Abstract
Background
Striae Distensae (SD) is a common dermatological lesion. The mechanism of formation is unclear, the prevailing theory is mechanical pulling of the skin and hormonal changes. Traditional SD treatment methods include topical drugs, photoelectric therapy, stripping and others, but each has limitations. Stromal vascular fraction gel (SVF‐gel) is a filler physically prepared from granular fat, enriched with adipose‐derived stem cells (ADSCs) and extracellular matrix (ECM). A good effect in the treatment of neck lines, wounds, acne, and other aspects. SD formation and treatment goals are comparable to those of neck lines. In this study, SVF‐gel filling will be used to treat mature SD, and its effectiveness and safety will be discussed in detail.
Methods
From December 2019 to June 2022, recruit patients who want to treat SD caused by obesity or pregnancy among those who have “autologous fat aspiration” to change their body shape. Preoperatively, the area to be treated for SD was marked, autologous fat aspiration was performed, and the aspirated fat was prepared as SVF‐gel and filled into the preoperatively marked SD. All patients had preoperative and postoperative follow‐up with planar photographs and VISIA skin analyzer photographs to assess surgical results and safety from subjective and objective perspectives.
Results
A total of 36 patients were enrolled, with 31 of them successfully followed up on. The mean Global Aesthetic Improvement Scale (GAIS) score six months after surgery was 1.87 ± 0.03. At six months postoperatively, the overall patient satisfaction rate was 90%. The depth, area, and color of SD improved six months after surgery, and no serious complications occurred in any of the patients.
Conclusions
SVF‐gel is a safe and effective method of improving mature SD and can be used as a clinical treatment option.
Keywords: adipose‐derived stem cells, extracellular matrix, stretch marks, Striae distensae, stromal vascular fraction gel
1. INTRODUCTION
SD is a striated skin lesion that can be found in clusters on the buttocks, chest, inner thighs, waist, and belly. Adolescents, pregnant women, and those who encounter rapid changes in body mass over a short period of time are the most likely candidates for SD. Striae gravidarum are commonly used to describe SD that develops during pregnancy. It also occurs in persons with Cushing's syndrome, Marfan's syndrome, 1 and after the use of protease inhibitors and steroidal corticosteroids. During adolescence, the prevalence of SD varied from 27 to 51 in the body mass index and was around 40.0% in males and 70.0% in females, according to a large sample. The prevalence of SD was found to be 43.0% to 88.0% in a large sample. 2
A smooth red raised line known as striae rubra (SR) marks the early stages of SD. Over time, it develops striae alba (SA), an uneven white depressed stripe that resembles a scar. The biophysical properties of SR and SA are similar, and both lesions are less dense, rougher, and less elastic than normal skin. 3 Spectroscopic study of SD for RNA, collagen, and protofibronectin revealed that the greatest difference in the presence or absence of SD occurred at a depth of 75–95 μm (corresponding to the dermal‐epidermal junction and the dermal area). 4 According to Wang et al., 5 , 6 the elastic fibril network was extensively disturbed in SR, with collagen bundles being significantly separated and the emergence of numerous disorganized, unbound protoelastin‐rich protofibrils.
SD therapy is a prominent study issue for dermatologists and plastic surgeons both at home and abroad. Photoelectric technology, such as laser, radiofrequency, and phototherapy, is currently the most common physical therapeutic modality. 7 Peeling, carboxylation therapy, platelet‐rich plasma (PRP) injection therapy, biodegradable collagen‐stimulating filler filling therapy, and other more popular treatments are also available, although each has drawbacks. 8 , 9 , 10 , 11
SVF‐gel 12 is a fat derivative rich in ADSCs and ECM created using appropriate physical procedures to remove oil droplets from adipose tissue and kill mature adipocytes, and it has been researched and shown promising results in the treatment of acne, 13 mid‐buccal folds, 14 and neck lines. 15 Neck lines are caused by a decrease in dermal collagen content and local mechanical skin pulling, and their mechanism and treatment target are similar to SD, therefore we consider employing SVF‐gel to treat SD and researching new treatment methods.
1.1. Patients and methods
1.1.1. Inclusions
Inclusion criteria are women with depressed SA on the abdomen, waist, or legs who have been stable for more than a year; Fitzpatrick skin types III and IV; and sign the informed consent.
1.2. Exclusions
Exclusion criteria included severe systemic disease; received other treatment in the past 6 months; inflammation or infection in the treated area; history of hormone therapy; history of keloid formation, Cushing's syndrome, etc; and pregnancy or lactation.
