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A. Sterodimas
a
b
Fig. 11.8 (a–c) Preoperative views of a 51-year old female patient complaining about her body. (d–f) Postoperative views of a 51-year old female
patient 4years after undergoing lipoabdominoplasty and gluteal augmentation by SEL
ab
11 Stromal-Enriched Lipograft™: Combining Chemical Automatic Cell Station and Mechanical Lipocube…
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c
117
Fig. 11.8 (continued)
Fig. 11.9 (a) Preoperative view of a 73-year-old woman presented complaining of her “unattractive” hands. (b) Postoperative view of a 73-year
old woman 2year after undergoing SEL transfer to the hands
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A. Sterodimas
Fig. 11.10 (a) Preoperative view of 42-year old female patient requesting rejuvenation of her external genitalia. (b) Postoperative view of a
42-year old female patient 1year after SEL of the external genitalia
11.5 Discussion
colonies in vitro. It is estimated that 1–3 million of these
small stellate-shaped cells typically reside in proximity to
Fat grafting for face and body contouring remains shrouded
in the stigma of variable results experienced by most plastic
surgeons when they rst graft fat. The need of standardization of the autologous fat-grafting technique needs to be
done. Numerous clinical reports have been published regarding techniques of fat graft harvesting, preparation, and injection. Techniques are still selected according to a surgeon's
individual preference, since quantitative evidence of clinical
fat survivability and predictability of volume restoration
does not exist. ADSCs can be distinguished from other adipocyte progenitor populations based on their expression of a
variety of surface markers. The regenerative capacity of
ADSCs during graft setting and their contribution to fat
regeneration has been proven [9]. Stromal vascular fraction
(SVF) is a heterogeneous population of cells that results
from the processing of adipose tissue and is composed
mainly of various blood cells, pericytes, macrophages,
smooth muscle cells, and both adipose-derived and vascular
endothelial progenitor cells. The factor in successful engraftment is the presence of ADSCs. These cells are pluripotent
mesenchymal stem cells that reside in large numbers in adipose tissue. These small stellate-shaped cells are identied
by surface antigens such as CD134 and their ability to form
small vessels of adipose tissue. They are known to tolerate
the conditions associated with harvest and graft injection
more successfully than mature adipocytes, participate in the
tissue response to these stresses, and direct adipose tissue
regeneration. ADSCs are able to differentiate into new adipocytes, replacing a portion of the adipocytes, which succumb to apoptosis due to hypoxic or physical stress and have
been shown to actively promote angiogenesis via growth factor secretion and through neovascular differentiation.
Clinical studies have demonstrated that the resident ADSCs
within fat-grafted tissues can differentiate into adipocytes
and add structure to ll the implanted tissue defect; secrete
growth factors, cytokines, and chemo-attractants that can
enhance angiogenesis and increase local vascularization and
blood supply; and inhibit innate immune responses after tissue transplantation [11]. Recent studies have indicated that
ADSCs can promote angiogenesis in addition to suppressing
inammation. An accepted principle of autologous fat grafting is that adipocytes survive only within 2mm of an arterial
blood supply. Fat cells outside this boundary may undergo
necrosis leading to scar tissue. The adipose tissue graft
enriched with SVF is woven into the targeted tissues, injecting only 5–10mL of fat with each pass as in order to obtain
11 Stromal-Enriched Lipograft™: Combining Chemical Automatic Cell Station and Mechanical Lipocube…
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119
the most reliable clinical outcome. The process of fat regeneration is progressed by ADSCs between 3 and 7days, so the
role of ADSCs is important in fat grafting. ADSCs are also
involved with establishing fat homeostasis. These properties
support successful tissue regeneration and the long-term survival of the fat graft. It has been shown that ADSCs harvested from supercial abdominal regions are signicantly
more resistant to apoptosis than other parts [12].
