Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132:1017-1026. [PMID: 23783059 DOI: 10.1097/prs.0b013e31829fe1b0]

Combining systemic and locally applied cellular therapies for the treatment of systemic sclerosis

Systemic sclerosis (SSc) is a complex autoimmune disease characterized by a functional and structural alteration of the microvascular network associated with cutaneous and visceral fibrosis lesions. Conventional therapies are based on the use of immunomodulatory molecules and symptomatic management but often prove to be insufficient, particularly for patients suffering from severe and rapidly progressive forms of the disease. In this context, cellular therapy approaches could represent a credible solution with the goal to act on the different components of the disease: the immune system, the vascular system and the extracellular matrix. The purpose of this review is to provide an overview of the cellular therapies available for the management of SSc. The first part will focus on systemically injected therapies, whose primary effect is based on immunomodulatory properties and immune system resetting, including autologous hematopoietic stem cell transplantation and intravenous injection of mesenchymal stem cells. The second part will discuss locally administered regenerative cell therapies, mainly derived from adipose tissue, developed for the management of local complications as hand and face disabilities.

The Role of Adipose Tissue in Hair Regeneration: A Potential Tool for Management?

Human adipose tissue (AT) is a rich and easily harvestable source of stem cells and various growth factors (GFs). It has been widely used hitherto for facial rejuvenation and volumization. Increasing evidence shows that dermal adipocytes are intricately associated with hair follicles (HFs) and may be necessary to drive follicular stem cell activation. Early published data have shown encouraging preliminary results for the use of adipocytes and their stem cells as a treatment option for hair growth. The aim of this review study is to analyze published literature on the effect of fat on hair growth and to summarize the current evidence.

Berberine Influences the Survival of Fat Grafting by Inhibiting Autophagy and Apoptosis of Human Adipose Derived Mesenchymal Stem Cells

Objective

Human adipose-derived mesenchymal stem cells (ADSCs) have the potential to be applied to solid organ treatments. However, tissue regeneration is limited by the death of transplanted cells. Ischemia is the main cause of the poor outcome. This study aimed to investigate the effect of berberine (BBR) on ADSCs after fat grafting.

Methods

The antioxidant BBR on apoptosis and autophagy of ADSCs in vitro ischemia model was induced by hypoxia and serum deprivation (HY/SD). The autophagy promoter rapamycin and autophagy inhibitor 3-MA were incubated separately to investigate the crosstalk between autophagy and apoptosis. Pathway inhibitors further verified whether the autophagy and apoptosis were regulated by AMPK/mTor signaling pathway. Fat survival, fibrosis, level of inflammatory cell infiltration, and the effect of angiogenesis after BBR treatment were observed in vivo.

Results

BBR could reduce ROS production and reverse the decreasing cell survival rate. HY/SD would induce apoptosis and autophagy in ADSCs, and BBR could alleviate these processes. After interfering with the level of autophagy, we also proved that apoptosis was regulated by autophagy and changed accordingly. The results also indicated that BBR could protect against autophagy and apoptosis of ADSCs through AMPK/mTor pathway. The treated human-derived adipose tissue was transplanted into BALB/c nude mice, and with the intervention of BBR, the fat grafting had a higher survival rate, lower inflammatory cell infiltration and fibrosis level.

Conclusion

Our present study revealed that BBR was a promising anti-autophagy and apoptosis agent for improving the survival rate of ADSCs during cell transplantation.

A Retrospective Study of SVF-gel Compared With Nanofat Combined With High-density Fat in the Treatment of Early Periorbital Aging

PURPOSE

To compare the effectiveness of transplantation with stromal vascular fraction (SVF)-gel or nanofat combined with high-density fat prepared with the Coleman technique (nanofat+high-density fat) to restore volume in the periorbital region or for periorbital rejuvenation in early periorbital aging.

METHODS

This retrospective study included 103 patients who received a transplant of SVF-gel (n = 58) or nanofat+high-density fat (n = 45) to restore volume in the periorbital region (n = 85) or for periorbital rejuvenation (n = 18) in our hospital between January 2016 and January 2020. Patient satisfaction and the reoperation rate were evaluated.

RESULTS

All patients had improved periorbital contouring and augmentation. Among the patients that received treatment to restore volume in the periorbital region, 17% and 65.9% of patients administered SVF-gel were very satisfied or satisfied, and 5.3% and 44.7% of patients administered nanofat+high-density fat were very satisfied or satisfied.

PATIENTS

administered SVF-gel were significantly more satisfied than patients administered nanofat+high-density fat with improvements in periorbital contouring (p < 0.05). Among the patients that received treatment for periorbital rejuvenation, 54.5% and 27.3% of patients administered SVF-gel were very satisfied or satisfied, and 28.6% and 42.8% of patients administered nanofat+high-density fat were very satisfied or satisfied. There was no significant difference between groups (p > 0.05). Some patients underwent a second operation after 3 to 8 months. Patients administered SVF-gel to restore volume in the periorbital region had a significantly lower reoperation rate than patients administered nanofat+high-density fat (12.7% [6/47] vs. 34.2% [13/38]; p < 0.05). There was no significant difference in the reoperation rate in patients treated for periorbital rejuvenation (9.1% [1/11] vs. 14.3% [1/7]; p > 0.05).

CONCLUSION

SVF-gel and nanofat+high-density fat are effective for restoring volume in the periorbital region and for periorbital rejuvenation in early periorbital aging. The reoperation rate was significantly lower and patient satisfaction scores were significantly higher in patients administered SVF-gel to restore volume in the periorbital region compared with patients administered nanofat+high-density fat.

Nanofat Cell-Mediated Anti-Aging Therapy: Evidence-Based Analysis of Efficacy and an Update of Stem Cell Facelift

BACKGROUND

Fat grafting has been extensively applied as natural filler and has been very promising in restoring volume loss. Lipografting has also been credited to reduce age-related skin changes due to the regenerative potential of adipose derived stem cells. Cell-mediated therapies in plastic surgery are rapidly evolving with growing applications. Nanofat, a bio-regenerative liquid suspension rich in stromal vascular fraction cells without viable adipocytes, has been described as an efficient cutaneous anti-aging therapy. We have published in 2013 a review entitled "stem cell facelift: between reality and fiction." Available clinical evidence at that time did not substantiate marketing and promotional claims of "stem cell facelift". The same year, the report about nanofat was published demonstrating striking clinical outcome. The current literature search is aimed at reviewing any evidence that has emerged since then regarding clinical efficacy of this modality.

METHODS

A thorough PICO tool-based comprehensive literature search of PubMed database for "the efficacy of nanofat cell-mediated anti-aging therapy" was conducted with a time frame from 2013 till present.

RESULTS

Despite apparent increasing popularity of stem cell rejuvenation, well-controlled clinical studies about this modality are surprisingly very scarce. Only seven papers published after 2013 were identified and were included in this review CONCLUSION: Though considered to be a safe procedure, and despite documented histologic improvement and striking clinical outcome in some reports, available evidence can hardly support clinical improvement of skin quality. Before cell-mediated aesthetic rejuvenation applications can be routinely undertaken, more robust evidence with well-defined primary outcome end points and objective outcome measures is required.

