Cell-Assisted Lipotransfer for Facial Lipoatrophy: Efficacy ofClinical Use of Adipose-Derived Stem Cells
KOTARO YOSHIMURA, MD, KATSUJIRO SATO, MD,y NORIYUKI AOI, MD, MASAKAZU KURITA, MD,z
KEITA INOUE, MD, HIROTAKA SUGA, MD, HITOMI ETO, MD, HARUNOSUKE KATO, MD,TOSHITSUGU HIROHI, MD,y AND KIYONORI HARII, MDz

BACKGROUND Lipoinjection is a promising treatment, but its efficacy in recontouring facial lipoatrophy
remains to be established.
OBJECTIVE The objective was to evaluate the efficacy and adverse effects of lipoinjection and supplementation of adipose-derived stem/stromal cells (ASCs) to adipose grafts.
METHODS To overcome drawbacks of autologous lipoinjection, we have developed a novel strategy
called cell-assisted lipotransfer (CAL). In CAL, stromal vascular fraction containing ASCs was freshly
isolated from half of an aspirated fat sample and attached to the other half of aspirated fat sample withthe fat acting as a scaffold. This process converts relatively ASC-poor aspirated fat into ASC-rich fat. We
performed conventional lipoinjection (non-CAL; n = 3) or CAL (n = 3) on six patients with facial lipoatrophy due to lupus profundus or Parry-Romberg syndrome.
RESULTS All patients obtained improvement in facial contour, but the CAL group had a better clinicalimprovement score than did the non-CAL patients, although the difference did not reach statisticalsignificance (p = .11). Adipose necrosis was found in one non-CAL case who took perioperative oralcorticosteroids.
CONCLUSION Our results suggest that CAL is both effective and safe and potentially superior to conventional lipoinjection for facial recontouring.
The authors have indicated no significant interest with commercial supporters.

F

acial lipoatrophy is a disfiguring and sociallydisabling problem that accompanies several inherited and acquired diseases (see Ascher et al.1 forreview). Lupus erythematosus profundus and scleroderma en coup de sabre (en coup de sabre morphea) frequently give rise to facial lipoatrophy,
which is often the most problematic manifestation of
the disease for the patients even though they require
medication, such as oral corticosteroids, to suppress
other symptoms associated with the systemic
morbidities. Facial lipoatrophy is also seen inpatients with human immunodeficiency virus(HIV) infection and Parry-Romberg syndrome(hemifacial progressive atrophy or idiopathic
hemifacial atrophy), which involves not only facial

lipoatrophy but also bony defects.2 Thus far
there is no medical treatment to correct
facial lipoatrophy.
Lipoinjection has been used for treating lipoatrophysuch as that associated with HIV infection withmoderate success,3,4 while microsurgical tissuetransfer has been a standard surgical treatment forrecontouring facial defects seen in Parry-Romberg
syndrome. However, the surgical procedure leaves
conspicuous scars on the face and the donor site.5,6Autologous lipoinjection is a promising treatment
for soft tissue augmentation because there is no
associated incision scar or complications
associated with foreign materials. AlthoughDepartment of Plastic Surgery, University of Tokyo School of Medicine, Tokyo; yCellport Clinic Yokohama, Yokohama;

Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo; yRitz Cosmetic Surgery Clinic Tokyo,
Tokyo, Japanz& 2008 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2008;34:1178–1185  DOI: 10.1111/j.1524-4725.2008.34256.x
1178

YOSHIMURA ET AL

many innovative efforts to refine autologous
lipoinjection have been reported,7–14 problems
such as unpredictability and a low rate of graft
survival due to partial necrosis remain.
To overcome these problems, we have developed
a novel strategy, called cell-assisted lipotransfer(CAL; Figure 1).
Since a fraction of stromal cells derived from theadipose tissue was found to have the capacity todifferentiate into various cell lineages,15 the stromalprogenitor cells have been designated ‘‘adipose-derived stem/stromal cells’’ (ASCs) and are expected to
become a valuable tool in a wide range of cell-based
therapies. The therapeutic concept of CAL wasdescribed in a previous report of our preclinicalstudies.16 In CAL, ASC-poor fat is converted toASC-rich fat by supplementing with cells freshly
isolated from the adipose tissue during preparationof the injectable material (Figure 1). We report
the preliminary clinical results of patients who
underwent CAL for recontouring of acquired
facial lipoatrophy. This is the first report ofthe clinical use of ASCs for soft tissue augmentationof the face.