A series of clinical cases have shown that fat graft
enriched with adipose-derived stem cells can improve the
survival rate of the traditional fat graftting. In 2005, the
research team led by the author Dr. Sterodimas described
a method of supplementing the lipoaspirate used for fat
grafting with the stromal vascular fraction found in adipose. This process was named Stromal-Enriched Lipograft
[13]. The rationale behind this technique is that aspirated
adipose tissue is poor in progenitor cells, growth factors,
and cytokines, which are contributing factors to poor survival invivo of the fat graft. While certain aspiration sites
were initially thought to produce better graft take, these
theories have not been supported by recent studies. In the
SEL technique, the donor sites are chosen together with
the patient, and care is taken in order to avoid reharvesting fat from a previous lipoaspiration site and not to create contour deformities. A stromal vascular fraction (SVF)
containing ADSCs is freshly isolated from half of the
aspirated fat and recombined with the other half. This process converts relatively ADSC-poor aspirated fat to
ADSC-rich fat. SEL is based on the use of adipose-derived
stem cells combined with a biomaterial that is the adipose
tissue that has been processed to be used as a natural scaffold and biomolecules, cytokines, and growth factors,
which are secreted by the stem cells and the adipose tissue
[14]. A recent study has conrmed that SEL fat can sur-
vive better than non-SEL fat, and microvasculature can be
detected more prominently in SEL fat, especially in the
outer layers of the fat transfer [15].
11.5.1 Face SEL
The use of SEL can augment certain areas of the breast, for
example, in the midline to build cleavage, adding upper pole
fullness, or under the intended nipple position to provide
additional projection, which cannot be achieved by the insertion of silicone implant alone. SEL can effectively improve
implant animation deformity, rippling, and visibility of the
implant in décolletage. With aging, soft tissue loss is inevitable, and the skin of the dorsal surface of the hand becomes
thinner, thereby revealing extensor tendons and dorsal veins.
Successful, three-dimensional sculpting of the hand requires
attention to patient preparation, meticulous planning, and
optimizing the harvesting and transplantation of adipose tis-
sue. Hand rejuvenation by SEL™ aims at successfully reversing this three-dimensional process. Recent reports showed
ADSCs as a powerful source of skin regeneration because of
their capability to provide not only cellular elements, but
also numerous cytokines. A standardized technique of combining liposuction of lumbosacral, subgluteal, and trochanteric areas with lipoinjection in the upper middle buttock to
improve the gluteal contour together with the projection of
the gluteus is paramount for a successful gluteal fat grafting.
Deep knowledge of the topography of the gluteal region and
familiarity with the technique are essential in order to safely
reach a pleasant result.
11.6 Conclusion
SEL is a safe and acceptable method for face, breast, and
body fat-grafting surgeries due to its high patient satisfaction
and low complication rate. Future research will hopefully
rene our understanding of the effect of fat grafting on the
local tissue micro-environment and provide clues toward its
optimization. In addition, large-scale, controlled studies are
needed to advance our ability to tailor the SEL technique for
further applications in the eld of plastic & reconstructive
surgery.
References
1. Sterodimas A, Boriani F, Magarakis E, Nicaretta B, Pereira LH,
Illouz YG. Thirty-four years of liposuction: past, present and
future. Eur Rev Med Pharmacol Sci. 2012;16(3):393–406.
2. Sterodimas A, De Faria J, Correa WE, Pitanguy I.Tissue engineering in plastic surgery: an up-to-date review of the current literature.
Ann Plast Surg. 2009;62(1):97–103.
3. Sterodimas A, de Faria J, Nicaretta B, Pitanguy I.Tissue engineering with adipose-derived stem cells (ADSCs): current and future
applications. J Plast Reconstr Aesthet Surg. 2010;63(11):1886–92.
4. Sterodimas A, de Faria J, Nicaretta B, Papadopoulos O,
Papalambros E, Illouz YG.Cell-assisted lipotransfer. Aesthet Surg
J. 2010;30(1):78–81.
5. Sterodimas A, Illouz YG. Conclusions and future directions. In:
Illouz YG, Sterodimas A, editors. Adipose derived stem cells and
regenerative medicine. Berlin Heidelberg: Springer-Verlag; 2011.
p.273–6.
6. Pereira LH, Sterodimas A.Composite body contouring. Aesthetic
Plast Surg. 2009;33(4):616–24.
7. Sterodimas A. Stromal enriched lipograft for rhinoplasty renement. Aesthet Surg J. 2013;33(4):612–4.
8. Sterodimas A, Huanquipaco JC, de Souza FS, Bornia FA, Pitanguy
I.Autologous fat transplantation for the treatment of Parry-Romberg
syndrome. J Plast Reconstr Aesthet Surg. 2009;62(11):e424–6.
