Autologous fat grafting: Harvesting techniques

Con en s lis s a ailable a ScienceDi ec Annals o Medicine and Su ge y jou nal homepage: www.else ie .com/loca e/amsu Re iew Au ologous a g a ing: Ha es ing echniques Tomás Fon es a,1 , Inês B andão a,b,1 , Ri a Neg ão a,b , Ma ia João Ma ins a,b , Rosá io Mon ei o a,b,c,∗ a Depa amen o de Biomedicina - Unidade de Bioquímica, Faculdade de Medicina, Uni e sidade do Po o, Po o, Po ugal b Ins i u o de In es igação e Ino ação em Saúde (I3S), Uni e sidade do Po o, Po o, Po ugal c Unidade de Saúde Familia Ped as Rub as, Ag upamen o de Cen os de Saúde Maia-Valongo, Maia, Po ugal ARTICLE INFO Keywo ds: Adipose issue Au ologous a g a Recons uc i e su ge y Plas ic su ge y Ha es ing echniques ABSTRACT Au ologous a g a ing is widely used o so - issue augmen a ion and eplacemen in econs uc i e and aes- he ic su ge y p o iding a biocompa ible, na u al and inexpensi e me hod. Mul iple app oaches ha e been de eloped in he pas yea s, a ying in he loca ion o adipose issue dono -si es, use o we ing solu ions, ha es ing, p ocessing and placing echniques. Despi e many ad ances in his subjec , he lack o s anda diza ion in he p o ocols and he unp edic abili y o he eso p ion o he g a ed issue pose a significan limi a ion o g a e en ion and subsequen filling. In his e iew, we discuss se e al app oaches and me hods desc ibed o e he las yea s conce ning he ha es ing o au ologous a g a s. We ocus on con en s such as he bes dono -si e, diffe ences be ween exis ing ha es ing echniques (namely issue esec ion, hand aspi a ion o liposuc ion echniques), ecommended ha es ing cannula diame e s, p essu e applica ion and olume o we ing solu ion injec ed p io aspi a ion. Resul s and compa isons be ween me hods end o a y acco ding o he ou come measu ed, hus posing a limi a ion o pinpoin he mos efficien me hods o apply in a g a ing. Addi ionally, he lack o a s anda d assay o de e mine iabili y o olume augmen a ion o a g a ing emains ano he limi a ion o ob ain uni e sally accep ed g a ing p ocedu es and p o ocols. 1. In oduc ion The fi s eco d o an au ologous a ans e p ocedu e da es back o 1893, when Neube ans e ed au ologous adipose issue o a acial sca dep ession and documen ed he ou comes [1]. Howe e , au o- logous a g a ing only came in o play as an impo an and easily ac- cessible fille wi h he ad en o liposuc ion in he 1980s [2]. Since hen, he numbe o applica ions epo ing on i s use has been g owing, mos ly because adipose issue is eadily a ailable, na u al, easy o ha es and inexpensi e. In addi ion, being au ologous, adipose issue does no igge an immunological esponse ha could lead o ejec ion, besides associa ing wi h e y li le dono -si e mo bidi y [3]. Fu he - mo e, his issue can be used no only as a olume eplace bu also as a issue quali y imp o e [4]. Some clinical applica ions o au ologous a g a s comp ise: a) aes he ic b eas p ocedu es (p ima y b eas aug- men a ion, eplacemen o p e ious b eas implan s, e e sal o adia- ion damage a e b eas cance ea men , b eas econs uc ion o econ ou ing a e mas ec omy and co ec ion o de o mi ies such as ube ous b eas o b assie e s ap g oo es [5–9]; b) mas oidec omy, hinoplas y, acial eju ena ion, hand eju ena ion, glu eoplas y and la yngoplas y [4,10–16]; c) imp o emen and/o co ec ion o de o - mi ies obse ed in Pa y-Rombe g synd ome, Poland