Materials and Methods
Patients
We analyzed the outcomes of six patients with facial
lipoatrophy who underwent lipoinjection for recontouring facial defects: three patients underwent
conventional lipoinjection (non-CAL), while threepatients underwent CAL. No patient underwent
more than one CAL or non-CAL procedure. Informed consent was obtained from all patients. The
clinical trial protocol conformed to the guidelines of
the 1975 Declaration of Helsinki and was approvedby individual institutional review boards.
One of the six patients had been diagnosed with
Parry-Romberg syndrome; the other five patients
had been diagnosed with lupus erythematosus profundus by their dermatologists. Two of the lupus
cases (one in the non-CAL group and one in the CAL
group) were taking oral steroids (predonisolone) at
the time of surgery. Severity grading of facial lipoatrophy was determined according to the grading
scale (graded 1 to 5, 5 being the most severe) developed by the Facial Lipoatrophy Panel.1 Patientswere evaluated between 9 and 13 months as described later. One of the three patients in each group
was male, and the patient’s ages ranged from 33 to
55 years (mean age 7 SD, non-CAL 46.3 7 7.8,
CAL 38.7 7 8.1). The mean volume of injected fat
was 133 7 104 mL in the non-CAL group and100 7 10 mL in the CAL group. Patient data aresummarized in Table 1.

Surgical Techniques

Figure 1. Scheme of CAL. Half of the volume of the aspirated
fat is processed for isolation of the SVF. During the isolation
process, the other half of the aspirated fat is prepared forgrafting. Freshly isolated SVF-containing ASCs are attachedto the aspirated fat with the fat acting as a living scaffold.
Finally, the SVF-supplemented fat is injected into the target
sites. Thus, aspirated fat, which is originally relatively poor
in ASCs, is converted to ASC-rich fat.

Before suctioning, the abdominal wall was infiltrated
with saline solution with diluted epinephrine(0.001%) with the patient under general anesthesia.
Adipose tissue was suctioned using a cannula with
2.5-mm inner diameter and a conventional liposuction machine. In the CAL group, about a half of thecollected liposuction aspirate was used for isolationof the stromal vascular fraction (SVF). The SVF was
isolated from both the adipose portion and thefluid portion of liposuction aspirates as previously

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CELL-ASSISTED LIPOTRANSFERTABLE 1.

Summary of Patients’ Data
MethodNon-CALCase
Sex
Age (year)
Diagnosis
Severity grading
Perioperative oralcorticosteroids
Donor site
Volume of injection (mL)Follow-up periods (month)
Clinical results
Complications

CAL

1
Male
25
LEP
3


2
Female
42
LEP
5
1

3
Female
42
LEP
2


1
Male
35
PRS
4


2
Female
33
LEP
5
1

3
Female48
LEP
4

Abdomen
100
10
Fair


Abdomen250
9Good
Adipose necrosis

Abdomen
50
9
Fair


Abdomen110
13
Excellent

Abdomen
90
9
Good


Abdomen
100
9
Good


LEP, lupus erythematosus profundus; PRS, Parry-Romberg syndrome.

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described.17 In brief, the adipose portion of liposuction aspirates was digested with 0.075% collagenase in buffered saline for 30 minutes on a shaker
at 371C. Mature adipocytes and connective tissue
were separated from the SVF containing ASCs bycentrifugation (800  g, 10 minutes), and then rinsed
three times with buffered saline. The fluid portionwas centrifuged (800  g, 5 minutes), and the pellets
were resuspended in hypotonic water to lyse
erythrocytes. The cell processing procedure took
about 90 minutes. During the processing period, theother half of lipoaspirates was harvested as graft
material. The surgery was performed in a sterile
operating room, and the cell isolation was performed
in a sterile cell processing room.

For the injection syringe, a 10-cm3 inflator (LeVeen,
Boston Scientific Corp., Boston, MA) was used because they are screw-type syringes (with a threaded
plunger) and threaded connections that fit both theconnecting tube and the needle, to allow for precise
control during injection. An 18-gauge needle (25 or
60 mm long) was used for lipoinjection and inserted
in several layers (the subcutaneous fatty layer andthe muscle layer) and directions to achieve diffuse
distribution of the graft materials. Quantity oftransplanted adipose tissue was determined by trying
to overcorrect by about 20%.

The adipose portion of liposuction aspirates wascentrifuged at 700  g for 3 minutes without washing and put into a metal jar (500 mL) that wasplaced in water with crushed ice. In the non-CAL
group, centrifuged fat was injected without
SVF supplementation. In the CAL group, thefresh SVF isolated from both the adipose and thefluid portion was added to the graft material and,after gentle mixing and waiting for 10 to 15 minutes
for cell adherence to the aspirated fat, the cellsupplemented fat was then put into an injection
syringe.

