Joris van Dongen

214 Chapter 9 population. Nevertheless, the small effect size raises questions if normal lipofilling is ‘just a filler’ in aesthetic procedures in the aging face which involve only lipofilling. Improvement in outcome when lipofilling is combined with lifting procedures could be explained by the large wound surface created and ASC modulation during healing, downregulating fibrosis pathways. Recent publication on SVF boosted/ASC expanded lipofilling however, do show a significant clinical effect 29, 30 and seem the way forward. In theory, adding PRP could affect overlying skin true several pathways and cell lines. Angiopoetin-1 and 2, abundantly present in platelets 31, 32 have shown to stimulate endothelial cell growth, migration and differentiation in cultured human dermal microvascular endothelial cells in vitro 22, 23 . Also, PRP-lysate is a strong proliferator for ASC 10, 33 , essential for graft take 34 and a proven down regulator of fibrosis 26, 35 . Effects of lipofilling with or without PRP on nasolabial fold depth. Grading of the nasolabial fold during follow-up showed no noticeable lasting effect of lipofilling nor lipofilling with PRP on the depth of the nasolabial fold. Even though the “Merz Scale’ used in this study, has shown to successfully differentiate in small volume changes (e.g. filler injection) 36 . We could not determine these differences probably because the lipofilling increased overall facial volume, not altering relative differences between facial zones. In our opinion, only in combination with a facelift, lipofilling may additional demonstrate its effect on the nasolabial fold: lifting probably is definitely needed as such. Furthermore, changes in facial volume are minimal because of the limited amount of lipografts that is injected, with uncertainty about the clinical impact of these minor changes if not combined with a lifting procedure. To this date, only one study has been published that reported facial graft retention determined with external 3D photographic reconstruction 37 after aesthetic facial lipofilling. In this study, an overall retention of 32% was reported, however the range and variation of reported data questions its scientific merit. Moreover, the vast number of patients in this study also received some form of lifting procedure that most likely changed distribution of facial volume, and by this means influenced facial volume attributed to lipofilling.Again suggesting that lipofilling should be combined with a lifting procedure in aesthetic facial rejuvenation. Even though lipograft survival in the face has been documented with MRI imaging 38 , the clinical relevancy of aesthetic facial lipofilling procedures without lifting procedures on facial fold depth remains to be determined. With ongoing uncertainty about lipograft survival, several fundamental studies explored PRP addition 39-41 and found positive effects. Graft take might improve by PRP effects on ASC proliferation 39 , blockage of apoptosis pathways 42 and differentiation into adipocytes 43 . Moreover, PRP lysate stimulates proliferation, migration and tube