9. Sterodimas A, de Faria J, Nicaretta B, Boriani F. Autologous fat
transplantation versus adipose-derived stem cell-enriched lipografts: a study. Aesthet Surg J. 2011;31(6):682–93.
10. Nicareta B, Pereira LH, Sterodimas A, Illouz YG.Autologous gluteal lipograft. Aesthetic Plast Surg. 2011;35(2):216–24.
11. Sterodimas A, Pereira LH.Liposuction of the abdomen and trunk.
In: Rubin JP, Jewell ML, Richter D, Uebel CO, editors. Body con-
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touring & liposuction. New York, NY: W.B. Saunders Elsevier;
2012. p.311–20.
12. Sterodimas A.Adipose Stem cell engineering: clinical applications
in plastic and reconstructive surgery. In: Illouz YG, Sterodimas
A, editors. Adipose derived stem cells and regenerative medicine.
Berlin Heidelberg: Springer-Verlag; 2011. p.165–80.
13. Sterodimas A.Tissue engineering with adipose derived stem cells
(ADSCs) in plastic & reconstructive surgery: current and future
applications. In: Di Giuseppe A, Shiffman MA, editors. New frontiers in plastic and cosmetic surgery. Jaypee; 2015.
14. Sterodimas A, Nicaretta B.Filippo Boriani composite face lifting:
the combination of stromal enriched lipograft with face minilift and
upper and lower blepharoplasty: a review of 210 cases. Ann Plast
Surg. 2020;85(6):e20–3.
15. Gentile P, Sterodimas A, Calabrese C, De Angelis B, Trivisonno A,
Pizzicannella J, Dionisi L, De Fazio D, Garcovich S.Regenerative
application of stromal vascular fraction cells enhanced fat graft
maintenance: clinical assessment in face rejuvenation. Expert Opin
Biol Ther. 2020;20(12):1503–13.
The Legacy ofMicro-Autologous Fat
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Transplantation: AReality
12
fromEvidence-Based Medicine
Tsai-MingLin, HidenobuTakahashi, andChih-KongChou
Contents
12.1 Brief History of Fat Grafting 121
12.2 Evidence-Based Medicine of the Volume of Each Delivered Fat Parcel 121
12.3 Introduction of Micro-autologous Fat Transplantation (MAFT) and MAFT-GUN 122
12.4 Basic Procedures for MAFT 122
12.5 Clinical Applications of MAFT 125
12.6 Discussion 153
12.7 Conclusions 154
References 154
12.1 Brief History ofFat Grafting
Fat grafting was rst addressed in 1893 by the German surgeon, Neuber [1]. Since then, techniques, methods, and protocols for fat grafting have been enhanced and developed
frequently to improve the fat survival/retention rate.
Numerous surgical mentors in this eld have demonstrated
innovative strategies for improving the results of fat grafting
[2–7].
Financial Disclosure Statement: Dr. Tsai-Ming Lin owns the patent
rights to the MAFT-GUN and is a scientic adviser for Dermato Plastica
Beauty Co., the manufacturer of the MAFT-GUN device. None of the
other authors has any nancial disclosures or conicts of interest.
T.-M. Lin (*) · C.-K. Chou
Charming Institute of Aesthetic and Regenerative Surgery
(CIARS), Kaohsiung City, Taiwan
H. Takahashi
Department of Surgery, Kaohsiung Medical University Hospital,
Kaohsiung City, Taiwan
12.2 Evidence-Based Medicine
oftheVolume ofEach Delivered Fat
Parcel
Fat grafting has been indispensably regarded as an important
plastic surgery innovation as hand/face transplantation of the
modern era in a survey conducted by the American Council
of Academic Plastic Surgeons (ACAPS) and the Southeastern
Society of Plastic and Reconstructive Surgeons (SESPRS)
[8]. Furthermore, Sydney R. Coleman has been ranked as
one of the top 10 most inuential plastic surgeons currently
in practice. In the past decade, fat grafting has been used for
facial rejuvenation, craniofacial deformity, cosmetic and
reconstructive breast surgeries, gluteal augmentation, hand
rejuvenation, and regenerative surgeries [9]. In the literature,
a few studies illustrate the critical issues of the size of each
fat parcel and the consistent control of fat parcels during
transplantation. The evolution of the volume of each fat parcel has been suggested from a volume between 1/8 [10] and
1/30mL [11] to between 1/50 and 1/30mL [12] by Coleman;
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_12
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however, in terms of the consistent control of grafting parcels, no conclusive methods or maneuvers have been agreed,
especially using the surgeon’s hands. Most commercial
instruments, such as the Rachet gun, reach a volume per parcel of only 1/20 mL, considerably large than the recommended volume of 1/50 to 1/30 mL [12].