synd ome, Du- puy en's and Raynaud's diseases and pec us exca a um [17–22]; d) ea men o sca s, ulce s and bu ns [23,24]. Al hough i has been widely used o decades now, one o he main issues in au ologous a g a ing is he unp edic able eso p ion a e ansplan a ion, which may equi e epea ed injec ions and lead o poo esul s [25,26]. The e o e, he need o op imizing a g a ing me ho- dology should be o maximal impo ance o minimize a g a loss. Ha es ed adipose issue is composed o ma u e adipocy es, ex a- cellula ma ix and a s omal ascula ac ion (SVF), cons i u ed by diffe en cells including adipose de i ed s em cells (ADSCs), pe icy es, endo helial cells, e y h ocy es, fib oblas s, ascula smoo h muscle cells, hema opoie ic cells and o he immune cells (Fig. 1)[2,27,28]. No ewo hy, ecen epo s ha e iden ified adipose issue as he issue in he body ha con ains he highes pe cen age o adul s em cells [29,30]. These ADSCs can unde go mul ilineage diffe en ia ion [30–38] and may be c ucial o a g a ake since ma u e adipocy es ha su - i e ha es ing p ocedu es will no eplica e and will e en ually die, gene a ing ha m ul inflamma o y esponses [39]. Indeed, ADSC- h ps://doi.o g/10.1016/j.amsu.2018.11.005 Recei ed 26 June 2018; Recei ed in e ised o m 31 Oc obe 2018; Accep ed 6 No embe 2018 ∗ Co esponding au ho . Depa amen o de Biomedicina, Unidade de Bioquímica, Faculdade de Medicina, Uni e sidade do Po o, Alameda P o . He nâni Mon ei o, 4200-319, Po o, Po ugal. E-mail add ess: [email p o ec ed] (R. Mon ei o). 1 Bo h au ho s con ibu ed equally o his wo k. Annals o Medicine and Su ge y 36 (2018) 212–218 2049-0801/ © 2018 Uni e si y o Po o. Published by Else ie L d on behal o IJS Publishing G oup L d. This is an open access a icle unde he CC BY license (h p://c ea i ecommons.o g/licenses/BY/4.0/). T en iched g a s obse ed in cell-assis ed lipo ans e (CAL) ha e been associa ed wi h be e g a iabili y and ou come a e ansplan a ion (Fig. 1)[28,40]. Ye , his is s ill a ma e o deba e, wi h o he clinical s udies claiming ha he e is no significan diffe ence in he su i al a e o he ansplan ed a be ween con en ional a g a ing and SVF- en iched a g a ing and e en adding ha pos ope a i e complica ions a e mo e o en obse ed in he la e [41]. Acco ding o a ecen me a- analysis by Laloze e al., ha e alua ed he efficacy o CAL by com- pa ing 16 s udies, he a su i al a e was significan ly highe wi h CAL when compa ed wi h con en ional p ocedu es, independen o injec ion si e (b eas o ace) bu only o small injec ion olumes (below 100 mL). The same analysis concluded ha CAL associa es wi h mo e complica ions and did no dec ease he numbe o addi ional su gical p ocedu es needed a e he fi s a g a ing [41]. So a , many echniques and p ocedu es ha e been documen ed ega ding he use o adipose issue g a s in econs uc i e su ge y. Dis inc ha es ing p ocedu es esul in diffe en ou comes o a g a ake, as obse ed by mul iple in i o analyses, in i o animal expe imen s and human s udies [25]. Se e al a iables need o be aken in o accoun in o de o ge he highes cell iabili y and su i al a es possible. Those include he body loca ion o adipose issue dono -si e, he ha es ing p ocedu e, he ha es ing cannula, he p essu e applied o he possibili y o injec ing a umescen solu ion wi h anes he ic be- o e issue collec ion. He ein, we will summa ize he a ious epo