The goal of this study is to specifically examine changes in facial skin appearance after facial fat grafting with autologous fat tissue that has either been washed with sterile saline before injecting, or left unwashed. This will be testing two variations of a standard of care surgical procedure, in two cohorts of subjects. One group will receive washed fat, and one group will receive unwashed fat, to both sides of the face. There are no experimental devices, drugs, or biological agents being used in this study. All fat tissue is autologous from the subjects treated.

Significance: This study will provide evidence that may directly impact clinical practice for a common procedure in plastic surgery. Regardless of whether the null hypotheses is accepted or rejected, the data will be of direct clinical use and impact practice in the operating room.

Autologous fat grafting is a very common standard of care procedure in plastic surgery, used for both aesthetic and reconstructive applications across the entire body.1 Facial fat grafting, in particular, is the most common site for use of autologous fat. The American Society of Plastic Surgeons (ASPS) statistics report showed 133,720 cases of facial fat grafting for cosmetic indications in 2020.2 This is mainly due to the fact that humans lose facial fat during the aging process, and that loss of volume leads to characteristic signs of aging.3 It is also well known that when autologous fat grafting is used for facial cosmetic injections, increasing the amount of fat in the dermal/subdermal region has very positive effects on the appearance of the skin.4-6 This is because adding more padding beneath the skin gives the appearance of suppleness and smoothness and mitigates the "deflated" appearance that patients complain of. Additionally, as the adipose graft tissue heals, it tends to increase vascularization in the region which also has a positive effect on the skin. This can improve fine and course wrinkles, and color tone and pigmentary variation can also improve.7-9 Facial fat grafting is commonly performed by surgeons at UPMC and throughout the Pittsburgh region, consistent with national practice patterns.

Autologous fat grafting is a minimally invasive procedure that involves harvest of fat tissue with a liposuction cannula. In many cases, the cannula is attached to a 10 mL syringe and negative pressure applied by withdrawing the syringe plunger during aspiration.1 In other cases, a mechanical aspiration machine is used to generate negative pressure.1 Either way, all of this equipment is standard in most operating rooms across the country. The aspirated material consists of small particles of adipose tissue, measuring between three and five mm in diameter.10 Once harvested into sterile vessels, the aspirate can be gently centrifuged or strained to separate and remove the aqueous and oil layers. If washed, a sterile saline solution would be used to perform the washing procedure. The material is often transferred between syringes using a Luer Lock connector and the graft material is then injected from syringes. Passing the tissue multiple times between Luer Lock connectors has become a very common method of breaking up clumps of tissue and enabling a more flowable graft material that can be injected through smaller gauge cannula without clogging.11

Controversy exists in the plastic surgery community as to the most beneficial preparation methods in the operating room.12 Different surgeons use a number of methods alone or in combination that include filtering or straining fat, gentle centrifugation, separation of fluid and oil layers by gravity, and rinsing/washing with sterile saline. All of these methods are well accepted as within standard of care and represent minimal manipulation of the tissue grafts. A national survey of the plastic surgery community, published by our group revealed that 28% of surgeons use a saline wash during their fat graft processing.13 The rationale for a saline wash is that it may decrease any residual free lipid/oil, as well as residual red cells, both of which can potentially cause irritation of the local tissues. However, opponents of washing often cite that there washing adds an extra step without clinical benefit.

Hypothesis: We hypothesize that a saline washed fat graft injectate will have improved appearance of facial skin. We speculate that the reduced free lipid and reduced red cell fraction will be beneficial in the healing process.

Significance: This study will provide evidence that may directly impact clinical practice for a common procedure in plastic surgery. Regardless of whether the null hypotheses is accepted or rejected, the data will be of direct clinical use and impact practice in the operating room.

Treatment Period: Autologous fat graft injections will be performed on Day 0 of the study period after eligibility determination has been made, and after baseline data collection. Subjects will be followed over a 12-month time period.