Photographs of each patient were taken before andafter treatment with a high-resolution digital camera(Model D30, Canon, Tokyo, Japan). The percentage
of volumetric improvement of facial defects wasdetermined via evaluation of preoperative and postoperative photographs by four certified plastic surgeons blinded to clinical data. The mean data of thevolumetric improvement of each patient were classified into four categories: excellent (80% improvement or better), good (60% to less than 80%
improvement), fair (40% to less than 60% improvement), and poor (less than 40% improvement).

D E R M AT O L O G I C S U R G E RY

Evaluation of Clinical Improvement

YOSHIMURA ET AL

Results
The transplantation of adipose tissue was successfully performed in all cases. Subcutaneous bleeding
was seen on some parts of the face and resolved
within 1 to 2 weeks. Patients usually recovered frompostoperative swelling at about 4 weeks. Transplanted adipose tissue was gradually absorbed during the first 2 postoperative months. The volumecontinued to be reduced in the non-CAL group,
while it showed a minimal change thereafter in the
CAL group. Patient data are summarized in Table 1,
and photographs of two representative cases in eachgroup are shown in Figures 2 through 5. All patients
showed cosmetic improvements, but the degree varied among patients. CAL had a better clinical improvement score than non-CAL, although thedifference did not reach statistical significance(p = .11).
The reconstructed tissue was generally soft and withnatural texture, although some fibrous tissues that
had existed before surgery appeared to remain. In
one case of the non-CAL group (non-CAL Case 2;
Figure 3), redness and fluctuation were detected on
the left cheek 1 month after surgery and necrotizedadipose fluids were drained through a small incision.
We cultured this fluid, but did not detect any bac-teria. In other cases, no adverse effects were seen andany nodules or cysts were not palpable.

Discussion
In the CAL strategy, autologous ASCs are used toenhance angiogenesis, improve the survival rate ofgrafts, and reduce postoperative atrophy. In CAL,
half the volume of the aspirated fat is processed for
isolation of the SVF-containing ASCs (Figure 1).
During the isolation process, the other half of theaspirated fat is prepared for grafting. Freshly isolated
SVF, which contains ASCs as well as vascular endothelial cells, pericytes, blood cells (WBCs and RBCs),
and other cells as previously described,17 is attachedto the aspirated fat with the fat acting as a living
scaffold before transplantation. Finally, the progenitorenriched fat tissue is injected into the target sites.
Using our technique, aspirated fat was harvested
with a relatively large-sized suction cannula, centrifuged at 700  g, and kept cool until transplantation.
We believe that centrifugation of aspirated fat substantially affects survival rate of injected fat because
centrifugation at 1,200  g experimentally decreases
the fat volume by 30%, damages 12% of the adipocytes, and 0% of the ASCs, which concentrates

Figure 2. Clinical views of non-CAL Case 1 (a 25-year-old man): preoperative views (Grade 3 lipoatrophy; A) and postoperative views at 1 month (B) and at 10 months (C). The patient was diagnosed as LEP at the age of 21 years and started oralcorticosteroid therapy. He stopped the medication 1 year ago and has experienced significant change in the past 12 months.
Conventional lipoinjection (100 mL) was performed to recontour the left cheek defect, which was successfully augmented at
1 month (B), but substantial absorption was seen at 10 months (C).

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CELL-ASSISTED LIPOTRANSFER

and into the muscle through a fascia, compared to a
blunt-tipped needle.
Adipose tissue contains not only adipose progenitor
cells but also multipotent stem cells that can differentiate into fat, bone, cartilage, and other types oftissue.15,19 Previously, we found that aspirated fat
loses a significant number of these precursor cells
during liposuction with a suction machine and the
preparation processes and that aspirated fat has
approximately half the number of ASCs as excisedwhole fat does.16 There seems to be two main
reasons for the relative deficiency of ASCs. First, amajor portion of the ASCs are located aroundlarge vessels and are left at the donor site after
liposuction;16 we have confirmed this phenomenonusing histologic analysis (manuscript in preparation).
Second, some ASCs are released into the fluid
portion of liposuction aspirates.17 The resulting
relative deficiency of precursor cells in aspirated
fat may contribute to the low survival rateand long-term atrophy of transplanted
lipoaspirates.

