A multi-center, open-label, pilot study of allograft adipose matrix for the correction of atrophic temples

Effects of adipose allograft matrix on viability of humeral head cartilage and rotator cuff tendon

BACKGROUND

Rotator cuff repairs may fail because of compromised blood supply, suture anchor pullout, or poor fixation to bone. To augment the repairs and promote healing of the tears, orthobiologics, such a platelet-rich plasma (PRP), and biologic scaffolds have been applied with mixed results. Adipose allograft matrix (AAM), which recruits native cells to damaged tissues, may also be a potential treatment for rotator cuff tears.

METHODS

To assess the potential use of AAM on rotator cuff tears, humeral head cartilage and subscapularis tendon were collected from patients undergoing reverse shoulder arthroplasty (RSA). Punch biopsies of the tissues were used to create explants for tissue culture, and the remaining tissue was digested to isolate the chondrocytes and tenocytes for cell culture. Explants and cells were then cultured in media containing AAM. After 48 h, the tissues and cells were measured for cell viability, cell proliferation, extracellular matrix (ECM) and metalloproteinase (MMP) gene expression and for MMP, inflammatory cytokine, and growth factor concentrations.

RESULTS

Cell viability was increased in humeral head chondrocytes and rotator cuff tenocytes cultured with AAM. Gene expression of the matrix proteoglycan, aggrecan, and of the proteolytic enzyme MMP-13 were downregulated in humeral head chondrocytes. MMP-13 concentrations were increased in subscapularis tenocytes and in humeral head chondrocyte/subscapularis tenocyte co-cultures. The anti-inflammatory cytokine, IL-1ra was increased in cartilage/tendon explant co-cultures. TGF-β1 concentrations were increased in chondrocytes, but decreased in tenocytes.

CONCLUSIONS

Overall, AAM had no significant negative effects on the cells or explants. The results of these experiments provide the basis for the future use of AAM as a scaffolding for tissue engineering, preclinical animal models of rotator cuff tear and glenohumeral osteoarthritis, and clinical models.

CLINICAL TRIAL NUMBER

Not applicable.

Regenerated fat induced by a decellularized adipose matrix can survive long-term in vivo

Decellularized adipose matrix (DAM) is considered to be the most potential biological scaffold for soft tissue repair and reconstruction, as it is able to induce the regeneration of adipose tissue in situ in adulthood. But how does this adipose tissue regeneration happen and develop in vivo? Is it the same as the original autologous one? Temporary existence or long-term survival? These are the key questions that will determine the future applications of DAM. In this study, we investigated the composition, structure and biomechanical properties of DAM before implanting it into the subcutaneous back of immunodeficient mice. The entire regeneration process in vivo was closely monitored histologically from 3 days to 1 year after implantation, including fat regeneration, vascular growth, inflammatory responses, and matrix degradation and remodeling. Transcriptome sequencing was used to analyze the difference in gene expression between regenerated fat and autologous fat at different periods. The results showed that the DAM-induced regenerated fat first appeared at 1 w and remained stable over 6 m, indicating remarkable similarity to autologous fat at the later stages of implantation. And about (18.3 ± 29.3) % of the regenerated adipocytes were still viable after one year. The process of adipogenesis was enhanced by the decrease in inflammatory infiltration and proceeded in parallel with angiogenesis. STATEMENT OF SIGNIFICANCE: The decellularized adipose matrix (DAM) is the only biological scaffold that can spontaneously generate adipocytes in vivo without the need to add exogenous cells. However, in the previous studies, the longest DAM-related animal experiments were about 3 months. The different stages and characteristics of DAM implantation cannot be fully captured. Comprehensive preclinical researches on the initiation, characteristics, and long-term outcomes of DAM-induced adipose tissue regeneration in adulthood is crucial. In this study, we closely observed various aspects of the entire process in vivo from 3 days to 1 year after implantation including fat regeneration, vascular growth, inflammatory reactions as well as matrix degradation and remodeling. The thorough research will contribute to the understanding of stability and dynamic remodeling of DAM regeneration models.

