CRYOPRESERVATION OF LIPOASPIRATE MATERIAL FOR FUTURE PURPOSES
- PhillipBlondeel
- FilipStillaert
- HildeBeele
Vettransplantatie de toekomst in plastische chirurgie ?
Liposuctie is wereldwijd één van de meest uitgevoerde cosmetische ingrepen. Vanwege deze populariteit zijn de mogelijkheden met het verwijderde vet enorm uitgediept. Vandaag de dag worden er meer en meer transplantaties met eigen vetweefsel, of lipofilling, uitgevoerd. Naast de mogelijkheid voor esthetische doeleinden, biedt het ook de mogelijkheid om defecten veroorzaakt door kanker, trauma, aangeboren afwijkingen en radiotherapie te behandelen. Vetweefsel (foto 1) is meestal het weefsel waar vele mensen een hekel aan hebben: op bepaalde plaatsen is het te veel aanwezig, andere net te weinig. Maar is het wel terecht dat dit weefsel zo gehaat wordt? Recente ontwikkelingen tonen immers aan dat vetweefsel wel eens het weefsel van de toekomst zou kunnen zijn.
De hele organisatie van het vetweefsel uitleggen zou ons te ver leiden, maar vetweefsel bestaat dus vooral uit cellen gevuld met vetdruppels en andere cellen die zorgen voor de opbouw van een ‘skelet’ waarin de vetcellen vastzitten. Nog een belangrijke component in het vetweefsel zijn de stamcellen waarbij één gram vetweefsel ongeveer 5000 stamcellen bevat.
De transplantatie van vet is niet iets heel recentelijk. Als we de literatuur bekijken zien we dat vrije vettransplantatie al decennia lang gebeurde, maar met slechte resultaten. In 1983 was Gustav Adolf Neuber de eerste om vet te transplanteren en dit bij een 20 jaar oude man met een inzakking in het gezicht. Deze vulde hij met blokjes vet, afgenomen van de arm. De eerste borstreconstructie met eigen vetweefsel gebeurde door Czerny in 1895. Later probeerden verschillende chirurgen hun eigen techniek, maar de resultaten waren steeds slecht. Ook moest het vet steeds weggenomen worden met een chirurgische incisie. Een grote stap vooruit was de uitvinding van de liposuctie door de dokters Fischer. Hierbij moet er dus geen chirurgische incisie gemaakt worden om vet weg te nemen en volstaat het met een kleine incisie voor de canule, vet weg te nemen. Maar de echte revelatie kwam pas op gang toen Dr. Illouz in 1986 het idee kreeg om het afgenomen vet via liposuctie ook terug in te spuiten. Hierdoor werd een revolutie gestart waarbij chirurgen vet gingen gebruiken om bijvoorbeeld een borst te reconstrueren.
De eerste stap in het lipofillingproces is de afname van vetweefsel. Dit gebeurt met de standaard Coleman liposuctie techniek. Nadat de gewenste hoeveelheid vet is afgenomen wordt dit vetweefsel gecentrifugeerd. Hierdoor ontstaan er drie lagen. De bovenste laag is een olieachtige substantie die ontstaat door geruptureerde vetcellen. De middelste laag is het effectieve lipoaspiraat dat gebruikt wordt tijdens de lipofilling. De derde laag bevat allerlei bloedcellen en celafval (foto 2&3).
De indicaties om gebruik te maken van lipofilling kunnen zowel esthetisch als reconstructief van aard zijn. We gebruiken het vooral voor weke delen defecten. Deze defecten kunnen veroorzaakt zijn door veroudering, trauma, misvormingen, chirurgie, enz… Eigen of autoloog vetweefsel is een ideale filler net omdat het lichaamseigen is, op deze manier worden afstotingsverschijnselen al vermeden. Iedereen heeft vetweefsel dus is het altijd aanwezig, het heeft bovendien een populatie van stamcellen die verantwoordelijk worden gesteld voor allerlei voordelen. Mogelijks zijn zij verantwoordelijk voor grote huidverbetering op plaatsen waar er lipofilling is gebeurd, vooral op vlak van elasticiteit en huidherstel. Hoewel er ongerustheid was omtrent de vertraging van borstkankerdiagnose of het in het gedrang brengen van de radiografie, werd er nog altijd geen wetenschappelijk bewijs gevonden dat lipofilling zorgt voor een verhoogde kans op borstkankerherval. Qua nadelen bespreken we de necrotische cysten en fibrosis maar het grootste nadeel is de resorptie van het vetweefsel. Na het inspuiten zien we een onvoorspelbare resorptie van het vetweefsel, welke 40 tot 60% kan bedragen. Hierdoor is er dus een noodzaak om het proces meermaals te herhalen, bijgevolg moet de patiënt steeds opnieuw een liposuctie ondergaan (foto 4&5). Ondanks de lage mortaliteit en morbiditeit, ontstaat er onvermijdelijk een stijging als dit meerdere keren na elkaar moet gebeuren. Om dit te vermijden zouden we vetweefsel kunnen invriezen. Op deze manier zou één liposuctieprocedure voldoende zijn, het vet dat niet werd ingespoten wordt dan ingevroren en terug ontdooit wanneer het nodig zou zijn. Maar is vetweefsel invriesbaar ?
Cryopreservatie is een proces waarbij gehele weefsels worden bewaard via een invriesprocedure. Deze procedure is eigenlijk de temperatuur zodanig verlagen dat de metabole activiteit wordt gestopt. Dit lijkt heel artificieel, maar wordt ook gedaan door dieren in de natuur. Deze dieren noemen we ‘extremofielen’ en zijn immuun voor bepaalde extreme omstandigheden. Tardigrades vervangen hun intern water met het suiker ‘trehalose’, op deze manier gebeurt er geen kristallisatie wat dan weer het celmembraan zou beschadigen. Deze capaciteit doet hen overleven in temperaturen net boven het absolute nulpunt wat -273,15°C bedraagt. Het invriezen van bepaalde menselijke weefsels gebeurt al decennialang, maar vanwege de heterogene opbouw van vetweefsel is dit voor vet vrij moeilijk. Bovendien werd er in het verleden geen echte indicatie gezien om vetweefsel in te vriezen.
Uit de literatuur is gebleken dat dit mogelijk zou zijn, maar er zijn verschillende technieken beschreven. In mijn masterproef werden eerst de meest succesvolle methodes uit de literatuur gefilterd en nadien aangevuld met de ervaring van werknemers van de weefselbank in het UZ Gent. Op deze manier werd er een protocol opgesteld dat gemakkelijk te hanteren is en bovendien haalbaar is. Het is een mooie eerste stap naar verder onderzoek, maar het is natuurlijk louter een theoretische benadering.
Hoewel het zo lijkt is deze procedure niet gelimiteerd tot plastische chirurgie alleen. We zien in recente ontwikkelingen dat patiënten met sclerodermie zouden geholpen zijn met lipofilling en dan vooral in de handen. Dit vooral ten verdienste van de stamcellen in het lipoaspiraat. Ook deze patiënten zouden baat hebben bij het invriezen van vetweefsel. Op deze manier zou er ambulant steeds vet kunnen worden ingespoten. Maar dit zijn natuurlijk allemaal zaken die in de toekomst verder moeten uitgewerkt worden hoewel we nu al vrij zeker zijn dat vetweefsel het weefsel van de toekomst wordt in de geneeskunde.
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