ed app oaches o ha es ing du ing au ologous a g a ing. 2. Ha es ing Dis inc ha es ing p ocedu es lead o diffe en ou comes o a g a ake. As a o emen ioned, de ails such as he bes dono -si e, wha adi- pose issue ha es ing echnique o use, wha ha es ing cannula dia- me e o choose, wha p essu e o apply o a oid he dec ease o cell iabili y o he possibili y o injec ing a umescen solu ion wi h anes- he ics be o e issue collec ion a e aken in o accoun in o de o ge he highes cell iabili y and su i al a es possible. 2.1. Wha is he bes dono si e? When i comes o choose he body loca ion o ha es ing, flank, abdomen, high and knee a e he mo e consis en ly used dono -si es. Li e al. compa ed a issue g a s ha es ed om 6 women and diffe en dono -si es (flank, uppe and lowe abdomen, la e al and inne high). The adipose issue was implan ed subcu aneously in o nude mice and g a s we e ha es ed and analyzed a 12 weeks. Au ho s ound no significan diffe ences among g a s om dis inc dono si es ega ding weigh , olume and his ological ea u es (including in eg i y, cys s, inflamma ion, fib osis and neo ascula iza ion). Also, he le els o cell su ace ma ke s and SVF did no diffe . Thus, au ho s sugges ed ha ac o s like accessibili y and pa ien p e e ence should be conside ed p imo dial c i e ia o dono -si e selec ion [42]. Simila ly, Ullmann e al. epo ed no diffe ence in e ms o weigh , olume and his ological ea u es, such as ascula iza ion and fib osis, be ween a om 3 dono si es ( high, abdomen, and b eas ) om a 48 yea -old woman ha we e implan ed in o a nude mice model [43]. Likewise, Lim e al. concluded ha bo h abdominal and non-abdominal sou ces o a p esen ed equal success in co ec ing c anio acial so - issue deficiencies in 27 pa ien s wi h c anio acial mac osomia (n = 19) o T eache Collins synd ome (n = 8) [44]. This was also suppo ed by Small e al. ha ound no diffe ence in olume e en ion be ween a ha es ed om abdomen o highs, in a e ospec i e s udy in ol ing 73 pa ien s ha unde wen b eas econs uc ion [45]. On he o he hand, Padoin e al. conduc ed a p ospec i e c oss- sec ional s udy in 25 women ha unde wen liposuc ion in 4 o mo e dis inc a eas. Mesenchymal s em cell we e ex ac ed and quan ified om lipoaspi a es and esul s e ealed a highe concen a ion o cells in samples collec ed om he lowe abdomen and inne high when compa ed o hose collec ed om he uppe abdomen, ochan e ic egion, knee and flank [46]. Recen ly, Tsekou as e al., in a s udy in ol ing 40 dono women, epo ed he ou e high adipose issue o ha e significan ly highe SVF cell coun in compa ison o any o he si es such as inne high, ab- domen, wais and inne knee. Also, inne and ou e high we e asso- cia ed wi h a significan ly highe numbe o ADSCs when compa ed o abdominal, wais , and inne knee lipoaspi a es [47]. O no e, Di Ta an o e al. e alua ed supe ficial and deep adipose issue (SAT and DAT, espec i ely) collec ed om 16 emale dono s unde going fi s - ime liposuc ion. Addi ionally, ull- hickness skin spe- cimens om he abdominal wall we e collec ed om 3 cada e dono s o his ological and immunohis ochemis y analysis o he hypode mal laye s. Resul s e ealed ha SAT was homogeneously p esen in all body a eas, whe eas DAT was mo e abundan in he abdomen, hips, knee, pe i ochan e ic a ea, uppe inne high, and pos e io Fig. 1. Lipoaspi a e componen s and en ichmen o he