Decellularized Extracellular Matrix Scaffolds for Soft Tissue Augmentation: From Host-Scaffold Interactions to Bottlenecks in Clinical Translation

Along with a paradigm shift in looking at soft tissue fillers from space-filling to bioactive materials, decellularized extracellular matrix (DEM) fillers have gained more attention considering their superior bioactivity. However, the complex mechanisms that govern the interaction between host tissues and DEMs have been partially understood. This review first covers the mechanisms that determine immunogenicity, angiogenesis and vasculogenesis, and recellularization and remodeling after DEM implantation into host tissue, with a particular focus on related findings from filler materials. Accordingly, the review delves into the dual role of macrophages and their M1/M2 polarization paradigm to form both constructive and destructive immune responses to DEM implants. Moreover, the contribution of macrophages in angiogenesis has been elucidated, which includes but is not limited to the secretion of angiogenic growth factors and extracellular matrix (ECM) remodeling. The findings challenge the traditional view of immune cells as solely destructive entities in biomaterials and indicate their multifaceted roles in tissue regeneration. Furthermore, the review discusses how the compositional factors of DEMs, such as the presence of growth factors and matrikines, can influence angiogenesis, cell fate, and differentiation during the recellularization process. It is also shown that the biomechanical properties of DEMs, including tissue stiffness, modulate cell responses through mechanotransduction pathways, and the structural properties of DEMs, such as scaffold porosity, impact cell-cell and cell-ECM interactions. Finally, we pointed out the current clinical applications, the bottlenecks in the clinical translation of DEM biomaterials into soft tissue fillers, as well as the naïve research areas of the field.

Real-World Clinical Experience With an Allograft Adipose Matrix for Replacing Volume Loss in Face, Hands, and Body

INTRODUCTION

Real-world experience using an allograft adipose matrix (AAM) (Renuva) is presented as a series of seven cases demonstrating successful use of the matrix by nine expert cosmetic physicians across the United States. AAM is donated tissue that is aseptically processed without terminal irradiation into a transplantable adipose matrix that functions as a natural, versatile, and nonimmunogenic cushioning and volume-restoring tissue. When injected, the adipose matrix is replaced with the body's own fat cells and provides the cellular scaffold required for volume restoration and retention.

METHODS

Nine expert dermatologists were selected to share and discuss real-world patient cases using AAM. The experts discussed a variety of cases and selected 7 cases that demonstrated successful, novel use of AAM to present in this manuscript.

RESULTS

Experts agreed that the novel AAM is an easy-to-use, effective, and safe alternative to traditional fillers and fat grafting.

CONCLUSION

The use of the AAM is recommended for the face, hands, and other adipose tissue-containing parts of the body. The presented real-world cases provide guidance on how to identify ideal candidates to ensure optimal volume restoration results.

Combined Use of Autologous Sustained-Release Scaffold of Adipokines and Acellular Adipose Matrix to Construct Vascularized Adipose Tissue

BACKGROUND

Adipose tissue engineering plays a key role in the reconstruction of soft-tissue defects. The acellular adipose matrix (AAM) is a promising biomaterial for the construction of engineered adipose tissue. However, AAM lacks sufficient adipoinduction potency because of the abundant loss of matrix-bound adipokines during decellularization.

METHODS

An adipose-derived extracellular matrix collagen scaffold, "adipose collagen fragment" (ACF), was prepared using a novel mechanical method that provides sustained release of adipokines. Here, the authors used label-free proteomics methods to detect the protein components in AAM and ACF. In vivo, ACF was incorporated into AAM or acellular dermal matrix and implanted into nude mice to evaluate adipogenesis. Neoadipocytes, neovessels, and corresponding gene expression were evaluated. The effects of ACF on adipogenic differentiation of human adipose-derived stem cells and tube formation by human umbilical vein endothelial cells were tested in vitro.

RESULTS

Proteomics analysis showed that ACF contains diverse adipogenic and angiogenic proteins. ACF can release diverse adipokines and induce highly vascularized, mature adipose tissue in AAM, and even in nonadipogenic acellular dermal matrix. Higher expression of adipogenic markers peroxisome proliferator-activated receptor gamma and CCAAT/enhancer-binding protein alpha and greater numbers of tubule structures were observed in ACF-treated groups in vitro.

CONCLUSION

The combination of ACF and AAM could serve as a novel and promising strategy to construct mature, vascularized adipose tissue for soft-tissue reconstruction.

CLINICAL RELEVANCE STATEMENT

The combined use of AAM and ACF has been proven to induce a highly vascularized, mature, engineered adipose tissue in the nude mouse model, which may serve as a promising strategy for soft-tissue reconstruction.

A Multicenter Pilot Study of a Novel Allograft Adipose Matrix in Malar and Prejowl Volume Restoration

Background

Allograft adipose matrix (AAM) offers a novel, off-the-shelf, and readily available natural option in the treatment of facial soft tissue volume and reconstructive deficits. AAM is a natural soft tissue supplement or replacement that can support cushioning and volume correction. A prospective multicenter pilot study evaluated AAM in facial volume restoration.