LEVEL OF EVIDENCE

IV.

Protective Effect of Fat-Tissue-Derived Products against Ultraviolet Irradiation-Induced Photoaging in Mouse Skin

BACKGROUND

Exposure to ultraviolet radiation causes erythema, inflammation, and photoaging. Mechanical micronization of adipose tissue can concentrate functional cells and has great potential as an alternative for regenerative medicine. Stromal vascular fraction gel is produced by means of a series of mechanical processes of lipoaspirates and can be injected intradermally. This study aimed to assess the therapeutic effect of stromal vascular fraction gel on photoaging skin.

METHODS

A photoaging model was established in nude mice. Photoaging mice received treatments of stromal vascular fraction gel, fat, tretinoin, or phosphate-buffered saline. Photoaging skin was characterized by histologic and immunohistochemical analyses. Expression of collagen synthesis-related or photoaging-related genes was assessed.

RESULTS

Stromal vascular fraction gel, fat, and tretinoin reversed photoaging, whereas stromal vascular fraction gel demonstrated the greatest therapeutic effect. Treatment with stromal vascular fraction gel restored intradermal fat tissue content and increased dermal collagen density. Injection of stromal vascular fraction gel had the strongest effect on stimulating fibroblasts and increasing the expression of transforming growth factor β1 (TGF-β1), propeptide of type-I procollagen, and Smad 2, decreasing the expression of Smad 3, compared with fat and tretinoin. Expression of photoaging-related genes was significantly reduced, whereas expression of fibulin-5 was significantly increased after stromal vascular fraction gel treatment.

CONCLUSIONS

Stromal vascular fraction gel demonstrated remarkable therapeutic effects in reversing photoaging skin. Stromal vascular fraction gel can be injected intradermally and survive within dermal layer after grafting. This product increased TGF-β1expression and activated fibroblasts to produce propeptide of type I procollagen, thus increasing the amount of collagen I, leading to thickening of the dermis of photoaging skin.

Nanofat: A therapeutic paradigm in regenerative medicine

Adipose tissue is a compact and well-organized tissue containing a heterogeneous cellular population of progenitor cells, including mesenchymal stromal cells. Due to its availability and accessibility, adipose tissue is considered a "stem cell depot." Adipose tissue products possess anti-inflammatory, anti-fibrotic, anti-apoptotic, and immunomodulatory effects. Nanofat, being a compact bundle of stem cells with regenerative and tissue remodeling potential, has potential in translational and regenerative medicine. Considering the wide range of applicability of its reconstructive and regenerative potential, the applications of nanofat can be used in various disciplines. Nanofat behaves on the line of adipose tissue-derived mesenchymal stromal cells. At the site of injury, these stromal cells initiate a site-specific reparative response comprised of remodeling of the extracellular matrix, enhanced and sustained angiogenesis, and immune system modulation. These properties of stromal cells provide a platform for the usage of regenerative medicine principles in curbing various diseases. Details about nanofat, including various preparation methods, characterization, delivery methods, evidence on practical applications, and ethical concerns are included in this review. However, appropriate guidelines and preparation protocols for its optimal use in a wide range of clinical applications have yet to be standardized.

Translational products of adipose tissue-derived mesenchymal stem cells: Bench to bedside applications

With developments in the field of tissue engineering and regenerative medicine, the use of biological products for the treatment of various disorders has come into the limelight among researchers and clinicians. Among all the available biological tissues, research and exploration of adipose tissue have become more robust. Adipose tissue engineering aims to develop by-products and their substitutes for their regenerative and immunomodulatory potential. The use of biodegradable scaffolds along with adipose tissue products has a major role in cellular growth, proliferation, and differentiation. Adipose tissue, apart from being the powerhouse of energy storage, also functions as the largest endocrine organ, with the release of various adipokines. The progenitor cells among the heterogeneous population in the adipose tissue are of paramount importance as they determine the capacity of regeneration of these tissues. The results of adipose-derived stem-cell assisted fat grafting to provide numerous growth factors and adipokines that improve vasculogenesis, fat graft integration, and survival within the recipient tissue and promote the regeneration of tissue are promising. Adipose tissue gives rise to various by-products upon processing. This article highlights the significance and the usage of various adipose tissue by-products, their individual characteristics, and their clinical applications.

Application of nanofat grafting to rescue a severe ischaemic hand with thromboangiitis obliterans: A case report about promising salvage procedure

RATIONALE

Currently, there is no consensus regarding the best treatment for patients with thromboangiitis obliterans (TAO). Regenerative medicine, such as bone marrow stem cells or adipose-derived stem cell (ASC) transplantation, have proven efficacy in improving tissue perfusion and wound healing in clinical trials. In this case, we used nanofat grafting to treat severe conditions in a patient with TAO, with promising outcomes.

PATIENT CONCERNS

This is a case of a 48-year-old smoker who presented with cyanosis in both hands and the right foot, with gangrenous changes. Investigative angiography showed severe vasospasm in the radial and ulnar arteries of the patient's left hand. Progressive cyanosis of the patient's left hand was noted which may eventually require amputation if left untreated.

DIAGNOSES

He was diagnosed with TAO under the Shionoya diagnostic criteria.

INTERVENTIONS

Fasciotomy and necrotic tissue debridement were performed, followed by centrifuged nanofat grafting. The nanofat graft was prepared using Pallua method and deployed with a MAFT-GUN (Dermato Plastica Beauty Co., Ltd., Kaohsiung, Taiwan).

OUTCOMES

Three months later, computed tomography angiography revealed a radial artery patency. The patient's wrist function was preserved with uneventful wound healing.

LESSONS

The regenerative ability of centrifuged nanofat grafts not only helps wound healing but also helps reverse vasospasm and preserve remnant tissue perfusion.

Comparison of the Rheological Properties and Structure of Fat Derivatives Generated via Different Mechanical Processing Techniques: Coleman Fat, Nanofat, and Stromal Vascular Fraction-Gel

Importance: Coleman fat, nanofat, and stromal vascular fraction-gel (SVF-gel) are three widely used fat derivatives. However, their rheological properties and structure remain unknown. Objectives: To disclose the rheological properties and structure of three different fat derivatives. Design, Settings, and Participants: Fat tissues obtained from eight different donors were processed into three separate groups: Coleman fat, nanofat, and SVF-gel (n = 8); their viscoelastic properties and structure were determined. Intervention: Oscillation measurements were performed in the context of serrated 25-mm parallel-plate geometry with a 1.2-mm gap at 25°C. In addition, fat samples were fixed using a patented protocol and observed under scanning electron microscopy. Main Outcomes and Measures: Comparison of the viscoelastic properties, microstructure, and particle size. Results: At 0.77 Hz, the elastic modulus of SVF-gel, Coleman fat, and nanofat was 201.6 ± 0.74, 69.94 ± 15.61, and 34.89 ± 3.484 Pa, respectively; their viscosity was 44.06 ± 3.038, 15.37 ± 2.0380, and 7.516 ± 0.7250 mPa, respectively. The particle size of SVF-gel, Coleman fat, and nanofat was 106.0 ± 4.796, 86.93 ± 3.597, and 12.61 ± 7.603 μm, respectively. Conclusion and Relevance: Mechanical processing may impact graft efficacy. The characterization of the rheological properties and structure of different fat derivatives in this study may help surgeons select the better type of tissue for a given intervention; however, further studies are still required.