aspi a ed a by cell-assis ed lipo ans e (CAL). SVF, s omal ascula ac ion; ADSCs, adipose de i ed s em cells. T. Fon es e al. Annals o Medicine and Su ge y 36 (2018) 212–218 213 compa men o he a m. SVF cell ac ion om abdominal SAT li- poaspi a es showed highe iabili y and highe exp ession o bo h s em/s omal su ace an igen endoglin (CD105) and ascula en- do helial g ow h ac o (VEGF) when compa ed wi h DAT om he same ha es ing si e. O e all, SAT was associa ed wi h be e s em p ope ies hus sugges ing i s p e e able use as a dono si e [48]. 2.2. Ha es ing p ocedu es and p essu e: impac on g a su i al A e choosing he body dono -si e, he nex s ep is o choose he ha es ing me hod. Di ec excision, sy inge hand aspi a ion and suc- ion-assis ed liposuc ion using a ious p essu es (and also using di - e en mechanisms o c ea e ha p essu e) a e some o he cu en ly used echniques [49–51]. In addi ion, liposuc ion can also be assis ed by a liquid-je , ul asound pulses o lase ene gy [52–54]. In o de o pe o m liposuc ion o manual aspi a ion, nega i e p essu es a e equi ed. Despi e he di e gence be ween ha es ing echniques (and dis inc p essu es) sugges ed by diffe en au ho s o ob ain be e unc ional g a s, i is well accep ed ha high acuum p essu es o con en ional liposuc ion a e mo e auma ic o he issue leading o adipocy e s uc u al dis up ion [55,56]. The diffe en ypes o ha es ing echniques wi h dis inc p essu es a e summa ized and compa ed in Table 1. 2.3. Wha is he ideal cannula? The cha ac e is ics o he cannula used o collec a , mainly i s diame e and numbe o holes, influence he success o a g a p o- cedu es. Campbell e al. epo ed an in e ed ela ionship be ween cellula damage and he diame e o he ins umen used o ex ac a [64]. Mul i-pe o a ed cannulas help educe p essu e on each hole, de- c easing damage in he samples collec ed [65]. T i isonno e al. com- pa ed 2 mm and 3 mm diame e cannulas, bo h wi h 170 mm leng h and a ounded ip. The 2 mm cannula had 5 ound spi ally placed po s, each wi h a 1 mm diame e , and he 3 mm cannula had a single side loca ed 3 × 9 mm po . The 2 mm cannula concu en ly acili a ed ha es ing om mo e supe ficial and ascula ized laye s o adipose issue, and educed pa ien discom o and auma. In addi ion, his 2 mm cannula was able o isola e mo e ADSCs, and wi h a highe po- en ial o capilla y-like s uc u e o ma ion han he 3 mm cannula. Ne e heless, ADSC iabili y, mo phology and p oli e a ion capaci y did no a y significan ly be ween he wo cannulas [66]. Alha bi e al. compa ed a mic o-ha es ing 2 mm cannula wi h ou 600 μm gauged o ifices and a blun ip wi h a con en ional 3 mm single hole blun ip cannula, wi h he fi s claiming significan ly highe iabili y and mi- g a ion o isola ed ADSCs [67]. Howe e , Rubino e al. concluded ha a ha es ed wi h a 3 mm cannula showed mo e adipocy e densi y han a ha es ed wi h a 2 mm cannula [68]. E dim e al. showed an in- c ease in g a iabili y in a ha es ed om 10 emale pa ien s using a 6 mm cannula du ing liposuc ion compa ed wi h g a s ob ained by 4 mm and 2 mm cannulas [69]. A p ospec i e s udy by Ozsoy e al. concluded ha a g ea e numbe o iable adipocy es was ob ained wi h a 4 mm-diame e cannula when compa ed wi h 2 o 3 mm can- nulas [70]. Al hough he op imal cannula size s ill lacks consensus, i is well accep ed ha i should be la ge enough o a oid shea s ess and o p ese e adipocy es and SVF cells [70–72]. 