12.3 Introduction ofMicro-autologous Fat
Transplantation (MAFT)
andMAFT-GUN
During the initial 24–48 h after fat grafting, the inow of
nutrients and outow of metabolites from adipocytes depend
on physiologic diffusion and plasmatic imbibition in the
recipient niche. The neo-vascularization of the grafted fat is
reformed by regaining blood circulation after 48h. Carpaneda
etal. [13, 14] demonstrated that the central area eventually
necrotized, and only the marginal zone survived at a rate of
approximately 40% at 1.5±0.5mm from the grafted margin,
regardless of the shape of the fat graft (spherical or cylindrical). Moreover, previous studies have reported several postoperative complications associated with the large size of an
implanted fat parcel, including absorption, cyst formation,
brosis, nodulation, calcication, ossication, and asymmetry [15]. Inevitably, the phenomenon of “central necrosis” at
any large fat parcel results in unpredictable graft survival/
retention rate and induces a vicious cycle of postoperative
complications. Therefore, the size of the implanted fat droplets should be as small as possible [16]. Based on the theory
postulated by Carpaneda, the mathematical formula for
determining the optimal volume of fat parcels (here, the fat
graft is presumed to be spherical in shape) is calculated as
follows: the volume of a globe is (4/3) πr3, where r is the
global radius and π is the ratio of any circle’s circumference
to its diameter in Euclidean space. Table12.1 presents information regarding the volume of each fat parcel at radii of 1,
1.5, and 2mm. We concluded that the injection frequency of
1mL fat parcels for a spherical graft with a 2mm radius can
be calculated by dividing 1000 mm3 (1 mL) by (4/3) π
(2mm3). Therefore, a minimal injection frequency of 30 was
Table 12.1 The volume of a spherical at a radius of 1.0, 1.5, and
2.0 mm is calculated, and the total injection frequency of 1 mL
(1000mm3) is concluded accordingly
Volume of
Radius
1.0mm
1.5mm
2.0mm
Therefore, the total injection frequency of 1mL (1000mm3) of fat
is 240, 70, and 30in sequence.
Spherical
4.2mm
14.1mm
33.5mm
Total Injection frequency for
each 1mL (1000mm3) fat graft
3
1000÷4.2=240
3
1000÷14.1=70
3
1000÷33.5=30
set for each 1mL of fat-graft parcel to achieve superior graft
survival rates. A patented instrument, the MAFT-GUN [17],
was invented to achieve precise, accurate, and consistent
control of each fat parcel from 1/60, 1/90, 1/120, 1/150,
1/180, and 1/240mL [18].
12.4 Basic Procedures forMAFT
Since 2010, more than 2800 cases of fat grafting involving
the face, neck, hand, breast, buttock, and other sites with the
assistance of MAFT-GUN have been performed by the
author (Tsai-Ming Lin) at the Charming Institute of Aesthetic
and Regenerative Surgery, Kaohsiung, Taiwan. The basic
procedures for MAFT are briey described here.
12.4.1 Fat Harvesting
The donor area (lower abdomen, ank, or thigh) was preinltrated with a tumescent solution prepared at a ratio of
10mL of 2% lidocaine (20mg/mL): 30mL of Ringer’s lactate solution: 0.2mL of epinephrine (1:1000) after the incision site was anesthetized. Approximately 10–15min after
the tumescent solution was administered, a blunt-tip liposuction cannula (2.5mm in diameter with one-sided-hole) was
used to harvest the fat, and the lipoaspirate volume was the
same as that of the inltrated tumescent solution to achieve a
high proportion of puried fat after centrifugation. Damage
to the lipoaspirate was minimized by pulling back the plunger
of a 10mL Luer lock syringe for 2–3mL and was sustained
so that while it was connected to the liposuction cannula, the
reactive aspirating negative pressure between 270- and 330mmHg was maintained (Fig.12.1a) [19].