The Effect of Different Diameters of Fat Converters on Adipose Tissue and Its Cellular Components: Selection for Preparation of Nanofat

BACKGROUND

Nanofat is an autologous product prepared mechanically from harvested fat. In nanofat grafting, converters are employed for mechanical emulsification to facilitate fat injection. To date, the study of different converters has received scant attention regarding whether they affect the characteristics of nanofat in terms of the practical applications and indications.

OBJECTIVES

The authors set out to investigate the influence of different internal diameters of converters on biological functionality of nanofat during shuffling.

METHODS

The 3-dimensional finite element method was employed to simulate the process of mechanical emulsification of fat and to research the stress with 5 different converters (3.76 mm, 2.00 mm, 1.20 mm, 1.00 mm, 0.80 mm). An assessment of the morphology of emulsified fat was conducted. Isolated stromal vascular fraction (SVF) was analyzed for cellular components, number, and viability through flowcytometry and live/ dead staining. Adipocytic and angiogenic differentiation assay allowed assessment of differentiation capacity of the SVF.

RESULTS

The smaller the aperture of the converter, the greater the mechanical force on adipose tissue during mechanical emulsification, showing the different macroscopic and microscopic structure of the emulsified fat. No difference in viability or ratio of endothelial progenitor cells and other cells was found. Angiogenic and adipogenic differentiation capacity of the SVF significantly changed in 5 different converters.

CONCLUSIONS

The mechanical emulsification from different apertures of converters exerts different effects of adipose tissue structure, cell content, and multipotency differentiation but not its viability. Converters with different apertures can be selected according to clinical needs.

Comparison of Microfat, Nanofat, and Extracellular Matrix/Stromal Vascular Fraction Gel for Skin Rejuvenation: Basic Research and Clinical Applications

BACKGROUND

Over the past 2 decades, fat grafting has been extensively applied in the field of tissue regeneration.

OBJECTIVES

The aim of this study was to investigate the therapeutic potential of microfat, nanofat, and extracellular matrix/stromal vascular fraction gel (SVF-gel) in skin rejuvenation.

METHODS

Microfat was harvested by a cannula with multiple 0.8-mm smooth side holes and processed with a fat stirrer to remove fibers. Nanofat and SVF-gel were prepared according to previously reported methods, and their structure and viability were evaluated. Then, SVF cells from the 3 types of samples were isolated and characterized, and the cell viability was compared.

RESULTS

The microstructure of the 3 samples showed distinct differences. The microfat group showed a diameter of 100 to 120.0 μm under the microscope and presented a botryoid shape under calcein acetoxymethyl (calcein-AM)/propidium iodide staining. Scanning electron microscopy analysis showed that the microfat maintained an integral histologic structure. In the nanofat group, no viable adipocytes and no normal histologic structure were observed, but high levels of free lipids were noted. The SVF-gel group showed uniform dispersion of cells with different sizes and parts of the adipose histologic structure. Cell count and culture revealed that the number of viable SVF cells decreased distinctly in the nanofat group compared with the microfat group. In contrast, the number of viable SVF cells in the SVF-gel group increased moderately. Clinical applications with microfat showed marked improvements in skin wrinkles.

CONCLUSIONS

Microfat can preserve the integrity of the histologic structure and presents the advantages of subcutaneous volumetric restoration and improvement of skin quality in skin rejuvenation compared with the nanofat and SVF-gel.

LEVEL OF EVIDENCE: 5

Efficacy of adipose-derived stromal vascular fraction cells in the management of chronic ulcers: a randomized clinical trial

Background: Cell therapy is a promising method for improving healing in chronic ulcers through delivery of isolated adipose-derived stromal vascular fraction. Objectives: This study investigates the autologous stem cell yield of adipose tissue and its efficacy in chronic ulcers compared with conventional methods. Methods: This study was a randomized controlled trial. After the study design and protocol were established and ethical committee approval was obtained, we enrolled 100 patients divided into study and control groups. In the study group, we performed debridement and autologous stem cell injection every 3 weeks. The control group was treated with debridement and conventional dressing. Assessments included clinical and histological parameters. Results: The study group showed improved healing. Conclusion: Using autologous adipose-derived stromal vascular fraction cells is an effective treatment method for chronic ulcers. This study was registered on the Pan-African Clinical Trial Registry and the number of the registry was PACTR201709002519185.

Modern Fat Grafting Techniques to the Face and Neck

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand age-related changes to the face and neck and pertinent anatomy and discuss important aspects of fat graft harvesting, processing, and infiltration. 2. Recognize key differences between common techniques for fat processing and infiltration and develop a plan for patients based on site-specific facial anatomical zones. 3. Appreciate the utility of fat grafting as an adjunct to other facial rejuvenating procedures such as face lift and blepharoplasty procedures and list the potential complications from fat grafting to the face and neck.

SUMMARY

Fat grafting to the face and neck aids in volume restoration, thereby addressing soft-tissue atrophy associated with the aging face, acquired conditions, or congenital malformations. Often, fat grafting may sufficiently restore facial volume alone or in conjunction with other facial rejuvenation procedures. Facial/neck fat grafting requires a systematic and thoughtful approach, with special care to atraumatic technique. This CME article covers the principles and techniques for modern facial fat grafting to the face and neck. Increasing data support the ability of autologous fat to produce significant and sustainable appearance-related changes. The authors follow the general principles of the Coleman technique for facial fat grafting and have observed tremendous success over the years. Other techniques for facial fat grafting are also discussed including microfat and nanofat processing. As the understanding of facial fat compartments continues to evolve, the authors may better predict fat grafting outcomes following augmentation. Finally, the technique described as "lipotumescence" has been successfully used in the breast and other regions of the body that have radiation damage and is discussed in this article specifically for the face and neck.

Three states of stromal cells-solid, liquid, and aerosol-and innovative delivery methods not previously reported

Clinical applications of stromal cells obtained mechanically from adipose tissue are quite popular methods. However, generally accepted protocols still do not exist. In this study, three new delivery methods using different protocols are presented as innovative methods in accordance with an approach called “Indication-based protocols.” In mechanical methods, before cutting the fat tissue with ultra-sharp blades, which we define as “Adinizing,” mixing it with different liquids such as saline or plasma provides the stromal cells in liquid form with high number and viability as a final product. At the same time, since stromal cells and extracellular matrix are preserved by mechanical methods, it was deemed appropriate to use the term total stromal cells (TOST) instead of stromal vascular fraction for this final product, unlike the product obtained with the enzyme. TOST can be combined with plasma and used for dermal filling in “solid” form. In addition to this filling effect, it will also cause a change in the tissue regeneratively. Finally, the stromal cells obtained from liquid can be applied clinically in aerosol form with the help of nebulizer. We believe that three innovative delivery methods can be used successfully in the treatment of many clinical situations in the future.

