Technique

The technique for this procedure is outlined in the following steps.

Step 1 Marking of the areas to be liposucted are made while the patient is in standing position.

Step 2 Preoperative sedation in the surgical suite is administered. Anaesthesia comprises an epidural block and intravenous sedation. The patient is placed in prone position. After the injection of a normal saline wetting solution containing 1:500000 of adrenaline by a small bore cannula and waiting 15 minutes, a 60 cc syringe attached to a 4 mm blunt cannula is inserted through small incisions in the abdominal area.

Step 3 Fat is aspirated by using the syringe method. A total of two thirds of aspirated fat is used in order to isolate the SVF (Figure 1). Digestion is done with 0.075% collagenase (Sigma, St. Louis, MO) in buffered saline and agitated for 30 minutes at 37°C in Celltibator (Medikan International, Inc., Los Angeles, CA). Separation of the SVF containing ADSCs is then done by using centrifugation at 1200 x g for 5 minutes15 with the Lipokit Centrifuge (Medikan International, Inc.). The SVF is located in the pellet derived from the centrifuged fat at the bottom of the lipoaspirate.

Step 4 The remaining third of the aspirated fat is treated in the following manner: with the syringe held vertically with the open end down, the fat and fluid are separated. Isotonic saline is added to the syringe, the fat and saline are separated and the exudate discarded. The procedure is repeated until the fat becomes yellow in colour, free of blood and other contaminants16–19. In SEL, freshly isolated SVF is attached to the aspirated fat, with the fat tissue acting as a living bioscaffold before transplantation20. This whole procedure is done manually by two tissue engineers inside the operating theatre, and the time required is approximately 90 minutes.

Figure 2 (A), (B) and (C) Preoperative photos of a 59-year-old woman requesting facial rejuvenation, and (D), (E), and (F) postoperative photos after face-lift assisted by stromal enriched lipograft

Figure 2 (A), (B) and (C) Preoperative photos of a 59-year-old woman requesting facial rejuvenation, and (D), (E), and (F) postoperative photos after face-lift assisted by stromal enriched lipograft

Step 5The adipose tissue graft enriched with SVF is woven into the targeted tissues (face, breast, body), injecting only a tiny amount with each pass in order to achieve the most reliable clinical outcome. Tissue planes are created by using specific cannulae in different trajectories, always from the deeper aspect to more superficial areas. The fat is injected as the cannula is withdrawn to avoid intravascular fat injection.

Step 6 Antibiotics, analgesics, and anti-inflammatory medications are prescribed during the following 7 postoperative days.

The patient’s overall satisfaction with the appearance of their treated areas after undergoing SEL was rated on a scale of 1 to 5, whereas 1 is poor, 2 is fair, 3 is good, 4 is very good, and 5 is excellent. The patient satisfaction scale has already been used in published papers and has been peer-reviewed21–23. Evaluation of patient satisfaction was done at least 12 months after the initial surgical procedure.

Stromal enriched lipograft cases

Case 1

A 59-year-old woman asked for rejuvenation of her face (Figure 2). She underwent a traditional round face-lifting combined with SEL. Postoperative photos after 2 years are shown and her overall satisfaction with her face was rated as excellent.

Case 2

Figure 3 (A) and (B) Preoperative photos of a 40-year-old woman requesting body contouring. (C) and (D) Postoperative photos after gluteal augmentation by stromal enriched lipograft

Figure 3 (A) and (B) Preoperative photos of a 40-year-old woman requesting body contouring. (C) and (D) Postoperative photos after gluteal augmentation by stromal enriched lipograft

A 40-year-old woman asked for body contouring (Figure 3). She underwent SEL in bilateral buttocks. After 2 years, the postoperative result is shown and her overall satisfaction with her body was rated as excellent.

Case 3

A 32-year-old woman requested breast augmentation (Figure 4). She underwent breast SEL and after 1 year; the postoperative result is shown and her overall satisfaction with her breast contour was rated as very good.

Case 4

A 45-year-old woman requested gluteal correction after suffering trauma (Figure 5). She underwent SEL and 18 months after surgery her overall satisfaction with her buttocks was rated as very good.