reliability was high for all scales, areas and the lower face unit. Conclusion Our rating scales are reliable tools for valid and reproducible assessment of the aging process in lower face areas.

A validated lip fullness grading scale.

OBJECTIVES To develop the Lip Fullness Grading Scale for objective quantification of lip volume for a reliable assessment and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify fullness of upper and lower lip separately. Nine experts rated photographs of 35 subjects, twice, separately for upper and lower lip. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS Agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the fullness of the upper and lower lip for which patients commonly seek correction. This scale is well stratified, with low intra- and interrater variability.

A validated grading scale for crow's feet.

OBJECTIVE To develop the Crows Feet Grading Scale for objective quantification of the severity of lateral canthal lines and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of lateral canthal lines at rest and at maximum contracture of the orbicularis oculi. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect crows feet in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was significantly high. Furthermore, the test–retest correlation coefficients were high for each expert after an overnight interval, demonstrating low inter- and intraevaluator variability. CONCLUSION The 5-point photonumeric scale generated spans the severity of the type of crows feet for which patients most commonly seek correction. The scale is well stratified for consistent rating.

A validated grading scale for forehead lines.

BACKGROUND As with other facial wrinkles, the gradual loss and disorganization of collagen fibers and elastin, connective tissues that provide underlying support for skin, cause horizontal forehead rhytides in large part. OBJECTIVES To develop the Forehead Lines Grading Scale for objective quantification of horizontal forehead rhytides at rest and with expression and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS The Forehead Lines Grading Scale is a 5-point photonumeric rating scale that was developed to objectively quantify resting (static) and hyperkinetic (dynamic) forehead lines. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was highly significant. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of forehead lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

A Validated Grading Scale for Marionette Lines

BACKGROUND Melomental folds, or marionette lines, are one of the consequences of facial aging. The curvilinear wrinkles formed because of facial movements and the aging process extend downward from the oral commissures. OBJECTIVES To develop the Marionette Lines Grading Scale for objective quantification of the severity of melomental folds and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of melomental folds. Nine experts rated photographs of 35 subjects, twice, with regard to marionette lines in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of marionette lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

Liporecycling: A Technique for Facial Rejuvenation and Body Contouring

Background. Soft tissue augmentation using autologous fat is a standard method in facial rejuvenation and in refinement of body contouring. Different procedures by different authors have been described, each with its specific advantages and disadvantages. Objective. The purpose of this article is to describe a method of harvesting, processing, and reinjection of fat that provides new aspects and advantages compared to previously described procedures. Methods. We report about a new method of autologous fat grafting. Fat is harvested during machine‐assisted liposuction in tumescent local anesthesia with microcannulas, processed in a special open manner, and reinjected through a 24‐gauge needle for intra‐ and subdermal augmentation. Results. Short‐ and long‐term results are equivalent to other methods of fat cell grafting. Conclusion. Advantages of the described method include easy harvesting during conventional machine‐assisted liposuction, the possibility of removing undesired bands of fibrous tissue from the graft, and easy passage through a 24‐gauge needle. Thus sub‐ and intradermal augmentation is possible with the same material and syringe.

Validated Assessment Scales for the Mid Face

Background The improvement of aesthetic treatment options for age‐related mid face changes, such as volume loss, and the increase in patient expectations necessitates the development of more‐complex and globally accepted assessment tools. Objective To develop three grading scales for objective assessment of the infraorbital hollow and upper and lower cheek fullness and to establish the reliability of these scales for clinical research and practice. Methods and Materials Three 5‐point rating scales were developed to assess infraorbital hollow and upper and lower cheek fullness objectively. Twelve experts rated identical mid face photographs of 50 subjects in two separate rating cycles using the mid face scales. Test responses of raters were analyzed to assess intra‐ and interrater reliability. Results Interrater reliability was substantial for the infraorbital hollow, upper cheek fullness, and lower cheek fullness scales. Intrarater reliability was high for all three scales. Both of the cheek fullness scales yielded higher reliabilities when three rather than two views were used to assess the volume changes of the cheek. Conclusion The mid face scales are reliable tools for valid and reproducible assessment of age‐related mid face changes.

Validated Composite Assessment Scales for the Global Face

Background Twenty grading scales have been developed to assess age‐related facial changes. Until now, the validity with regard to the patients actual age and the clinical importance of combined measurement tools to describe facial aging was unclear. Objective To investigate the reliability and validity of a total face score and three global face assessment scales for estimated age, estimated aesthetic treatment effort, and signs of aging in the facial units. Materials and Methods Descriptive, reliability, correlation, and principal component analyses based on the assessment of 50 subjects by 12 raters using the 20 grading scales and the global face assessment scales. Results Inter‐ and intrarater reliability was high for the total face score and for the scales on estimated age and aesthetic treatment effort. Actual age was highly correlated with these three measures. Facial aging was indicated particularly by scales of the lower face. Conclusion The aesthetic grading scales and global scales on estimated age and aesthetic treatment effort are reliable and valid instruments. The results suggest that a more‐comprehensive evaluation of the human face and its age‐related changes can help to identify important areas of facial aging and to define optimal aesthetic treatment strategies.