A Combined Approach for Fast Nanofat Microneedling

Background

Lipofilling is currently a fundamental component of rhytidoplasty and fat harvesting has become a common procedure. Tonnard introduced the concept of nanofat grafting, a revolutionary milestone, in which adipocytes are mechanically separated from the stromal vascular fraction and the latter is injected, adding the possibility of cellular therapies to the surgical field. Later, Verpaele et al. published a report using a new device to apply this nanofat in a uniform manner, which they termed nanofat needling. The device has 24 microneedles of 1.5 mm length and is applied as a stamp, in a tapping motion. The same manufacturer offers a similar model with 64 microneedles, 1.0 mm length, and available as a roller.

Objectives

We sought to evaluate the combination of the above-mentioned microneedling devices to achieve faster nanofat delivery.

Materials and Methods

A prospective evaluation of patients undergoing a combined nanofat microneedling approach for skin rejuvenation and scar revision, using both a stamp device as well as a roller, was performed in a private practice setting, from January 2019 to January 2020. Patient satisfaction, complications, and surgical time were evaluated.

Results

We applied this combination treatment to over 100 treatment areas in 86 patients over a 12-month period, with a short operative time, no increase in complications, consistent results, and good patient satisfaction.

Conclusions

We recommend the use of this new device in association with the original one, in order to decrease the procedure time. We designate this strategy "fast nanofat microneedling."

An Adipose-Derived Injectable Sustained-Release Collagen Scaffold of Adipokines Prepared Through a Fast Mechanical Processing Technique for Preventing Skin Photoaging in Mice

Ultraviolet A (UVA) radiation is the major contributor to skin photoaging, associated with increased collagen degradation and reactive oxygen species (ROS) expression. Adipokines have been proven as promising therapeutic agents for skin photoaging. However, adipokine therapy is generally limited by the short in vivo release duration and biological instability. Therefore, developing a treatment that provides a sustained release of adipokines and enhanced therapeutic effects is desirable. In this study, we developed a novel mechanical processing technique to extract adipose tissue-derived ECM components, named the "adipose collagen fragment" (ACF). The physical characterization, injectability, collagen components, residual DNA/RNA and adipokine release pattern of ACF were identified in vitro. L929 cells were treated with ACF or phosphate-buffered saline for 24 h after UVA irradiation in vitro. The expression of senescence-associated xβ-galactosidase (SA-β-gal), ROS and antioxidase were investigated. Then, we evaluated its therapeutic efficacy by injecting ACF and phosphate-buffered saline, as a control, into the dermis of photoaging nude mice and harvesting skin samples at weeks 1, 2, and 4 after treatment for assessment. The content of adipokines released from ACF was identified in vivo. The collagen synthesis and collagen degradation in ACF implants were evaluated by immune staining. Dermal thickness, fibroblast expression, collagen synthesis, ROS level, antioxidase expression, capillary density, and apoptotic cell number were evaluated by histological assessment, immune staining, and polymerase chain reaction in the skin samples. We demonstrated that ACF is the concentrated adipose extracellular matrix collagen fragment without viable cells and can be injected through fine needles. The lower expression of SA-β-gal, ROS and higher expression of antioxidase were observed in the ACF-treated group. ACF undergoes collagen degradation and promotes neocollagen synthesis in ACF implants. Meanwhile, ACF serves as a sustained-release system of adipokines and exhibits a significantly higher therapeutic effect on mouse skin photoaging by enhancing angiogenesis, antioxidant abilities, antiapoptotic activities, and collagen synthesis through sustainedly releasing adipokines. To sum up, ACF is an adipokines-enriched, sustained-release extracellular matrix collagen scaffold that can prevent UVA-induced skin photoaging in mice. ACF may serve as a novel autologous skin filler for skin rejuvenation applications in the clinic.

Fate of Fat Grafting In Vivo and In Vitro: Does the Suction-Assisted Lipectomy Device Matter?

BACKGROUND

Recently, there has been increasing research interest in identifying the effect of liposuction procedures on fat graft survival in order to clarify whether different harvest techniques affect the quality of fat grafts.

OBJECTIVES

The aim of this study was to investigate the effect of 2 liposuction methods on the survival and regeneration potential of grafted fat tissue. The proliferation and differentiation potentials of adipose-derived stem cells (ASCs) isolated by both methods was also investigated.

METHODS

Fat grafts were collected from patients who underwent liposuction procedures by 2 different methods: traditional suction-assisted liposuction (TSAL) and vibration amplification of sound energy at resonance (VASER). One portion of the lipoaspirates was implanted into the subcutaneous layer of nu mice for 4 and 12 weeks. ASCs were isolated from the other portion of the lipoaspirate and subjected to proliferation and differentiation assays.

RESULTS

Although in vivo fat grafting presented similar adipose tissue survival for the 2 different liposuction methods, more angiogenesis and less fibrosis was observed in the VASER group based on histologic evaluation. Furthermore, VASER-derived ASCs presented better quality in terms of cell differentiation capacity.

CONCLUSIONS

The in vivo study confirmed better graft angiogenesis with less inflammation, apoptosis, and scar formation in the VASER group. ASCs harvested with VASER exhibited increased differentiation capacity compared with those obtained by TSAL, and represent an excellent source for fat grafting and regenerative medicine.

Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats

INTRODUCTION

Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.

MATERIALS AND METHODS

12 male Wistar albino rats were divided into two groups; one group received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison.

RESULTS

Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group.

CONCLUSION

Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.

The Use of Adipose-Derived Stem Cells (ADSCs) and Stromal Vascular Fraction (SVF) in Skin Scar Treatment-A Systematic Review of Clinical Studies

In recent years, lipofilling became a popular scar treatment method. Its beneficial outcomes have been partly attributed to the regenerative capacity of adipose-derived stem cells (ADSCs), suspended in an extracellular matrix-the stromal vascular fraction (SVF). The aim of this review was to verify if existing data support the clinical use of ADSC-related interventions in scar treatment. A systematic search of the literature was performed in July 2020 in five databases (Medline, Cochrane, Web of Science, Scopus and Embase). Articles written in English, except for reviews, letters and editorials, were identified and screened for eligibility. We looked for reports of any outcomes in scars treated with ADSCs or SVF. Data from selected articles were extracted and the quality of each study was assessed. Five hundred and fourteen studies were identified in the primary search, of which nineteen were eventually included in the systematic review. Extracted data pointed to beneficial microscopic, functional and aesthetic outcomes in a total of 665 patients. Six studies included comparative interventions-platelet-rich plasma or CO2 fractional laser. Collected data give low-to-average quality evidence for beneficial effects of ADSC-related interventions in scar treatment. Some studies suggest that these interventions are noninferior to PRP or fractional CO2 laser.