2.4. Is he e a diffe ence in we o d y aspi a ion ou comes? The e a e a ew ypes o liposuc ion echniques acco ding o he olume o injec ed solu ion in o he a dono -si e. The d y echnique consis s o di ec aspi a ion wi hou injec ing any p epa a ion solu ion and i is nowadays obsole e due o blood loss ha can accoun o 20–50% o he aspi a ed olume [25,73–75]. In he we echnique, p oposed by su geons Clay on and He e , he a dono -si e is injec ed wi h a we ing solu ion (which may con ain saline, anes he ics and o he subs ances) p io o aspi a ion, ollowing a a io o infil a e o- lume: aspi a ed olume lowe han 1:1, esul ing in a blood loss o 4–30% o he aspi a ed olume [75–77]. La e , in he supe we ech- nique p oposed by Fodo e al., a a io o infil a e o o al aspi a e o 1:1 was used and was associa ed wi h educed blood loss o 1–2% o he aspi a ed olume [43,75,76]. Finally, he umescen echnique, in oduced by Klein, p esen ed a la ge olume o infil a e wi h a a io o infil a e olume o o al as- pi a e olume o 2–3:1. This echnique is accompanied by a educed blood loss o a ound 1% o he aspi a ed olume and does no equi e gene al anes hesia, he e o e being conside ed as he sa e p ocedu e o la ge aspi a ions and wi h imp o ed aes he ic esul s. Tumescen anes hesia mus be injec ed 45 min be o e ha es ing o ensu e hyd o- dissec ion and bloodless collec ion [74,75,78]. Lidocaine alone has been associa ed wi h dec eased adipocy e unc ion, wi h Moo e e al. finding ansien changes o lipolysis and glucose anspo in he p esence o local anes he ic. In e es ingly, e- mo al o lidocaine h ough washing ha es ed lipoaspi a e e u ned hese le els o no mal [79]. Tumescen anes hesia can also be a ehicle o d i e subs ances wi h a gi en effec o he adipose issue o be ha - es ed (Table 2). Local anes he ics, ei he wi h o wi hou asocon- s ic o agen s we e ound no o ha e a significan effec on long- e m su i al o g a ed a , con adic ing he hypo hesis p oposed by Moo e e al. sugges ing ha lidocaine inhibi ed g ow h o adipocy es [79,80]. Agos ini e al. e ified ha his omo phome ic cha ac e is ics (like c oss-sec ional p ofile, cy oplasmic im, connec i e issue, amo phous g ound subs ance, acuoles, cy oplasmic swelling/dis up ion, apop osis o nec osis) and cell iabili y did no significan ly diffe be ween d y and we ha es ing liposuc ion [73]. 3. Conclusion Au ologous a g a ing has become inc easingly used as a me hod o mul iple olume filling applica ions. The majo obs acle o he widesp ead o i s clinical use is he lack o s anda dized guidelines du ing ha es ing, p ocessing and implan a ion s eps [91]. Indeed, many au ho s ha e ecognized ha he e is no uni e sally accep ed me hodology o a g a ing [92,93]. Fa is a delica e issue and mus be handled wi h maximal ca e o main ain i s iabili y [6]. The ideal me hodology o app oach au o- logous a g a ing has been a majo ocus in he las yea s, bu pa ien - ela ed ac o s should also be aken in o accoun when designing a s udy. Dono -si e mo bidi y, like hema oma o , mo e equen ly, local de o mi ies caused by liposuc ion, and ecipien -si e complica ions, such as in ec ions and, al hough e y unlikely, pulmona y embolism, ca diac a es , o deep enous h ombosis, ep esen d awbacks o adipose issue ansplan . Ne e heless, au ologous a g a ing is e- po ed o be a e y