Regenerative Medicine and Stem Cell Applications

Today, in cell therapies, only the use of the person's own cells is permitted.

Stem cells quickly adapt to the area where they are applied, transform into the cells lacking in the tissue, eliminate the deficiencies in the areas where they are placed and begin to renew the tissue. Blood circulation increases in the treated area and the inflammatory process decreases.

Although there are different ways of producing stem cells under laboratory conditions, the clinical use of laboratory-produced stem cells is prohibited. In our country, the Ministry of Health requires that permission be requested through an individual application for every patient who is to receive stem cell treatment. The Ministry of Health permits stem cells prepared under laboratory conditions to be used only in patients at risk of death. At present, the use of stem cells prepared under laboratory conditions for aesthetic procedures is not permitted.

Today, all applications performed with stem cells are based on isolating and concentrating stem cells from the patient's tissues (bone marrow or adipose tissue) and then transferring them back to the same person without any processing of the cells.

In addition to fat cells, adipose tissue contains stem cells with regenerative potential, cells that accelerate the formation of new vessels (pericytes), connective tissue elements that allow all these cells to attach, and cells that produce connective tissue (fibroblasts). When the fat cells in the adipose tissue taken from the patient are separated from the other cells under laboratory conditions, all the other remaining cells and connective tissue elements form a cocktail that increases the body's healing capacity. When this cell cocktail is applied around non-healing wounds, it accelerates wound healing, and when it is applied for cosmetic purposes to areas such as the face, neck and hands, it accelerates skin renewal and improves skin quality.

Most substances used as fillers are absorbed after a while and lose their effect. Permanent fillers, on the other hand, cannot adapt to the changes that occur with ageing, so although they look good when first applied, over time they may begin to look out of place. Fat used as a filler is superior to other permanent fillers because it adapts to the environment where it is placed and adjusts to the patient's weight changes and to the changes that come with ageing. It has been shown that after the fat to be applied as a filler is mixed with the cell cocktail, also obtained from adipose tissue, it takes hold at a higher rate and remains viable in the environment where it is placed. Fat enriched with the cell cocktail does not only have a filling effect. At the same time, by increasing regeneration in the area where it is applied, it creates a more positive effect than expected, beyond the filling effect. With fat enriched with the cell cocktail, an increase in quality in the skin over the treated area and a reduction in wrinkles are observed.

First, about 300-400 ml of fat is taken from the patient. The fat tissue is sent to the laboratory under sterile conditions and processed; the fat cells in it are separated from the remaining cells with enzymatic processes and removed from the medium by washing and centrifugation. The cell cocktail is obtained. What remains is a cocktail containing stem cells, cells that accelerate the formation of new vessels (pericytes), cells that produce connective tissue (fibroblasts) and connective tissue elements that allow all these cells to attach.

Where fat will be taken from the patient is decided by looking at their current condition. It is appropriate to take fat first from whichever area of the patient has excess fat.

The prepared cell cocktail can be applied by injecting it little by little into the area to be treated. However, the more common application is to add the prepared cell cocktail to the fat to be used as a filler, proportionally increasing the amount of regenerative cells in this fat, and then to apply the enriched fat.

When fat enriched with stem cells is used, both the chance that a significant proportion of the applied fat survives in the area where it is applied increases, and tissue healing (tissue regeneration) accelerates in the area where the fat is applied, providing rapid healing in this area.

• It can take the place of an implant in breast reconstruction. Fat enriched with the cell cocktail has begun to be used where fat is to be injected for breast reconstruction in patients who have had a breast removed. Although it is still at the development stage, it is thought that a breast created with fat grafting applied in repeated sessions will be an alternative form of treatment to silicone breast implants.
• It is effective in skin rejuvenation. When fat enriched with the cell cocktail is applied to patients with age-related volume loss in the face, rapid improvement is observed in the early period due to the volume effect. However, the real benefit develops as time passes after the procedure, due to the regenerative effect of the stem cells in the cell cocktail. Rejuvenation of the skin, a reduction in wrinkles and positive changes in skin quality (reduction in pigmentation and scars) are observed.
• It erases the signs of ageing from the hands. An important part of the signs of ageing is the change in the skin of the hands. In particular, the skin on the backs of the hands thins, the amount of fat it contains decreases, wrinkles develop and increased pigmentation (colour changes) is observed. By making small fat injections at many points under the skin on the back of the hand, the lost volume is replaced, while thanks to the regenerative cells in the fat, an increase in the quality of the ageing skin, a reduction in wrinkles and a reduction in dark colour changes can be achieved.
• Successful results are obtained in wound treatment. Using the cell cocktail obtained from adipose tissue, which is known to contain a high proportion of stem cells, open wounds that are very difficult to close are now treated successfully. Successful results are obtained with the cell cocktail obtained from adipose tissue in the non-healing wounds of diabetic patients, in closing wounds in areas with circulation problems, and even in the treatment of wounds that, although rarely, form on patients' skin during radiotherapy treatment.
• Reduction of scars: Following the application of the cocktail containing stem cells, clinical improvement in burn scars and hypertrophic scars, softening of hardness, and a reduction in complaints such as itching and pain are observed.