1.3. Preparation of SVF‐gel
SVF‐gel was prepared using the method described in the literature, 12 which simply means that fat was aspirated from a surgical site outside the SD treatment area. After allowing the aspirated pellet fat to stand for 10 min, the bottom liquid portion was discarded to obtain the resting fat. To obtain Coleman fat, the resting fat was centrifuged at 1200 g/min for 3 min, and the bottom liquid layer was discarded. The Coleman fat was mechanically emulsified and centrifuged at 2000 g/min for 3 min to define the viscous material beneath the oil layer as SVF‐gel (Figure 1).
FIGURE 1.
Prepared SVF‐Gel. The upper layer is made up of fat oil droplets, the lower layer is made up of liquid, and the sticky glue in the middle is made of SVF‐gel.
1.4. Filling of Striae Distensae
A fractionated pressurized injection gun was prepared, the prepared SVF‐gel was transferred into a 1 mL threaded syringem (with injection needles of about 30 mm in length and an outer diameter of the needle of about 0.45 mm), the parameters were adjusted to 0.1 mL per injection, the 1 mL syringe needle was completely pierced into the subdermal layer of the SD site, the trigger was pulled, and one injection was made every 0.5 cm of retreat. If there is no syringe gun available, a syringe can be used directly (Figure 2). The severe area (severe skin fracture, wide, and different color from normal skin) is frequently chosen for treatment; the treatment area generally encompasses the entire serious area.
FIGURE 2.
Weight compression gun (A); An illustration of the surgical process schematically (B).
1.5. Subjective evaluations
At the 6‐month postoperative follow‐up, three professional plastic surgeons who were not involved in the surgery used the Global Aesthetic Improvement Scale (GAIS) to score the patient's improvement in preoperative and postoperative comparison photos (Table 1). Patients were asked to make a rating of their own treatment outcome at the 6‐month postoperative follow‐up, which included five levels (very satisfied, satisfied, unsure, dissatisfied, very dissatisfied).
TABLE 1.
Global Aesthetic Improvement Scale (GAIS).
| Score | Grade | Delineation |
|---|---|---|
| −1 | Worse | Appearance worse than original condition |
| 0 | No change | Appearance essentially the same as original condition |
| 1 | Improved | Obvious improvement but touch‐up or retreatment in indicated |
| 2 | Much improved | Marked improvement in condition, but not optimal for the subject; touch‐up would slightly improve the result |
| 3 | Very much improved | Optimal cosmetic result for the subject |
| GAIS, global aesthetic improvement scale. | ||
1.6. Objective evaluations
(1) Deep Change: Using the VISIA skin tester (American Canfield, Inc), photographs are taken during the patient's preoperative and postoperative follow‐up visits. Using the three‐dimensional viewer function, the images are magnified and colored, with red, yellow, and blue representing different skin heights. Although the system function has no data, the VISIA system is regarded as a practical digital method for determining the effects of SD treatment. 16
(2) Area change:Image J software has been used to quantify various skin studies, such as psoriatic area quantification. 17 As a result, we used a similar approach to quantify changes in SD area before and after treatment. To control for variables, preoperative and postoperative planar photographs were opened in Adobe Photoshop CS5, and the SD treatment area was intercepted within a 6*6 cm area, and regardless of the number of SDs within this area, only one with a width in the range of 3–5 mm was selected for marking, first using the “brush” tool to draw a circle around the SD treatment area. First, the lesion area was marked with the “brush” tool (hardness set to 100%, colour set to green). Check each hand‐drawn image with a fully trained physician to ensure that all lesions are properly covered. The images are then imported into image J, which analyses the area of the lesion as a percentage of the total image area before and after treatment (Figure 3).
FIGURE 3.
Changes in graphic pictures (A); Changes in adobePhotoshopCS5 (B); Changes in Image J software (C).
(3) Color change:Import the intercepted 6*6 cm image into Adobe Photoshop, align and move the pre‐ and post‐operative photos to the same layer, switch to grayscale mode, use the color sampler to measure the grayscale value of each point, the smaller the value, the lighter the color of the stripes, and vice versa, the larger the value, the darker the stripes (create multiple reference lines to ensure that the pre‐ and postoperative value points are in the same position as possible). Three points were taken at different locations of the target atrophy striae before and after surgery, and one point was taken on the normal skin, and the grayscale value of the atrophy striae was divided by the grayscale value of the surrounding normal skin to calculate the relative grayscale value (Figure 4).
FIGURE 4.
The gray value shift at each position is measured by Adobe Photoshop's color sampler. Normal skin gray values are represented by points 1 and 2, pre‐treatment gray values by points 3, 5, and 7, and post‐treatment gray values by points 4, 6, and 8.
1.7. Statistical analysis
The quantitative data that met the assumption of normality is represented as the mean (SD), and the changes in values before and after surgery were compared by the paired samples t‐test. All statistical analyses were performed using SPSS software, version 25.0, and p < 0.05 was considered statistically significant.