12.4.2 Fat Processing andRenement
Various methods, such as the sieve method, multiple-layer
gauze ltration, and centrifugation, have been proposed for
fat processing [20, 21]. The internationally accepted
Coleman’s technique was used for processing the lipoaspirate through centrifugation because of its advantages of less
environmental exposure and lower manual manipulation in
the aseptic procedure [22]. Standard centrifugation at
3000 rpm, which was approximately 1200 × g for 3 min
(Fig. 12.1b), was applied to process (purify) the fat.
Thereafter, the puried (condensed) fat was in the middle
layer of each 10mL syringe and meticulously collected after
removing the top oil layer and the bottom bloody tumescent
solution (Fig.12.1c).
a
b
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c
123
d
e
f
Fig. 12.1 (a) Fat aspiration is performed by back-pulling the plunger
of a 10mL syringe to approximately 2–3mL to maintain an appropriate
negative pressure. (b) Processing by centrifugation is maintained at
3000rpm (~1200×g) for 3min to purify the fat. (c) The lower part of
the centrifuged lipoaspirate (bloody content) is leaked out, and the oil
in the upper part is wiped off using gauze. (d) The puried, condensed
fat is transferred to a 1mL Luer slip syringe for transplantation. (e) The
fat-lled syringe is loaded into a MAFT-GUN (Dermato Plastica
Beauty Co., Ltd. Taiwan). (f) The six-graded dial is set at 60 for neck
and dorsal hand rejuvenation, 120 for most facial areas, and 240 for
periorbital areas, and the delivered volumes of the fat parcel are
1/60mL (0.017mL), 1/120mL (0.008mL), and 1/240mL (0.004mL),
respectively
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12.4.3 Fat Transplantation
tion, there are three layers: a deep layer above the inferior
orbital rim, a middle layer, the suborbicularis oculi muscle
The puried fat was carefully transferred into a 1mL Luer
slip syringe using a transducer and prepared for transplantation (Fig.12.1d). Information regarding MAFT for facial
rejuvenation is summarized in Table12.2. Generally, 1mL
of a fat-lled syringe was loaded into the MAFT-GUN
instrument (Fig.12.1e). The predetermined volume of the
fat parcel to be injected during each triggering was selected
by rotating the adjustable volume dial (Fig. 12.1f), with
labeled numbers depicting the total injection frequencies
per 1mL of the fat graft. For facial rejuvenation, an 18-G
blunt cannula was used to inject fat while withdrawing the
MAFT- GUN. Each delivered fat volume was set at
1/120mL (however, the periorbital areas were preferred at
1/240mL) and meticulously transplanted in three to four
layers according to the characteristics and anatomy of the
recipient tissue. For example, in sunken eyelid rejuvena-
Table 12.2 Information of micro-autologous fat transplantation (MAFT) for facial recontouring and rejuvenation
Type of cannula Fat parcel per triggering (mL)
Size
Facial area
Forehead [23, 24] 18 Blunt One 1/120 1/120 1/120 A 10–25
Sunken temporal fossa [23, 25] 18 Blunt One 1/120 1/120 1/120 B1, B
Sunken upper eyelid [23, 26,
27]
Nasojugal groove and
Lid-cheek junction [23, 28]
Nasal dorsum [23, 29] 18 Blunt One 1/120 1/120 1/120 E 1.0–4.0
Cheek [23] 18 Blunt One 1/120 1/120 1/120 D1, D
Nasolabial groove [23, 30, 31] 18 Blunt One 1/120 1/120 1/120 D1’G1, D2’G
Upper/ lower lip [23] 18 Blunt One 1/120 1/120 1/120 F1, F
Chin [23, 32] 18 Blunt One 1/120 1/120 1/120 F1, F
(gauge)
18 Blunt One 1/240 1/240 1/240 C1, C
18 Blunt One 1/240 1/240 1/240 D1, D
Tip Side hole Deep
(deep in the muscle), and a supercial layer, the supraor-
bicularis oculi muscle (just beneath the dermis of the
eyelid).
