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Injectable Tissue Replacement and Regeneration (ITR²): Anatomic Fat Grafting - A Unique Anti-Ageing

Ageing is a dynamic process that can be modelled and understood tissue by tissue, cell by cell - this can be done by breaking down the anatomy of facial fat compartments, so that a practitioner can better understand the effects of ageing on facial tissues such as skin, fat, bone and fibrous ligaments.

The ageing process is a complex interaction between individual genetic composition and the body’s particular responses to the outside and inside environment. These interactions lead to progressive deterioration of tissues and cells over time, beginning during stages of growth and development. Despite the body doing its best to supply new cells as others die, the natural process is not exactly sustainable as decay accelerates faster than the rate of new cell supply.

The Injectable Tissue Replacement and Regeneration (ITR²) technique is therefore, a unique method created and developed to replace decayed tissues using “like tissues” in an effort to delay and retard the rate of tissue decay due to ageing.

General Facial Ageing Patterns

Ageing Related Fat Pad Loss

Advances in the understanding of facial ageing over the years have brought forth significant results and insights into facial soft tissue and bony volume loss. In one study, it has been documented in soft tissue photometric changes; showing the deflating effects of facial soft tissues as one age, while in another, it is noted that facial skeletal surface areas of bone shrinks with time, although there was no corresponding shrinkage of the soft tissue envelope.

Regardless, advances in genetics have also provided us with a basis for measuring early interventions that have the potential to slow the ageing of cells and findings in stem and regenerative cells research in fat has introduced the possibility of regenerating ageing tissues.

In the same vein, studies have also showed that controlled trials of enzymatically derived stromal vascular fraction (SVF) in scleroderma and osteoarthritis (although, not having reached statistical significance); has however, shown improvement over controls to the range of 20%–30%, and in certain cases, such as, diffuse disease in scleroderma hands, yielded statistically significant clinical benefits.

Furthermore, there are almost no other therapies in aesthetics other than fat grafting, SVF-enriched fat grafting, nano-fat grafting, platelet rich plasma (PRP), and growth factors that have demonstrated neo-angiogenesis and “trophic” effects of some degree in virtually all subjects.

Generally, ageing happens over a lifetime with growth and development primarily occurring during the first 22 years followed by a continual and gradual decay of tissues thereafter, until death. Anatomic and histologic changes due to ageing can be seen in the skin, fat compartments, and underlying bone as well as in the dynamic relationships existing between them.

Phenotypic shifts such as photodamage, laxity, and volume loss are the most prevalent results of these physical changes, although severity varies per individual. These changes are interrelated, and therefore, can be modelled as a continuum of anatomic and physiologic changes occurring in an individual’s tissues and cells.

Understanding Facial Anatomy

To understand how the general ageing pattern can be predicted and modelled after, it is important for a practitioner to understand the mechanics, anatomy, areas and composition of the face such as, but not limited to, skin, fat compartments, nasal area, craniofacial bones and ligaments.

Skin: The skin is one of our largest and most complex organs of the body. Over time, intrinsic and extrinsic ageing processes can cause the skin to suffer from losses in function and integrity. Thickness reduction of the epidermis (about 6.4% per decade on average), decreased fibroblast content - which may lead to slower collagen turnover rates, and increased elastin calcification are core characteristics of age disruptions in the skin. Continual sun damage can cause the rete pegs that engage the undersurface of the dermis attachment to regress and the dermoepidermal junction becomes flattened. The thinning layers of the skin become more susceptible to separation due to both loss of microcirculation and disengagement of rete pegs as a consequence of sun damage.

Fat Compartments: Fat is separated into compartments by facial musculature and fascial ligaments. Morphological changes in these compartments can be understood by analyzing the topography of the face, while true ligaments in the face arise from the periosteum, whereas as false ligaments do not start at the periosteal surface. As the fascial septae move closer to the skin surface, they progressively arborize, leading to smaller and smaller subcompartments within the superficial fat compartments.

With age, it eventually lead to a redistribution and loss of fat throughout the face as it changes in the intracellular matrix, decreased proliferation of cells (ie, preadipocytes), and reduces adhesion between tissues and the skin.

Tear trough deformities may also start to appear as deep fat loss occurs in the periorbital region and medial SOOF. Decay of tissues in the malar fat pad results in ptosis, which enhances the appearance of tear trough deformities, as both the nasolabial folds and perioral lines gradually deepen. The patterns of these changes vary across individuals with most exhibiting combinations of superficial and deep compartment fat loss.

Nasal: Nasal ageing can be associated with changes in the glabellar region, forehead, and brow, which are subject to the loss of prominence with the thinning of soft tissues and deepening of frown lines. Supraorbital brow and glabellar projection may also influence the nasofrontal junction in patients experiencing facial aging as well as in patients with a high radix or shallow nasofrontal junction.

One example is that pyriform atrophy has been noted to have profound effects on the nasal tip, soft tissue envelope, upper lip, and nasolabial fold; as the entire soft tissue envelope slides down the nasal bones and as the tip plunges, the upper lip lengthens, loses volume, and involutes. Pyriform atrophy is also often associated with deepened nasolabial folds, giving the upper lip, nose, and nasolabial folds a “sucked” in appearance.