2. RESULTS
2.1. General results
From December 2019 to June 2022, 36 patients with SD who met the inclusion criteria were recruited for SVF‐gel filling treatment at our institution. Thirty‐one of these patients were successfully followed up on; all were female (100%); ranged in age from 23 to 51 years (mean age 32 ± 2.3 years); had a mean BMI of 25.53; Figures 5 and 6 show a comparison of pre‐surgery and post‐surgery pictures; it is obvious that SD has improved significantly following treatment. Table 2 is a summary of statistics on the of the 31 patients who completed the follow‐up.
FIGURE 5.
A 26‐year‐old female patient with striae distensae on abdomen due to short‐term obesity. (A) Preoperative. (B) Six months after surgery.
FIGURE 6.
Striae distensae on the lower back in a 30‐year‐old woman with pubertal overgrowth. (A) Preoperative. (B) Six months after surgery.
TABLE 2.
General information about the patient's SD.
| Reason for occurrence | Position | Time for existence |
| Pregnancy ( 16 ) | Inner thighs ( 9 ) | 5‐10 years ( 3 ) |
| Growth ( 10 ) | Behind the calf ( 5 ) | 10‐15 years ( 9 ) |
| Weight gain ( 4 ) | Abdomen ( 13 ) | 15‐20 years ( 14 ) |
| Other reason ( 1 ) | Other position ( 4 ) | > 20 years ( 5 ) |
| Total: 31 | ||
2.2. Subjective results
Three physicians who were not involved in the surgery used GAIS to score the patient's six‐month postoperative planimetric photographs (−1 to 3), with a mean score of 1.90 ± 0.79 for physician 1, 1.84 ± 0.73 for physician 2, 1.87 ± 0.56 for physician 3, and 1.87 ± 0.03 for all three physicians(Table 3).
TABLE 3.
GAIS scores of physicians.
| GAIS | Mean ± SD |
| Doctor 1 | 1.90 ± 0.79 |
| Doctor 2 | 1.84 ± 0.73 |
| Doctor 3 | 1.87 ± 0.56 |
| Mean score | 1.87 ± 0.03 |
Six months after surgery, 1 case (3%) was very satisfied, 28 cases (87%) were satisfied, 2 cases (7%) were unsure, 1 case (3%) was dissatisfied, and 0 cases (0%) were very dissatisfied, resulting in an overall satisfaction rate of 90% (Figure 7).
FIGURE 7.
Self‐satisfaction evaluation of patients.
2.3. Objective results
The VISIA skin analyzer's three‐dimensional viewing mirror function detected color changes in the lesions, where yellow, red, and blue represent different skin heights. Before, three months after, and 6 months after surgery, the red and yellow colors gradually faded, and the depth of SD improved (Figure 8).
FIGURE 8.
Depth change of striae distensae under VISIA 3D microscope. Yellow and red tones represent elevation in rendered color‐relief images, whereas blue shades imply depression. The plane photos that were captured by the VISIA system before, three months, and six months after the surgery are A, B, and C, respectively; the color height changes in the VISIA system that correspond to A, B, and C are D, E, and F; and the black and white height changes in the three‐dimensional viewing mirror are G, H, and I.
The preoperative, one‐month postoperative, three‐month postoperative, and six‐month postoperative SD area percentages were 6.89% ± 1.72%, 5.75% ± 1.65%, 3.81% ± 0.85%, and 3.47% ± 0.89%, respectively, A paired‐samples t‐test was used to compare preoperative and postoperative data, and p < 0.05 was considered statistically significant (Figure 9).
FIGURE 9.
The change of atrophic striae area was calculated by Image J software.
The mean relative grayscale values calculated in Photoshop before surgery, one month after surgery, three months after surgery, and six months after surgery were 0.682 ± 0.043, 0.896 ± 0.04, 0.842 ± 0.048, and 0.827 ± 0.05, respectively. p < 0.05 was considered statistically significant (Figure 10).
FIGURE 10.
Photoshop grayscale color changes. Normal skin (NS), preoperative (PRE), 1 month after (1 M), 3 months after (3 M), 6 months after (6 M).
2.4. Complications
None of the patients experienced serious adverse events including scarring, pruritus sensation, hematoma, infection, nodules, and no significant swelling was observed within six months after the procedure. None of these patients received a second complementary treatment. Only a small number of inconspicuous fibrous nodules were observed after treatment as well as inconspicuous discoloration, all of which gradually recovered within 3–6 months.
3. DISCUSSION
People are paying more attention to their own skin condition as the economy and living conditions improve; smooth, white, and elastic skin will give people confidence. However, many people will experience troubling “streaks” after puberty and pregnancy. The areas where they tend to occur are frequently exposed in the summer, causing a lot of trouble for many beauty lovers, and even many high‐profile women are afraid of childbirth due to SD fear. SD is not an isolated disease, and its severity frequently indicates that the organism is at risk of other problems. The severity of SD, for example, can predict the degree of abdominal adhesions at the time of re‐cesarean delivery, as well as the severity of low back pain in late pregnancy. 18 It has also been linked to anal sphincter damage after caesarean delivery, 19 and it has been suggested that urogenital prolapse and urinary incontinence may be related to the presence of SD. 20 As a result, SD is most likely a disease caused by a systemic connective tissue dysfunction.