sa e p ocedu e wi h e y low mo bidi y [94]. Re iewing and compa ing ha es ing echniques epo ed in he li e a u e comp ises a big challenge gi en he eno mous ou come a iables and he mul iple ac o s o ake in o accoun o each me hod desc ibed (e.g. dono loca ion, ype o a aspi a ion, p essu e, cannula ype, e c), he e o e no allowing us o gi e a s aigh o wa d answe o he ques ion o which me hod is he bes o assu e he highes quali y a g a . Also, when e iewing some o he ha es ing me hods and p essu es applied o collec adipose issue, we ha e concluded ha mos s udies ocus on endpoin s such as in i o coun and iabili y o cells, howe e hese endpoin s ha e no been p o ed o ansla e in o be e a g a su i al in humans [95]. Op imizing a g a ing me hodology in he u u e is o maximal impo ance, since pa ien - ela ed ac o s a e mos o he imes un- changeable and success may ely almos only on effec i e a g a ing echniques. T. Fon es e al. Annals o Medicine and Su ge y 36 (2018) 212–218 214 Table 1 Compa ison be ween ha es ing echniques and diffe en p essu es. Techniques Me hods Resul s Re e ence Manual aspi a ion (sy inge) and PAL (350 and 700 mmHg) T ochan e ic a ha es ed om 3 heal hy pa ien s aged 36, 43 and 58 yea s. Numbe o isola ed SVF cells was assessed. Cell yield wi h a p essu e o 350 mmHg, assis ed o no , was highe han ha ob ained a 700 mmHg. Cell yield wi h PAL (350 mmHg) was significan ly supe io o aspi a ion wi h a sy inge (p < 0.05). Mojallal e al. [57] Yea : 2008 Manual aspi a ion (275, 394 and 550 mmHg) and PAL (350 and 700 mmHg) Compa a i e s udy in 15 heal hy man and women aged 25–60 yea s, unde going abdominal cosme ic su ge y. Samples unde wen his ological analysis in o de o e i y he in eg i y and unc ionali y o he ha es ed adipocy es and ADSCs. Values o nega i e p essu e p oduced by he sy inges as well as p essu es o 350 and 700 mmHg ob ained by PAL did no lead o diffe ences in he numbe o adipocy es and iabili y o he ADSCs ex ac ed. Cha les-de-Sá e al. [58] Yea : 2015 Manual aspi a ion and PAL (375 mmHg) Fa issue was ob ained om 9 dono s unde going abdominoplas y. Samples we e di ided in o 2 a sec ions, ha es ed using ei he manual aspi a ion o PAL. Numbe o isola ed ADSCs was coun ed and p oli e a ion a e and cell iabili y we e assessed. The abili y o isola ed ADSCs o diffe en ia e in o ma u e adipocy es was analyzed by gene ma ke exp ession. PAL e ealed a leas simila quali y and quan i y o ADSCs as manual aspi a ion. Cells ha es ed by PAL had highe exp ession le els o diffe en ia ion ma ke s (e.g. adiponec in). Keck e al. [51] Yea : 2014 PAL a high p essu e (760 mmHg) and low p essu e (250 mmHg) Abdominal lipoaspi a ion was pe o med on 3 pa ien s on he opposi e sides o he flank a e infil a ion wi h umescen solu ion. Adipocy e su i al and cell iabili y we e measu ed in i o. Adipocy e coun was 47% highe when aspi a ed a low p essu e compa ed wi h high p essu e, immedia ely a e ha es ing. Cell iabili y was significan ly highe a day 7 wi h low-p essu e aspi a ion. Che iyan e al. [59] Yea : 2014 PAL ( <760 mmHg) and issue esec ion 6 heal hy women unde wen abdominoplas y su ge y. Subcu aneous adipose issue o he abdomen was analyzed. SVF isola ed om abdominal a ha es ed om pa ien s (n = 6). Cell yield and iabili y o ADSCs we e assessed. Cell pheno ypes we e de e mined by immunos aining and FACS, and