Inclusion Criteria:

1. Ability to perform informed consent

2. Healthy female adults, from 35 to 70 years of age

3. Fitzpatrick Skin Type Scale scores < 3.

4. FWAS-greater than moderate, equal to or greater than 4

5. Noticeable Physical signs of facial aging and sun damage including skin wrinkles, loss of elasticity and pigmentary changes, with greater than mild (≥4 on a 0 to 9 scale) signs of the following, per investigator discretion

   1. Facial wrinkles (periorbital//periorbital//cheek)
   2. Dyschromia (hyperpigmentation//uneven skin tone)
   3. Rough skin texture (visual skin roughness//pore sizes)

6. Willingness to undergo the proposed treatment and comply with study procedures.

7. Negative pregnancy urine dip test (as indicated-unless s/p hysterectomy or past menopause documentation can be sourced to research chart.)

8. Willingness to avoid the use of laser, IPL, Botox (6 months), injectable fillers or other surgical cosmetic procedures on the face for 6 months ducts

9. Ability to produce sufficient fat tissue from donor site during harvest (up to a maximum of 1 liter)

Exclusion Criteria:

1. Age < 35 or > 70 years of age
2. Any medical condition that would preclude safe administration of anesthesia and safe conduct of the adipose harvest procedure (such as an uncontrolled bleeding disorder or severe pulmonary disease), per investigator discretion.
3. Active infection on the face (e.g., acne, HSV (herpes simplex), etc.,) per investigator discretion.
4. Female in pregnancy (positive pregnancy-test performed before inclusion) or lactation or without effective contraception)
5. Received laser, IPL, botox (6 months), injectable fillers or other surgical cosmetic procedures on the face within 12 months of study consent and screening date. -prohibited for 6 months
6. Acutane use within past 12 months
7. Individuals with any contraindications of autologous lipografting, such as cutaneous rashes or infection in the area of intended fat harvest, lack of available donor fat, or other factors that, in the determination of the investigator, would be considered a contraindication.
8. Individuals diagnosed with known allergies to skin care products, topical antibiotics, adhesives, bandages, lidocaine, epinephrine, or other agents that might be used in the study
9. Individuals with any disease state or inappropriate physical skin condition (e.g., active/history of psoriasis, active eczema, excessive hair, scars, tattoos, etc. on face) that might impair evaluations or increase the health risk to the subject by participation in the opinion of the Investigator
10. Individuals with a history of immunosuppression/immune deficiency disorders/ known or suspected defect of healing (including HIV infection or AIDS)
11. Individuals with an uncontrolled disease such as hypertension, hyperthyroidism, or hypothyroidism, which may impact safety. Individuals having multiple health conditions may be excluded from participation even if the conditions are controlled by diet, medication, which in the opinion of the Investigator, may create safety concerns or interfere with the study.
12. Individuals currently taking substances known to affect bleeding time, which in the opinion of the Investigator, may create safety concerns or interfere with the study (e.g., aspirin, Heparin, Warfarin, Plavix, supplements, etc.).
13. Individuals currently and chronically taking substances known to impair the immune system at doses anticipate to have a systemic effect on wound healing (e.g., corticosteroids, immunosuppressant, etc. or currently using immunosuppressive medications (e.g., azathioprine, belimumab, cyclophosphamide, Enbrel, Imuran, Humira, mycophenolate mofetil, methotrexate, prednisone, Remicade, Stelara.) within 30 days of the study start and in the discretion of the PI would impact the results of the study. Steroid treatments that would not be expected to impact study results could include steroid inhaler, nasal spray, eyedrops, topical creams used in areas outside of the face, or transient oral dose of steroids to treat acute conditions (eg pulsed oral dose for respiratory airway constriction or skin rash)
14. Individuals with a history of documented keloid scar formation, prominent skin lesions or scars that would render data collection and aesthetic evaluation impossible. The investigator will make that determination based on examining other scars and reviewing any history of treatment for keloid lesions.
15. Individuals with a diagnosis of diabetes
16. Subject participating in another interventional clinical trial assessing treatments that may interfere with the accuracy of data collection for this study within 1 month of Visit 1
17. The inability to obtain sufficient fat from the donor site during the harvest to allow the autologous fat tissue processing prior to facial injection.

Healthy female adults, from 35-70 years of age

Blinded grading based on VECTRA images and VISIA images will be performed on de-identified photography by a third-party vendor at the end of the study.