SD treatment goals include stimulation of fibroblast activity and induction of dermal collagen production; improvement of skin texture and elasticity; increased blood perfusion; increased skin pigmentation; anti‐inflammatory properties; increased cell proliferation; and increased skin moisture. 7 Furthermore, the use of fillers to improve the depression of SD with wide depressions is a treatment goal.
Some topical medications or laser therapy can have a decent therapy effect for SR, and it will improve on its own over time. However, SA is an established lesion with dermal collagen rupture that is more difficult to treat than SR, and stabilized SA resembles a sort of dermal scar that seldom changes unless externally disturbed, so we chose SA as the study topic in this investigation. In our study, 9% of people had lesions that persisted longer than 5 years, and 91% had lesions that lasted longer than 10 years, to preclude spontaneous improvement in early SD.
The area and color of the SD were enhanced to some extent in our experimental results. The color of the SD was the darkest one month after surgery and subsequently faded as the trauma was treated and the inflammatory reaction diminished. In conclusion, all of the SD improved in the objective evaluation. In subjective results, the majority of the patients in the study improved in their SD after treatment. However, only one case (3%) was very satisfied in the patient self‐satisfaction score, while the majority of patients (87%) were satisfied and one patient (3%) was dissatisfied. The three physicians' GAIS scores had a mean score of 1.870.03 (range −1 to 3), indicating that great improvement and better improvement were less common. The reasons for this may be due, on the one hand, to the patients' high expectations and, on the other, to the selection of a mature SD.
SVF‐Gel is a small, smooth, jelly‐like filler that can be injected with a 27G needle. It causes less inflammation, has higher retention rates, and has fewer side effects than traditional fat grafting. After filling injection, there are no nodules or surface irregularities. Most other treatments for SD have the mechanism of action of causing localized damage to directly or indirectly stimulate collagen regeneration, whereas SVF‐gel, which is rich in collagen, can be directly filled into the broken skin depressions, and this filling effect can further stimulate collagen regeneration. Since SVF‐gel has a 80% retention rate 21 , most patients only require a single treatment and do not require many sessions of follow‐up procedures, which lessens patient discomfort.
ADSC and ECM are the most abundant components of SVF‐Gel, and ADSC promotes angiogenesis, modulates inflammatory response, promotes fibroblast proliferation and migration, and builds cellular epithelialization, among other things. 22 ECM is rich in collagen, which can directly contribute to the treatment of depressed SD, and this filling effect can further stimulate fibroblast activity and collagen regeneration. regeneration. Furthermore, ECM contains cytokines that stimulate cell proliferation, increase blood perfusion, and promote vascularization, all of which aid in tissue regeneration. 23 All of these mechanisms are consistent with the therapeutic objectives of atrophic striae. The ECM in SVF‐gel can accommodate ADSCs while also protecting them from phagocytosis by macrophages, allowing SVF‐gel to play a multifaceted role in the treatment of SD. In addition, the use of SVF‐gel fillers for SD in this study may provide a double benefit for patients who also want to change their shape through “autologous liposuction.” The current study discovered that synergistic treatment of SD may be more effective than single treatment, the combination of SVF‐gel with other treatments may be considered in the future study to achieve better results in the treatment of SD.
Limitations:Because SVF‐gel is partially absorbed during its action, multiple filler treatments may be necessary for individual cases of severely depressed SD. Despite the fact that our treatment needle has a very small area in comparison to SD, it nevertheless generates a weak needle stab injury, which has an influence on the therapeutic effect. Furthermore, no blank control group was established in our experiments because we discovered that the color, width, skin fracture degree, and subcutaneous fibrosis of each SD differed, and the error in setting the control test was too large, so we anticipate that the next step will be to research and develop a standard unified SD animal model to more accurately evaluate the treatment effect.
4. CONCLUSION
In this study, SVF‐gel filling prepared by physical methods was used for the first time to improve mature SD, and more satisfactory clinical results were obtained. This study has practical and guiding implications, giving clinicians more options for treating SD.
ACKNOWLEDGMENTS
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Li M, Tian Y, Cheng R, Hao L. Clinical efficacy of stromal vascular fraction gel in the treatment of mature striae distensae. Skin Res Technol. 2024;30:e13551. 10.1111/srt.13551
Meijia Li is the first author.
DATA AVAILABILITY STATEMENT
Data openly available in a public repository.
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Data Availability Statement
Data openly available in a public repository.