doubling imes we e calcula ed. Senescence a ios o he cells we e measu ed. Mul ipo ency was e alua ed by induced diffe en ia ion analyses. No diffe ences in mul iplica ion a es, senescence a ios and mul ipo ency o cul u ed ADSCs. Ba zelay e al. [50] Yea : 2015 PAL (760 mmHg) and issue esec ion Adipose issue ob ained om pai ed issue esec ion and PAL adipose issue om he abdomen o 3 heal hy women aged 26–54 yea s. In i o analysis: samples we e p ocessed o isola e he SVF. ADSC yield and cell iabili y we e assessed. Adipogenic and os eogenic diffe en ia ion capaci y we e assessed in i o using pheno ypic s aining and quan ifica ion o gene exp ession. In i o analysis: ADSCs we e applied in an in i o mouse model o issue epai o e alua e hei egene a i e po en ial. Lowe ADSCs yield in SVF cells using PAL (42.4%) in compa ison o issue esec ion (55.8%). No diffe ence in he o he pa ame e s. Dusche e al. [60] Yea : 2016 WAL (375 mmHg) and manual aspi a ion (290 mmHg) 8 women we e included in he s udy and he wo echniques we e used o each pa ien . The lipoaspi a es o subcu aneous abdominal a we e collec ed on bo h side o he umbilic in each pa ien . In i o analysis: cell yield, iabili y and immunopheno ype o he SVF ac ion. Os eogenic and adipogenic diffe en ia ion and immunosupp essi e capaci y o ADSCs was assessed in i o. In i o analysis: immunosupp essi e capaci y o ADSCs du ing a delayed- ype hype sensi i e esponse model in mice. Equi alen numbe o iable cells, fib oblas colony- o ming uni s and immunopheno ype. In e es ingly, ADSCs isola ed om manual liposuc ions showed significan ly highe immunosupp essi e po en ial han hose om WAL in i o bu no in i o. Bony e al. [61] Yea : 2015 LAL and PAL Fa issue ob ained om he b eas o 7 men aged 19–24 yea s diagnosed wi h gynecomas ia. In i o analysis: cell yield, iabili y, plu ipo ency, su ace ma ke s exp ession and apop osis o ADSCs we e assessed. No diffe ence in su ace and cellula diffe en ia ion ma ke s. Lowe numbe o iable ADSCs and highe apop osis indica o s in LAL, 24 h a e ha es ing, bu hese diffe ences we e e e sed a e 72 h. Yildiz e al. [62] Yea : 2016 Fa issue ob ained om 12 heal hy women be ween he ages o 33–55 yea s who we e unde going elec i e lipoaspi a ion o he abdomen. Each pa ien unde going lase -assis ed liposuc ion (n = 6) was ma ched o age (wi hin 2 yea s) wi h a pa ien unde going suc ion-assis ed liposuc ion (n = 6). Age-ma ched pa ien s unde wen liposuc ion p ocedu es on he same day. LAL and PAL could no be ha es ed om he same ana omical loca ion. In i o analysis: Cell yield, cell iabili y and p oli e a ion, su ace ma ke pheno ype, os eogenic diffe en ia ion and adipogenic diffe en ia ion capaci y o ADSCs. In i o analysis: egene a i e capaci y o ADSCs in a c anial de ec in nude mice. All in i o pa ame e s such as cell yield, iabili y, p oli e a ion and equency o ADSCs we e all significan ly less wi h LAL compa ed o PAL. In i o, ADSCs om LAL led o significan ly less osseous healing in compa ison o PAL. Chung e al. [53] Yea : 2013 (con inued on nex page) T. Fon es e al. Annals o Medicine and Su ge y 36 (2018) 212–218 215 E hical app o al N/A. Sou ces o unding This wo k was suppo ed by FEDER –Fundo Eu opeu de Desen ol imen o Regional, h ough NORTE 2020 P og ama Ope acional Regional do No e - NORTE-01-0145-FEDER-000012 and Ins i u o de In