The simpler, the better: tissue vascularization using the body's own resources

Tissue regeneration is crucially dependent on sufficient vascularization. In regenerative medicine, this can be effectively achieved by autologous vascularization strategies using the body's own resources. These strategies include the administration of blood-derived factor preparations, adipose tissue-based vascularization, and the in situ engineering of vascularized tissue. Due to their simplicity, the translation of these strategies into clinical practice is easier in terms of feasibility, safety requirements, and regulatory hurdles compared with complex and time-consuming procedures involving intensive cell manipulation. Hence, they are close to clinical application or are already being used to successfully treat patients by distinct personalized medicine concepts.

Microfat and Nanofat Grafting in Genital Rejuvenation

BACKGROUND

Genitourinary syndrome of menopause (GSM) is a major problem in many post- or perimenopausal women. Lipofilling has long been considered to be an effective technique for restoring volume, but the discovery of its trophic proprieties has made it the most widely utilized method in regenerative medicine.

OBJECTIVES

The authors aimed to assess the safety and efficacy of microfat and nanofat grafting for vulvovaginal rejuvenation.

METHODS

Women with GSM who met the inclusion criteria were enrolled. Women received microfat in the labia majora and nanofat in the vagina; follow-up was conducted 1, 3, 6, 12, and 18 months. The vaginal health index (VHI) and Female Sexual Distress (FSD) were utilized to assess improvement in vulvovaginal atrophy, orgasm, and sexual desire posttreatment.

RESULTS

Fifty women were included; their average age was 53 years (range, 45-63 years). The VHI score significantly increased at 1 and 3 months after treatment (P < 0.0001). Moreover, the average FSD score showed a significant improvement at 1 and 3 months posttreatment. This score stabilized from 6 to 12 months but showed further improvement at 18 months. At 6 months posttreatment, for both scales, data pertaining to 80% of patients appeared normalized. There was a particular benefit noted for dryness and dyspareunia. At 18 months, the results remained stable for all of patients. No major side effects were observed.

CONCLUSIONS

There are now many ways to rejuvenate the intimate sphere, but microfat and nanofat grafting seem to offer good results with an autologous procedure. Their utilization appears promising for genital rejuvenation.

LEVEL OF EVIDENCE: 4

Autologous nanofat injection in treatment of scars: A clinico-histopathological study

BACKGROUND

Scars are the unfortunate outcome of most injuries and some diseases. Its psychological impact on patients can deeply affect their quality of life.

AIM

The aim of this study was to evaluate the efficacy of autologous nanofat injection in improving the aesthetic outcome of scars, combined with histopathological correlation of the response.

PATIENTS AND METHODS

Thirty patients with scars of different etiologies undergone one session of nanofat injection and evaluation was done 6 months after the session. Efficacy of treatment was assessed clinically using Vancouver scar scale by two independent blinded dermatologists and histopathologically using image analysis system.

RESULTS

The age of enrolled patients ranged from 18 to 40 years old. There was a statistically significant improvement on the total Vancouver scar scale regarding the height and pliability of the scars. Pathological evaluation showed an increase in epidermal thickness, increased number and density of collagen and elastic fibers along with neovascularization.

CONCLUSION

Evidenced by clinical and pathological improvement, autologous nanofat injection is an effective strategy for treating scars of different etiologies.

Regenerative and stem cell-based techniques for facial rejuvenation

This review discusses the most novel ideas and modalities being incorporated into facial rejuvenation. Recent innovative techniques include the use of regenerative stem cell techniques and regeneration supportive modalities such as nano-technology or gene therapies. This review aims to investigate approaches that are less well known and lacking established evidence in order to proactively study these techniques prior to them becoming popularized. These applications and relevant research were reviewed in the context of both surgical and non-surgical modalities in clinical practice. Future directions include the concept of "precision cosmetic medicine" utilizing gene editing and cellular therapies to tailor rejuvenation techniques based on each individual's genetic make-up and therefore needs.

Nanofat Injection for the Treatment of Depressed Facial Scars

BACKGROUND

Patients with depressed facial scars complain of their negative effects. However, the efficacy of optional treatment techniques is never completely adequate. This study aimed to assess the efficacy of nanofat injection in the improvement of depressed facial scars.

METHODS

This retrospective study included patients who underwent depressed facial scar filling with nanofat between November 2017 and January 2020. The FACE-Q scale was sent to patients for feedback regarding satisfaction. Evaluations of the results were also performed by three plastic surgeons.

RESULTS

Among the 52 included patients, 44 patients (29 women and 15 men) completed the questionnaire. Obvious and stable effects were usually acquired 3 months after surgery. Temporary erythema appeared at the injection site to varying degrees, lasting 2 to 3 weeks in 93% of the patients. No other serious postoperative complications were observed in the injection area. The FACE-Q outcomes showed that patients who completed injection therapy more than 1 year prior were significantly more satisfied with the decision to undergo this therapy than those who completed the treatment less than 1 year prior. Furthermore, according to the physicians' evaluations, 91% of patients experienced improvement in scar appearance after treatment.

CONCLUSIONS

The low rate of injection-site complications and the safety of this procedure both support the current implementation of nanofat in the treatment of depressed facial scars. The results of the physicians' evaluations and patient satisfaction surveys confirmed the stable effect of nanofat injection in the treatment of depressed facial scars.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Addition of Tissue Stromal Vascular Fraction to Platelet-Rich Plasma Supplemented Lipofilling Does Not Improve Facial Skin Quality: A Prospective Randomized Clinical Trial

BACKGROUND

Lipofilling has become popular as a treatment to improve aging-related skin characteristics (eg, wrinkles, pigmentation spots, pores, or rosacea). Different additives such as platelet-rich plasma (PRP) or stromal vascular fraction (SVF) have been combined with lipofilling to increase the therapeutic effect of adipose-derived stromal cells (ASCs).

OBJECTIVES

The aim of this study was to examine the hypothesis that mechanically isolated SVF augments the therapeutic effect of PRP-supplemented lipofilling to improve facial skin quality.

METHODS

This prospective, double-blind, placebo-controlled, randomized trial was conducted between 2016 and 2019. In total, 28 female subjects were enrolled; 25 completed the follow-up. All patients received PRP-supplemented lipofilling with either mechanically isolated SVF or saline. SVF was isolated by fractionation of adipose tissue (tSVF). Results were evaluated by changes in skin elasticity and transepidermal water loss, changes in skin-aging-related features, ie, superficial spots, wrinkles, skin texture, pores, vascularity, and pigmentation, as well as patient satisfaction (FACE-Q), recovery, and number of complications up to 1 year postoperative.

RESULTS

The addition of tSVF to PRP-supplemented lipofilling did not improve skin elasticity, transepidermal water loss, or skin-aging-related features. No improvement in patient satisfaction with overall facial appearance or facial skin quality was seen when tSVF was added to PRP-supplemented lipofilling.

CONCLUSIONS

In comparison to PRP-supplemented lipofilling, PRP-supplemented lipofilling combined with tSVF does not improve facial skin quality or patient satisfaction in a healthy population. PRP-supplemented lipofilling combined with tSVF can be considered a safe procedure.