Methods

Eleven women (mean age of 55.8 ± 10.9 y) with midface volume deficit were followed up for 24 weeks after AAM treatment in this institutional review board-approved multicenter pilot study. The clinical safety and efficacy of the AAM treatment were evaluated using clinical scales and three-dimensional quantitative facial photography.

Results

AAM was safe to address facial volume deficits, with minor site-related adverse events and discomfort that resolved within 2-4 weeks. Observations also revealed facial volume improvements throughout the study with 91% positive responders. At week 24, the subject facial satisfaction scores revealed an 86% increase compared to baseline, along with a statistically significantly improved midface fullness compared to baseline.

Conclusion

AAM offers a natural and safe option for midface volume restoration and supports overall satisfaction and volume improvements.

Combining Allograft Adipose and Fascia Matrix as an Off-the-Shelf Scaffold for Adipose Tissue Engineering Stimulates Angiogenic Responses and Activates a Proregenerative Macrophage Profile in a Rodent Model

OBJECTIVE

Bioscaffolds for treating soft tissue defects have limitations. As a bioscaffold, allograft adipose matrix (AAM) is a promising approach to treat soft tissue defects. Previously, we revealed that combining superficial adipose fascia matrix with AAM, components of the hypodermis layer of adipose tissue, improved volume retention, adipogenesis, and angiogenesis in rats 8 weeks after it was implanted compared with AAM alone. Here, we modified the fascia matrix and AAM preparation, examined the tissue over 18 weeks, and conducted a deeper molecular investigation. We hypothesized that the combined matrices created a better scaffold by triggering angiogenesis and proregenerative signals.

METHODS

Human AAM and fascia matrix were implanted (4 [1 mL] implants/animal) into the dorsum of male Fischer rats (6-8 weeks old; ~140 g) randomly as follows: AAM, fascia, 75/25 (AAM/fascia), 50/50, and 50/50 + hyaluronic acid (HA; to improve extrudability) (n = 4/group/time point). After 72 hours, as well as 1, 3, 6, 9, 12, and 18 weeks, graft retention was assessed by a gas pycnometer. Adipogenesis (HE), angiogenesis (CD31), and macrophage infiltration (CD80 and CD163) were evaluated histologically at all time points. The adipose area and M1/M2 macrophage ratio were determined using ImageJ. RNA sequencing (RNA-seq) and bioinformatics were conducted to evaluate pathway enrichments.

RESULTS

By 18 weeks, the adipose area was 2365% greater for 50/50 HA (281.6 ± 21.6) than AAM (11.4 ± 0.9) (P < 0.001). The M1/M2 macrophage ratio was significantly lower for 50/50 HA (0.8 ± 0.1) than AAM (0.9 ± 0.1) at 6 weeks (16%; P < 0.05). This inversely correlated with adipose area (r = -0.6; P > 0.05). The RNA-seq data revealed that upregulated adipogenesis, angiogenesis, and macrophage-induced tissue regeneration genes were temporally different between the groups.

CONCLUSIONS

Combining the fascia matrix with AAM creates a bioscaffold with an improved retention volume that supports M2 macrophage-mediated angiogenesis and adipogenesis. This bioscaffold is worthy of further investigation.

Treatment of Recurrent Pressure Injury Using an Allograft Adipose Matrix

ABSTRACT

A 77-year-old man with a more than 10-year history of a spinal cord injury developed bilateral trochanteric stage 3 pressure injuries (PIs) several years ago. They initially healed. The right trochanteric PI opened again and continued to reopen every 2 to 3 months, likely because of deficient adipose layer in the area of the healed PI.To treat the recurrent PI, providers injected a total of 3 mL of allograft adipose matrix into the ulcerated area of the right trochanter PI in a fanning fashion to increase subcutaneous cushioning over the bony prominence. Silicone foam was used to assist with pressure reduction for the first month. When the ulcerations healed at 1 month, the silicone foam was discontinued, and an emollient ointment was applied bilaterally to provide both the currently affected site and healed scar tissue with moisture and enhanced barrier function. Follow-up examinations were completed at 1, 3, 7, 11, 14, 16, 19, 22, and 24 months; the ulcerations remained closed, and no new PIs developed.The authors propose that allograft adipose matrix is a potential treatment modality for recurrent PIs needing a supplemented subcutaneous layer that other modalities cannot provide. Further use is ongoing in clinical scenarios when there is deficient adipose layer such as recurrent PIs or to prevent PI deterioration in early stages.