es igação e Ino ação em Saúde (P oje o Es a égico UID/BIM/04293/2013). Au ho con ibu ion Tomás Fon es: da a collec ion and w i ing he manusc ip . Inês B andão: da a collec ion, da a analysis and w i ing he manu- sc ip . Ri a Neg ão: s udy design. Ma ia João Ma ins: s udy design. Rosá io Mon ei o: s udy design and da a analysis. Conflic s o in e es None o decla e. Resea ch egis a ion numbe N/A. Gua an o Inês B andão. Rosá io Mon ei o. P o enance and pee e iew No commissioned, ex e nally pee e iewed. Acknowledgemen s This wo k was suppo ed by FEDER –Fundo Eu opeu de Desen ol imen o Regional, h ough NORTE 2020 P og ama Ope acional Regional do No e - NORTE-01-0145-FEDER-000012 and Ins i u o de In es igação e Ino ação em Saúde (P oje o Es a égico UID/BIM/04293/2013). Re e ences [1] F. Neube , Fe ansplan a ion. Be ich übe die Ve handlungen de deu schen Gesellsca ü Chi u gie, Zen albl Chi 22 (1893) 66. [2] C.J. Tabi , G.C. Slack, K. Fan, D.C. Wan, J.P. B adley, Fa g a ing e sus adipose- de i ed s em cell he apy: dis inguishing indica ions, echniques, and ou comes, Aes he . Plas . Su g. 36 (3) (2012) 704–713. [3] S.R. Coleman, S uc u al a g a s: he ideal fille ? Clin. Plas . Su g. 28 (1) (2001) 111–119. [4] S.R. Coleman, E.B. Ka zel, Fa g a ing o acial filling and egene a ion, Clin. Plas . Su g. 42 (3) (2015) 289–300. [5] S.S. E gün, E.G. Baygöl, R.B. Kayan, İ.M. Kuzu, O. 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Two lipoaspi a e samples we e ha es ed om iden ical si es in each pa ien , wi h PAL being pe o med be o e UAL. In i o analysis: Cell yield, iabili y and p oli e a ion, su ace ma ke pheno ype, os eogenic, adipogenic and chond ogenic diffe en ia ion capaci y o ADSCs. In i o analysis: egene a i e capaci y o ADSCs in an excisional wound in nude mice Equi alen esul s be ween bo h echniques. Cells ha es ed a e sui able o cell he apy and issue enginee ing. Dusche e al. [63] Yea : 2016 ADSCs, adipose de i ed s em cells; FACS, fluo escence-ac i a ed cell so ing; LAL, lase -assis ed liposuc ion; PAL, powe -assis ed liposuc ion; SVF, se um ascula ac ion; UAL, ul asound-assis ed liposuc ion; WAL, wa e -je assis ed liposuc ion. Table 2 We ing solu ions used in umescen anes hesia. We ing solu ions Desc ip ion Examples C ys alloid solu ions Diluen s o anaes he ics. Iso onic saline 0.9% NaCl (Neu alizes he acidic pH o lidocaine. Associa ed wi h bu ning sensa ion.) Lac a ed Ringe 's solu ion (Does no cause bu ning sensa ion and educes he sodium load.) [81,82] Vasocons ic o s Cons ic he blood essels, educe blood loss, and amelio a e issue pe usion wi h he anaes he ics by inc easing he du a ion and he quali y o anes hesia. Ad enaline (epineph ine) L-o ni hine 8- asop essin [81–84] Local anaes he ics Allow absence o pain sensa ion du ing liposuc ion. Lidocaine P ilocaine A icaine [85–88] Buffe s Raise he pH o he solu ion and a oid he bu ning sensa ion. Augmen he p opo ion o nonionized lipid soluble lidocaine, which can mo e apidly en e he ne e cells. Sodium bica bona e [82,89] An ioxidan s Reduce oxida i e s ess in he a g a . Amelio a e su i al o ADSCs and p ese e g a olume. N-ace ylcys eine [90] T. Fon es e al. Annals o Medicine and Su ge y 36 (2018) 212–218 216 Plas . Recons . Su g. 119 (3) (2007) 775–785. [10] R. Delfini, P. Misso i, R. 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