LEVEL OF EVIDENCE: 2

Adipose tissue versus stem cell-derived small extracellular vesicles to enhance the healing of acute burns

Aim: Proper healing of extensive burns remains a healthcare challenge. In the present study, we proposed a distinct therapeutic application of adipose tissue and small extracellular vesicles isolated from human menstrual blood-derived mesenchymal stem cells (MenSC) small extracellular vesicles (sEVs) to enhance the repair of third-degree burn injury. Materials & methods: Mouse model of third-degree burn was used. Adipose tissue in the form of nano-fat (NF) and MenSC-sEVs was injected subcutaneously at the site of injuries. Results: NF and sEVs were capable of enhancing wound closure and increasing neoangiogenesis. NF was also effective in accelerating the formation of granulation tissue and boosting the thickness of the new epithelial layer. Conclusion: This study demonstrates the effectiveness of NF and MenSC-sEVs as promising therapeutic approaches to facilitate the repair of skin burns.

Comparison of Fat Repositioning Versus Onlay Segmental Fat Grafting in Lower Blepharoplasty

BACKGROUND

Lower blepharoplasty is one of the most challenging procedures in aesthetic surgery. In particular, blending the lid-cheek junction and correction of the tear trough are prone to failure and unsatisfactory outcomes.

OBJECTIVES

The aim of this study was to combine lower eyelid blepharoplasty with a novel technique of autologous fat grafting, commonly called segmental fat grafting, and to analyze the safety and efficacy of this approach.

METHODS

A retrospective analysis of 339 lower blepharoplasties was performed to compare the novel technique of segmental fat grafting to traditional fat transposition during lower blepharoplasty. Outcomes were assessed objectively by several measurements as well as via online survey of 148 invited experts in plastic surgery. Statistical analysis included t test for unpaired and paired samples as well as 1-way analysis of variance for matched data.

RESULTS

There were no differences in baseline characteristics and comorbidities between study groups. After a mean follow-up of 12.9 months (range, 5-120 months), the group that underwent segmental fat grafting had a significant reduction in tear trough width compared compared with the group receiving lower blepharoplasty with fat transposition. Based on an expert (blinded) online survey, segmental fat grafting was superior or equal in 47% and 35% of cases, respectively. Complications (4%) and revision surgeries (9%) did not differ significantly between study groups.

CONCLUSIONS

The novel technique of transplantation of a segmental fat graft during lower blepharoplasty is a safe and effective way to overcome tear trough deformity and blend the lid-cheek junction.

LEVEL OF EVIDENCE: 4

Systematic review: Advances of fat tissue engineering as bioactive scaffold, bioactive material, and source for adipose-derived mesenchymal stem cells in wound and scar treatment

Fat tissue (FT) has been used for many years in regenerative surgery as a bioactive material through the lipofilling/fat graft (F-GRF)-nano-fat technique, as a bioactive scaffold when it was enriched with adipose-derived mesenchymal stem cells (AD-MSCs) contained in the stromal vascular fraction (SVF), and as a direct source of AD-MSCs used in wound healing (WH) and scar treatment (ST). This systematic review aims to describe the advances in FT engineering applied to regenerative surgery (from bench to clinic), through the use of AD-MSCs, SVF contained in F-GRF in WH and ST. The work has been performed by assessing in the selected studies autologous graft of AD-MSCs, SVF, and F-GRF compared to any control for ST and WH. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. A multistep search of the PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov , Scopus database, and Cochrane databases has been performed to identify papers on AD-MSCs, SVF, and F-GRF use in WH and ST in which FT was used as bioactive material-scaffold and source of AD-MSCs. Of the 714 articles initially identified, 453 articles focusing on regenerative strategies in WH and ST were selected and, consequently, only 84 articles that apparently related to AD-MSC, SVF, and F-GRF were analyzed. Of these, 61 articles identified as pre-clinical, experimental, and in vitro, and 5 articles identified as a comment and systematic review were excluded. Only 18 original articles which strictly and exclusively focused on autologous AD-MSCs, SVF, and F-GRF in ST and WH were analyzed. The included studies had to match predetermined criteria according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach. The identified studies described microscopic and clinical outcomes in patients treated with AD-MSCs, SVF, and F-GRF. Collected data confirmed the safety and efficacy of FT both as bioactive material-scaffold and source of AD-MSCs in WH and ST without major side effects.

[Modern technologies of regenerative rehabilitation in the treatment of patients with abnormal scars]

OBJECTIVE

To evaluate an efficacy of lipoaspirate-based products in pathologic scarring management.

MATERIAL AND METHODS

There were 118 patients with external scars. Depending on scar type, localization and need for soft tissue augmentation, three different methods were used for lipoaspirate-based product preparation: 15-minute sedimentation, centrifugation at 1200 g for 3 minutes and emulsification with a channel diameter of 1.2 mm. Results were assessed using the Manchester Scar Scale (MSS) and photographing.

RESULTS

According to MSS analysis, the following results were obtained: before treatment - 11.6 (9.3-13.3) scores, 3 months after treatment - 6.5 (5.1-7.2) scores, 6 months after treatment - 5.2 (4.5-6.1) scores. Significant differences were obtained for baseline values and both control points. Stable results were obtained in long-term follow-up period (12-24 months). No major adverse effects were observed. Minor complications were registered in 10.1% of patients.

CONCLUSION

Injections of lipoaspirate-based products is an effective option for the treatment of patients with pathologic scarring. This approach is intermediate between conservative and conventional surgical treatment.

The Future of Fat Grafting

One of the earliest reported cases of autologous fat grafting (AFG) was by Neuber in 1893 and consisted of the transfer of small lobules of fat from the upper arm for cicatrical depression of the face. He advocated the use of smaller grafts, noting that pieces larger than the size of a bean would form cysts. In 1895, Czerny excised a lumbar lipoma and transplanted it to the chest for breast reconstruction. Since these early reports, the knowledge base around AFG has expanded exponentially, as illustrated by the other papers within this special topic. As we embark on the next phase of AFG in the clinical setting, there are several directions which are near-clinical translation. This paper discusses future directions in fat grafting that build on optimization of our current techniques as clinical indications expand, such as supplementing purified lipoaspirate and the associated regulatory burden, or deconstructing adipose tissue to selectively use adipose graft components for a variety of regenerative indications.

Facial Rejuvenation With Fat Grafting and Fillers

Facial rejuvenation requires a multi-modality approach to address the sun damage, volume loss, and thinning of skin that occurs with aging. With age, the collagen fibrils that provide strength become fragmented and fibroblasts connections become weak, leading to skin laxity and loss of youthful skin. Fillers can lead to a more youthful appearance by providing volumetric support. Synthetic fillers such as hyaluronic acid products, calcium hydroxyapatite, polylactic acid, and polymethylmethacralate have bio-stimulatory affects, ranging from small effects on fibroblast production to prolonged stimulatory effects on dermal thickness and blood supply. Fat grafting is also an ideal technique for facial rejuvenation because it is readily available, natural, and has regenerative effects. This review describes a new technique of fat grafting for the face called Injectable Tissue Replacement and Regeneration that specifically addresses the different anatomic compartments of the face with volume loss. With this brief review, we aim to evaluate the currents trends of fat grafting and fillers in the management of facial rejuvenation, including the cellular changes that occur with facial aging, the bio-stimulatory effects of fillers, and the anatomic replacement of tissue with fat grafting. >Level of Evidence: 4.