Figure 3. Clinical views of non-CAL Case 2 (a 42-year-old
woman): preoperative views (Grade 5 lipoatrophy; A) andpostoperative views at 9 months (B). The patient has been
taking oral corticosteroid since she was diagnosed with LEP
at the age of 20 years. Conventional lipoinjection (250 mL)
was performed to augment facial defects on both cheeks,
and she continued the medication perioperatively. Redness
and fluctuation were seen on the left cheek at 1 month, andnecrotic adipose fluid was removed by a small skin incision.
However, the facial defect was relatively improved at 9months (B).

the number of cells per volume by 25% for adipocytes and 43% for ASCs.18 We prefer an 18- or
16-gauge sharp-tipped needle for fat injection because we have found that a sharp needle facilitatesplacing fat grafts more diffusively and with higher
accuracy, even into fibrous or relatively hard tissue1182

D E R M AT O L O G I C S U R G E RY

In CAL, we compensate for this ASC deficit bysupplementing the aspirated fat intended for lipoinjection with freshly isolated SVF containing ASCs.
To maximize the biologic function and avoid unexpected behavior of ASCs, we believe that it is important to ensure adherence of supplemented ASCs
to adipocytes or connective tissue.20 Centrifugationof adipose grafts seems to be important also for
reducing water content in the graft, which may
disturb the adherence of supplemented ASCs to
the adipose tissue.
Preclinical studies have partly confirmed somepotential mechanistic benefits for using ASCs in
CAL.16,21,22 ASCs can differentiate into adipocytes
and contribute to the regeneration of adipose tissue.
In addition, ASCs can differentiate into endothelial
cells and also probably into vascular mural
cells,16,23,24 resulting in the promotion of angiogenesis and graft survival. ASCs are known to releaseangiogenic growth factors in response to hypoxia

YOSHIMURA ET AL

Figure 4. Clinical views of CAL Case 1 (a 35-year-old man): preoperative views (Grade 4 lipoatrophy; A) and postoperative
views at 13 months (B). The patient noticed the right facial defect during his 20s, was diagnosed with PRS, and has no
history of oral corticosteroid use. CAL (110 mL) was performed to correct the facial defect, which was improved, and thefacial contour maintained at 13-month follow-up (B). The cheek is soft and natural appearing with no visible scars.

and other conditions,25,26 and these factors may
promote angiogenesis from surrounding host tissue.
The most influential role we considered is that ASCs
remain as original undifferentiated ASCs in surviving
adipose tissue.16 ASCs are assigned to participate intissue turnover of adipose, and the turnover isknown to be very slow, taking 2 years or more.27
However, transplanted adipose tissue experiences

temporary ischemia followed by reperfusion and so
the adipose grafts probably turn over in the earlystage (up to 3 months) after transplantation. We
hypothesize that the relative deficiency of ASCs inaspirated fat may affect the replacement process andlead to postoperative atrophy of grafted fat, which
commonly occurs during the first 6 months after
lipoinjection.

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CELL-ASSISTED LIPOTRANSFER

Figure 5. Clinical views of CAL Case 3 (a 48-year-old woman): preoperative views (Grade 4 lipoatrophy; A) and postoperative
views at 13 months (B). The patient noticed the right facial defect during her 20s and was diagnosed with LEP. She has ahistory of oral corticosteroid use, but has not taken them for several years. CAL (100 mL) was performed to correct the facial
defect, which was improved at 9 months follow-up (B).

In our series, we observed no adverse side effects orcomplications except for one case of lupus erythematosus profundus in the non-CAL group who took oralcorticosteroids preoperatively. The patient showed
necrosis of a part of the transplanted adipose tissue
and the necrotic fluids were drained. A patient in the
CAL group who had taken oral corticosteroids showeda lower clinical score compared to non–steroid-taking
patients, suggesting that steroids taken perioperatively,or possibly the activity of lupus requiring the medication, has negative effects on angiogenesis and graft
survival. Thus, it may be recommended that lipoinjection, either non-CAL or CAL, is performed at aperiod of minimal lupus activity and after corticosteroid therapy has been discontinued.

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D E R M AT O L O G I C S U R G E RY

There were notable differences between the twogroups in the ages of the patients and in the injection
volumes in this preliminary trial. Nonetheless, thedata suggest that lipoinjection is an effective tool forrecontouring facial lipoatrophy, and ASC supplementation is suggested to boost effectiveness. Our
clinical experience using CAL for cosmetic breast
augmentation with 1 to 4 years of follow-up alsosuggests that CAL is safe and may be superior toconventional lipoinjection.20 We believe that CAL
can improve disfigurement and social disability ofpatients with facial lipoatrophy and that it has someadvantages over conventional surgical methods:
lack of facial and donor site scarring, lack ofcomplications derived from foreign materials, andYOSHIMURA ET AL

applicability to any shape of facial defects. Larger
studies and longer follow-up times are needed toestablish the superiority and the durability of the
CAL-mediated improvements in facial lipoatrophy
patients.

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Address correspondence and reprint requests to: Kotaro
Yoshimura, MD, Department of Plastic Surgery, Universityof Tokyo School of Medicine; 7-3-1 Hongo, Bunkyo-ku,
Tokyo 113-8655, Japan, or e-mail: yoshimura-pla@
h.u-tokyo.ac.jp

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