Postoperative care was provided regularly without any
special dressings or massage. Oral and non-steroidal antiinammatory drugs were administered for 3 days, as
required. Hyperbaric oxygen treatment (“HearMEC”
Hyperbaric Oxygen Chamber O2 Prime Cabin Model:
CA200 OX-II, Health Way Biomedical Co, Ltd. Taiwan) is
routinely deployed after MAFT procedure in the author’s
institute. All patients were regularly photographed at each
follow-up visit, and the preoperative and postoperative
images of each patient were compared. Touchup MAFT is
recommended 4–6months after the rst session to enhance
the appearance or address severe depression or scar
tissue.
Insertion site
layer
Middle
layer
Supercial
layer
of cannula
(see Fig.12.2)
2
2
2
2
2
2
Average
volume (mL)
6.0–12/unilateral
0.5–2.0/unilateral
1.0–4.0/unilateral
3.0–8.0/unilateral
4.0–10/unilateral
2
1.0–2.0/upper or
lower
4.0–8.0
12 The Legacy ofMicro-Autologous Fat Transplantation: AReality fromEvidence-Based Medicine
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the long-term effects (Figs.12.7 and 12.8). The total trans-
12.5 Clinical Applications ofMAFT
planted volume varies from 4 to 8mL for each neck line to
6–12 mL for recontouring per depression individually.
12.5.1 Facial Contouring
Touchup might be necessary 4–6months after the rst session to enhance the effect of the procedure.
Table 12.2 and Fig.12.2 summarize the fundamental information on the MAFT technique for facial contouring and
rejuvenation, including the authors’ preferred cannula pat-
12.5.3 Dorsal Hand Rejuvenation
tern, volume per delivered parcel, insertion site, and suggestive average volume (mL) with insertion sites for each
recipient area. Briey, an 18-G (1.2mm in diameter) blunttip one- sided hole injection cannula (disposable cannula preferred) was selected for transplantation. The ideal volume for
grafting was 1/120mL per fat parcel with the adjustable dial
switched to 120 and 240 (to reect each delivered parcel
1/120 and 1/240mL) for periorbital areas, sunken upper eyelid, tear trough, and lid-cheek junction, where the skin is thin
to avoid irregularity. In more than 2500 cases performed by
the senior author (TM Lin) for facial contouring, the average
volume for each area was suggested (Table12.2) but subjective to change due to individual variation. Figures12.3, 12.4,
12.5, 12.6 demonstrate the clinical results of facial recon-
touring and rejuvenation by MAFT [23–30].
In the aging of the dorsal hand surface, soft tissue loss is
inevitable, and the skin becomes thinner, thereby revealing
the dorsal veins and extensor tendons that could hinder social
activities in some individuals. Using a 16-G injection cannula, with a delivered volume of 1/60mL per parcel, an average volume of 15–25 mL for each dorsal hand, including
digits (up to the proximal interphalangeal joint), was transplanted in three layers [33]. In our earlier study, favorable
outcomes (very satised: 58.8% and satised: 39.7%) were
demonstrated in patients who underwent a single session of
MAFT. The volume of the aging dorsal hand surface was
restored, and skin texture improved with sustainable longterm effectiveness, conrming that the technique is a reliable
and simple strategy for rejuvenating the dorsal surface of
aging hands (Fig.12.9).
125
12.5.2 Neck Recontouring
Using a 16-G (1.6mm in diameter) blunt tip with a one-sided
hole injection cannula, the predetermined volume was set at
1/60 mL per parcel, and the procedure was performed for
neck recontouring in the elderly group for alleviating neck
lines in the younger group. Satisfactory results demonstrated
Fig. 12.2 Recommended
cannula insertion sites for
facial rejuvenation in the
MAFT procedure
12.5.4 Scar andRelated Skin Rejuvenation
Issues
For old traumatic scars, there are not only brotic tissue
formations that cause subcutaneous hardness and/or tissue
deciency but also widening or hypertrophic scar forma-
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