Assessing Clinical Outcomes in Autologous Fat Grafting: A Current Literature Review

Autologous fat grafting, first described in the 1890s, has since undergone many modifications to optimize safety and efficacy. These changes have resulted in the technique that we now consider standard of care, one that is applied to reconstruction and cosmetic enhancement of the breast and the face both independently and in conjunction with surgical treatment. There is a growing body of evidence that this application has positive outcomes for patient satisfaction, surgeon satisfaction, and overall aesthetic appearance. This article summarizes the body of literature regarding these outcomes, reviews complications of fat grafting in the face and breast, and discusses controversies including radiologic imaging changes and longevity of grafting. Level of Evidence: 4.

Effects of concentrated growth factor and nanofat on aging skin of nude mice induced by D-galactose

This investigation studied the effect of concentrated growth factor and nanofat on aging skin of nude mice induced by D-galactose. BALB/c mice were randomly divided into five groups: 5 mice in the control group were fed normally without any intervention, 9 mice were treated with concentrated growth factor (CGF), 9 mice were treated with nanofat (NF), 9 mice were treated with CGF+NF, and 9 mice in the model group (no treatment after subcutaneous injection of D-galactose). Relevant indicators are measured and recorded. In skin and serum, SOD and GSH content in the model group were significantly lower than those in other groups (P<0.05), and the MDA of the three treatment groups was significantly lower than that of the model group (P<0.05). Compared with the control group, the contents of total collagen, type I collagen and type III collagen in the NF group and model group were decreased in different degrees (P<0.05); the contents of elastin and elastic fiber in the skin of nude mice in the model group and NF group were significantly decreased. Compared with the model group, he number of CD31 and VEGF in the treatment group was significantly increased (P<0.01); the skin AGE content of three treatment groups was significantly lower (P<0.05). These findings suggest that concentrated growth factor and nanofat may have a significant effect on delaying aging skin induced by D-galactose in nude mice.

Adipose-Derived Mesenchymal Stem Cells (AD-MSCs) against Ultraviolet (UV) Radiation Effects and the Skin Photoaging

The skin is a natural barrier against the ultraviolet (UV) radiation of sunlight. The long-term and/or repetitive exposure to the sunlight and related UV radiation may change the skin structure, decreasing collagen production, promoting premature skin aging, which is termed "photoaging". The signs of photoaging include wrinkle formation, mottled pigmentation, and/or cancerous changes. For many years, adipose-derived mesenchymal stem cells (AD-MSCs) and fat grafting (F-GRF) have been used to combat photoaging signs, wrinkles, loss of elasticity, and face soft tissue defects. Several studies have analyzed in vitro actions of AD-MSCs against photoaging's effects, thanks to their migratory activity, paracrine actions, and related in vivo-ex vivo outcomes. In fact, AD-MSCs act against skin photoaging in vitro via activation of dermal fibroblast proliferation, antioxidant effect, and matrix metalloproteinases (MMPs) reduction. In vivo and ex vivo outcomes regard the local injection of AD-MSCs, F-GRF, and/or enriched-F-GRF with AD-MSCs directly in the wrinkles and the face's soft tissue defects. This concise review summarizes the most recent in vitro, in vivo and ex vivo outcomes and developments on the effects of AD-MSCs and F-GRF against photoaging.

Effect of additive-assisted fat transplantation on fat graft survival rate: A preliminary experimental study based on a rabbit animal model

BACKGROUND

Improving the survival rate of fat grafts is yet a difficult problem in the field of autologous fat transplantation. Prevailing methods such as making nanofat and SVF are time-consuming. Hence, the role of additives application in the improvement of fat graft survival during fat transplantation was considered and preliminarily evaluated in a rabbit animal model.

METHODS

A rabbit animal model was established where rabbit ears were injected with a mixture of 1.5mL of adipose tissue and 1mL of saline (group A), 1.5mL of adipose tissue and 1mL of botulinum toxin A (BoNTA) (group B), 1.5mL of adipose tissue and 1mL of prostaglandin E2 (groupC), 1.5mL of adipose tissue and 1mL of PDRN (group D) respectively. Then, the extents of neovascularization and inflammation were evaluated on the 7th, 14th, 28th, 42nd, 56th and 70th day after injection by ELISA assays and H&E and immunofluorescence staining.

RESULTS

The results showed that pre-treatment with BoNTA, prostaglandin E2 and PDRN improved graft volume and weight. The H&E and immunofluorescence staining revealed that BoNTA, prostaglandin E2 and PDRN improved the graft angiogenesis. Simultaneously, TNF-α expression level detected by ELISA was the lowest in the PDRN group.

CONCLUSION

Henceforth, the present preliminary study suggests that pre-transplantation treatment with BoNTA, prostaglandin E2 and PDRN can improve the fat graft angiogenesis and graft integrity, whereby the effect of adding PDRN may be significant.

Fat Grafting Improves Fibrosis and Scarring in Vulvar Lichen Sclerosus: Results From a Prospective Cohort Study

OBJECTIVE

The aim of the study was to evaluate the effect of lipotransfer in women presenting with fibrosis and scarring due to lichen sclerosus.

MATERIALS AND METHODS

This prospective cohort study included 33 women attending the vulvar clinic of a public hospital. Patients received one lipotransfer treatment. Validated measures were used prospectively to assess the sexual function (Female Sexual Function Index, Female Sexual Distress Scale); symptoms (visual analog scale for itching, burning, soreness), pain (Pain Anxiety Symptoms Scale 20); psychological status and quality of life (Hospital Anxiety and Depression Scale, Relationship Assessment Scale, Wound Management Questionnaire Revised); physician-based disease signs (Vulvar Architecture Severity Scale). Data were analyzed using paired t test with nonparametric Wilcoxon matched-pairs signed rank test and unpaired t test with nonparametric Mann-Whitney test (Prism6 Software).

RESULTS

The mean (SD) follow-up was 12.9 (3.5) months. Sexual function improved after treatment (p < .001), as well as the distress associated with sexuality (p < .0001). A significant improvement was reported in itching (p < .001), burning (p < .05), soreness (p < .001), and pain (p < .0001). Patients reported a significant improvement in romantic relationship (p < .05), anxiety (p < .0001), and depression (p < .0001). Improvement was not significant in the self-care associated with self-disgust assessment (p = .42). The clinical physician-based score showed an overall improvement in all the treated areas to lesser or greater extent.

CONCLUSIONS

The use of fat grafting in lichen sclerosus is promising. Further studies are required to rule out a potential placebo effect and to better understand the underlying molecular mechanism of action.