Craniofacial Bones: Craniofacial growth is thought to be one that continuously expand throughout one’s life. As the face ages, the orbits and pyriform aperture gradually expand, which often lead to an non-uniform resorption in the midface skeleton. Ageing can also lead to a significant decrease in the maxillary angle, resulting in a loss of projection. Similarly, the mandibular body may also gradually shrink in both height and width. In early adulthood, the facial skeleton reaches a “peak projection” and subsequent site-specific resorption begin to occur - particularly around the orbit, maxilla, pyriform region, and mandible.

Some studies have also indicated possibility of atrophy and intrinsic ageing of both the subcutaneous superficial and deep fat compartments which may lead to reduced loading on the craniofacial skeleton thus producing patterns of bone loss. Depending on the underlying dentition, these bony changes may accelerate as masticatory loading is changed hence, contributing to the erosion of facial volume.

Retaining Ligaments: The idea that ligaments, especially the zygomatic retaining ligament, stretch with age remains a supposition. In one study, it is suggested that the fibrous network in the face, including the retaining ligaments are relatively immobile and any changes that take place in the ageing face are not solely due to gravitational forces, but also losses in soft tissue and bone. In practice, however, retaining ligaments are difficult to cut, which has led to the thought that age-related stretching of these ligaments is possibly unlikely unless there is histologic or gross findings of ligamentous tears and/or disruptions.

Injectable Tissue Replacement and Regeneration (ITR²) Technique

The Injectable Tissue Replacement and Regeneration (ITR²) technique was created and developed by IFAAS faculty, Dr. Steve R. Cohen. Since its initiation, it has not only become one of the latest and most advanced methods to be employed in practice, but also the standard of fat grafting and regenerative procedures, allowing a practitioner to:

  1. Diagnose the anatomic components of volume loss by evaluating the surface topography of the face

  2. Address specific anatomic losses of the different tissues, including skin, facial fat in the deep and superficial compartments, and bone

  3. Replace the anatomic losses of fat and bone with autogenous or allogeneic fat grafts (and allogeneic bone) that are sized for structural replacement of bone and deep fat losses, superficial fat replacement, and dermal and epithelial replacement and/or regeneration

The ITR² technique’s basic principles introduces an anatomic and regenerative approach in which allows a performing surgeon to not only replenish and supplement fat to the superficial and deep fat compartments, the supraperiosteal regions of the pyriform and mandibles but also the other areas of bone, fat, and skin atrophy. Microparticles of fat are then placed into tissues to optimise their interface.

As fat is usually not uniformly distributed in the face, but separated into compartments both above and below the facial musculature and facial ligaments, it is important for the performing physician to administer the right types of fats to the correct compartments.

In addition, because fat is more tightly clustered in the superficial compartments above the muscles and larger and more loosely organized in the deep compartments below the facial musculature, an analysis of facial topography can help the practitioner to better understand how anatomic changes affect the various layers of the face.

As surgical artists, it is tempting to use fat as if it were “clay” to sculptor, placing it wherever one think may create an aesthetic outcome. However, with the present understanding of the anatomy of the face and how its ageing patterns, it is extremely crucial to place the properly sized fat grafts into the correct anatomical compartments of loss. The ITR² technique attempts to mimic the parcel sizes seen in the respective compartments, especially the deep and superficial compartments, at the same time, taking into account patient safety by modifying fat into different sizes according to the fat compartment treated, degree of bone loss, and extent of skin damage.

ITR² Technique - Delivering Results and Raising the Bar

Ageing is a dynamic process that can be modelled and predicted. The (ITR²) Technique can allow a performing surgeon to replace decayed tissues of the face using “like tissues” in an effort to potentially delay and retard the rate of tissue decay as observed in facial ageing patterns.

Using facial topography and proportion analysis, a physician can diagnose individual-specific losses of facial fat, and account for the degree of sun damage and skin thinning by the degree of loss in the superficial fat compartment, while deep compartment fat loss can be evaluated as is pyriform aperture, orbital, mandibular ramus, mandibular body, and chin resorption.

Over the years, advancements in science and technology has led to the birth of innovative techniques, and as one of the most cutting-edge techniques, the ITR² Technique is able to anatomically replace most, if not all, areas of tissue loss using the different types of fats; with milli-fat used for deep compartment and bone losses, micro-fat for superficial fat losses above the facial musculature, and nano-fat for intradermal layers and/or as a biological cream for topical application.

The ITR² Technique makes it not only possible to improve volume loss in the various areas, but also can enhance regenerative effects, revolutionising and raising the bar for fat grafting, tissue replacement and cell regeneration procedures.

Hope you have enjoyed the article! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!



Learn How to Deliver a More Natural and Longer-Lasting Result in Your Patients using Dr. Steve R. Cohen's Exclusive ITR2 Technique ​​at our upcoming Mini-Fellowship happening in San Diego, California, USA!

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Injectable Tissue Replacement and Regeneration & ABC Face Lift

November 7-8, 2019 | San Diego, California, USA

Mini-Fellowship (Observation) Injectable Tissue Replacement and Regeneration & ABC Face Lift November 7-8, 2019 | San Diego, California, USA

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