The term ‘stem cell facelift’ is not a correct expression for applying fat grafts to the face to replace age-related volume loss in the face. Although it can be applied together with facelift procedures so that the volume loss and sagging that occur in the face with ageing can be corrected at the same time, it would not be a correct approach to describe the fat transfer procedure, in which the patient's own fat is injected into the face, as a facelift.

The procedure, known by different names such as fat grafting, autologous fat transfer and fat injection, is the application of the patient's own fat, taken from the abdomen or another area, to the patient's face using microcannulas in order to add volume to the face. The person's own fat, applied like the synthetic fillers used to add volume to the face, is better than all these synthetic fillers. It lasts longer and does not cause application-related side effects.

If the volume loss that occurs in the face with ageing is the main problem, fat grafting alone can also be used for facial rejuvenation. However, since in a significant proportion of patients sagging, especially in the neck and lower jaw due to the effect of gravity, and volume loss in the face develop together, we generally prefer to use both methods together in the older age group. For this reason, fat grafting and facelift methods are used as complementary methods in modern aesthetic surgery.

Although facial fat grafting provides a youthful appearance by replacing the volume the face has lost with ageing, the long-term follow-up of patients who received this treatment revealed that the aesthetic gain was greater than this. After the treatment, a reduction was also observed in the effects of skin ageing, the third component of the ageing face, which other methods cannot solve. In skin that has dried out, lost water content and developed micro-wrinkles, regeneration occurs in the months following fat injection and skin quality improves. Research has shown that adipose tissue contains a high number of adult-type stem cells. It is now known that these cells provide the late improvement that occurs after fat grafting.

Thanks to developing technology, a large volume of fat can now first be taken from patients and the stem cells in it isolated, and the stem cells obtained can be added to the fat to be applied to the face, so that a stem cell-enriched fat grafting can be performed. In this way, there is both less resorption, and therefore less volume loss, in the fat graft applied to the face, and the late regenerative effect is more pronounced and stronger.

These procedures are not used in place of one another; they are separate treatment options, each directed at the different changes that occur in the face due to the ageing process (sagging of the face, loss of volume and skin ageing). For this reason, evaluating the patient's condition and applying treatment directed at whatever the most prominent problem is will produce the best result for the patient. In some patients, the optimum result can be achieved only by applying more than one method together.

In a young face, the eyebrows, temples, cheeks and lips are fuller and more defined. This full appearance diminishes as a person ages, and the facial bones and blood vessels begin to look more prominent. Wrinkles and hollows begin to appear in the face. With fat transplantation applied to these critical areas, the soft tissue volume that decreases with ageing can be restored and a youthful appearance can be achieved again. While the lost volume is replaced with the fat transplantation, the stem cells that adapt to the environment over time increase the production of connective tissue, the building block of the skin, such as collagen and elastin, whose production by the body decreases, and help the skin cells renew themselves. In this way, regeneration continues in the skin at the cellular level and the skin quality of the treated person also improves.

Unlike other filler treatments, since the person's own fat is used in fat grafting, no allergic or inflammatory problem is ever expected.

As may occur after any surgical procedure, side effects such as pain, bruising and temporary oedema (swelling), even if minimal, may occur after these procedures in the area where fat is taken or applied. In addition, although very rarely, there is also a risk of wound infection developing at the site of the procedure.

The most important problem of fat grafting for aesthetic purposes is that it cannot be predicted in advance how much of the fat will be resorbed after the procedure and how much will be permanent. Where the amount of resorption of the applied fat is not equal everywhere, minimal asymmetry between the two sides or irregularity in the treated area may sometimes be observed after the treatment. Although many factors, such as patients' constitutional factors, genetic make-up and whether or not they smoke, affect this process, resorption (dissolving) of the fat after application has decreased greatly with stem cell-enriched fat grafting. In addition, with increasing surgical experience, harvesting the fat with special cannulas, purifying it before application by washing it free of blood and other tissue debris, and placing it in the treatment area in a controlled way with microcannulas, problems related to fat resorption are no longer encountered very often.