Efficacy, safety and complications of autologous fat grafting to the eyelids and periorbital area: A systematic review and meta-analysis

Background

In recent years, autologous fat grafting (AFG), also known as fat transfer or lipofilling, has been widely performed for periorbital rejuvenation and defect correction, although the evidence regarding its efficacy and safety is still lacking. Besides, with respect to the periorbital region, it is invariably the earliest appearance area of the facial aging phenomenon. Therefore, a systematic review and meta-analysis is needed to evaluate the efficacy and safety of this technique.

Methods

A literature search was performed in PubMed, Embase, and the Cochrane library databases on November 20, 2020, adhering to the PRISMA guidelines, to identify all relevant articles. Then, a data extraction and standardization process was performed to assess all outcome data. Ultimately, the data were assessed using a random effects regression model with comprehensive meta-analysis software.

Results

Thirty-nine studies consisting of 3 cohorts and 36 case series with a total of 4046 cases were included. Meta-analysis revealed a relatively high satisfaction rate of 90.9% (95% CI, 86.4%–94.0%). Frequent complications in 4046 patients receiving AFG were edema, chemosis, and contour irregularity, with an overall complication rate of 7.9% (95% CI, 4.8%–12.8%).

Conclusion

This systematic review and meta-analysis showed that AFG for rejuvenation of eyelids and periorbital area provided a high satisfaction rate and did not result in severe complications. Therefore, AFG might be performed safely for periorbital rejuvenation and reconstruction.

An Update on Mesenchymal Stem Cell-Centered Therapies in Temporomandibular Joint Osteoarthritis

Temporomandibular joint osteoarthritis (TMJOA) is a degenerative disease characterized by cartilage degeneration, disrupted subchondral bone remodeling, and synovitis, seriously affecting the quality of life of patients with chronic pain and functional disabilities. Current treatments for TMJOA are mainly symptomatic therapies without reliable long-term efficacy, due to the limited self-renewal capability of the condyle and the poorly elucidated pathogenesis of TMJOA. Recently, there has been increased interest in cellular therapies for osteoarthritis and TMJ regeneration. Mesenchymal stem cells (MSCs), self-renewing and multipotent progenitor cells, play a promising role in TMJOA treatment. Derived from a variety of tissues, MSCs exert therapeutic effects through diverse mechanisms, including chondrogenic differentiation; fibrocartilage regeneration; and trophic, immunomodulatory, and anti-inflammatory effects. Here, we provide an overview of the therapeutic roles of various tissue-specific MSCs in osteoarthritic TMJ or TMJ regenerative tissue engineering, with an additional focus on joint-resident stem cells and other cellular therapies, such as exosomes and adipose-derived stromal vascular fraction (SVF). Additionally, we summarized the updated pathogenesis of TMJOA to provide a better understanding of the pathological mechanisms of cellular therapies. Although limitations exist, MSC-centered therapies still provide novel, innovative approaches for TMJOA treatment.

Stromal vascular fraction and emulsified fat as regenerative tools in rejuvenation of the lower eyelid area

In the lower eyelid area, dermal melanocytosis, fine lines, skin atrophy, dryness, and loss of subcutaneous fat tissue represent the initial signs of aging. Beside the addition of volume, adipose tissue injections can also improve pigmentation and skin texture. Clinical studies of simultaneous stromal vascular fraction (SVF) and emulsified fat transfers have not been reported so far. Our aim was to investigate the clinical results of transferring SVF and emulsified fat into the lower eyelid area. A total of 16 patients underwent tumescent liposuction and injection of SVF and emulsified fat into the lower eyelid area. For preparation of SVF and emulsified fat, ACP double syringes with 2.4, 1.4, and 1.2 mm connectors, and a swing-out rotor centrifuge, were used. At follow-up, improvements on before and after pictures were rated by the treating physician and two independent physicians, using the global aesthetic improvement scale (GAIS). Clinical outcomes were rated as exceptional, very improved, or improved in all patients, with an average GAIS score of 1.6. No serious adverse events occurred. Our initial results suggest that SVF and emulsified fat are safe and effective tools for skin rejuvenation and correction of volume deficiencies in the lower eyelid area. More studies need to be conducted to corroborate these encouraging findings.

Facial Rejuvenation with Concentrated Lipograft-A 12 Month Follow-Up Study

Lipofilling is a popular technique to treat volume loss in aging patients. The isolated adipose tissue is composed of adipocytes and stromal vascular fraction cells, which include adipose-derived stem cells (ASC). We hypothesize that the patient’s wrinkle severity scale (WSS) and patient’s satisfaction on the global aesthetic improvement scale (GAIS) can be improved after using concentrated lipoaspirate. Fourteen patients (54 years ± 11.09 years) with volume loss in the midface area underwent waterjet-assisted liposuction (Human Med AG, Schwerin, Germany). Fat was centrifuged in an ACP Double Syringe (Arthrex GmbH, Munich, Germany) using Rotofix 32A centrifuge (Andreas Hettich, GmbH & Co.KG, Tuttlingen, Germany). Homogenization was performed using the double syringe and a 1.4 mm female–female luerlock connector. After a second centrifugation, patients received periorbital (PO) and nasolabial (NL) lipografting. ASC count was performed after enzymatical digestion. Vitality of cells was assessed using a resazurin assay. During long-term follow up (12 months, n = 10), we found a high patient’s satisfaction (GAIS 1+/−0.52) and a good improvement of the WSS during short- and long-term follow-up. The ASC count of processed lipoaspirate was 2.1-fold higher than of unprocessed lipoaspirate (p < 0.001). The difference of ASC in sedimented and simply centrifuged lipoaspirate was also significant (p < 0.05). Facial rejuvenation with concentrated fat graft offers good results concerning objective aesthetic outcome and patient’s satisfaction.

Biofat grafts as an orthobiologic tool in osteoarthritis: An update and classification proposal

Among degenerative musculoskeletal disorders, osteoarthritis remains one of the main causes of pain and disability in the adult population. Current available alternatives to alleviate symptoms include conservative treatments such as physical therapy, anti-inflammatory drugs and an educational approach to lifestyle modification. The use of certain analgesics, such as opiates and corticosteroids offer short-term results but does not address the etiological source of pain and disability. In addition, prolonged use of such medications can cause additional complications. Therefore, the demand for regeneration of joint cartilage has led to an alternative approach called "orthobiologics". This alternative is based on cellular and molecular components capable of inducing and promoting tissue repair. Products derived from adipose tissue have been studied as an excellent source of orthobiologics in an attempt to promote joint cartilage repair. However, the lack of standardization regarding collection and processing protocols presents a challenge for the generalization of study results and determination of effectiveness. To the best of our knowledge, orthobiologics derived from fat have not yet been classified. Therefore, this manuscript proposes the HGS classification system which aims to describe certain parameters that are relevant to the quality of organic products regarding harvesting techniques (H), graft type (G), and number of centrifugations (S). The more parameters used would imply greater characterization and complexity of the evaluation of the biological product used. The HGS classification may provide a valuable contribution to the understanding of clinical procedures and research results, aiming to ultimately usher in a standardization of optimal practice.