Use of allograft fat for aesthetic and functional restoration of soft tissue contour deformities

The authors report a case series of five patients with Leneva grafted into the nose, hand, genitalia and below-the-knee stump. Leneva is an allograft adipose matrix derived from aseptically processed human adipose tissue with retained matrix proteins, growth factors, cytokines and collagens. It is manufactured hydrated and is available in pre-loaded syringes. Five patients (3F, 2 M) with a mean age of 50.7 (range 31-77 years) injected with a mean volume of 4.2 cc (range 3-6 cc) of Leneva in various anatomic locations with an average follow up time of 4.25 months (range 0.5-12 months) experienced no allergic reactions, infection, fat necrosis or oil cysts. All patients were pleased with the restoration of fullness to the injected site. The authors believe that Leneva is a promising multi-use filler for restoring soft tissue defects following resection of tumours, to rejuvenate age-related atrophy, aesthetically enhance the genitals and provide padding for transtibial prostheses.

Deconstructing Allograft Adipose and Fascia Matrix: Fascia Matrix Improves Angiogenesis, Volume Retention, and Adipogenesis in a Rodent Model

BACKGROUND

Autologous fat grafting is commonly used for soft-tissue repair (approximately 90,000 cases per year in the United States), but outcomes are limited by volume loss (20% to 80%) over time. Human allograft adipose matrix (AAM) stimulates de novo adipogenesis in vivo, but retention requires optimization. The extracellular matrix derived from superficial fascia, interstitial within the adipose layer, is typically removed during AAM processing. Thus, fascia, which contains numerous important proteins, might cooperate with AAM to stimulate de novo adipogenesis, improving long-term retention compared to AAM alone.

METHODS

Human AAM and fascia matrix proteins (back and upper leg regions) were identified by mass spectrometry and annotated by gene ontology. A three-dimensional in vitro angiogenesis assay was performed. Finally, AAM and/or fascia (1 mL) was implanted into 6- to 8-week-old male Fischer rats. After 8 weeks, the authors assessed graft retention by gas pycnometry and angiogenesis (CD31) and adipocyte counts (hematoxylin and eosin) histologically.

RESULTS

Gene ontology annotation revealed an angiogenic enrichment pattern unique to the fascia, including lactadherin, collagen alpha-3(V) chain, and tenascin-C. In vitro, AAM stimulated 1.0 ± 0.17 angiogenic sprouts per bead. The addition of fascia matrix increased sprouting by 88% (2.0 ± 0.12; P < 0.001). A similar angiogenic response (CD31) was observed in vivo. Graft retention volume was 25% (0.25 ± 0.13) for AAM, significantly increasing to 60% (0.60 ± 0.14) for AAM/fascia ( P < 0.05). De novo adipogenesis was 12% (12.4 ± 7.4) for AAM, significantly increasing to 51% (51.2 ± 8.0) for AAM/fascia ( P < 0.001) by means of adipocyte quantification.

CONCLUSIONS

Combining fascia matrix with AAM improves angiogenesis and adipogenesis compared to AAM alone in rats. These preliminary in vitro and pilot animal studies should be further validated before definitive clinical adoption.

CLINICAL RELEVANCE STATEMENT

When producing an off-the-shelf adipose inducing product by adding a connective tissue fascial component (that is normally discarded) to the mix of adipose matrix, vasculogenesis is increased and, thus, adipogenesis and graft survival is improved. This is a significant advance in this line of product.

Decellularized Adipose Matrices Can Alleviate Radiation-Induced Skin Fibrosis

Objective: Radiation therapy is commonplace for cancer treatment but often results in fibrosis and atrophy of surrounding soft tissue. Decellularized adipose matrices (DAMs) have been reported to improve these soft tissue defects through the promotion of adipogenesis. These matrices are decellularized by a combination of physical, chemical, and enzymatic methods to minimize their immunologic effects while promoting their regenerative effects. In this study, we aimed at exploring the regenerative ability of a DAM (renuva®; MTF biologics, Edison, NJ) in radiation-induced soft tissue injury. Approach: Fresh human lipoaspirate or DAM was injected into the irradiated scalp of CD-1 nude mice, and volume retention was monitored radiographically over 8 weeks. Explanted grafts were histologically assessed, and overlying skin was examined histologically and biomechanically. Irradiated human skin was also evaluated from patients after fat grafting or DAM injection. However, integrating data between murine and human skin in all cohorts is limited given the genetic variability between the two species. Results: Volume retention was found to be greater with fat grafts, though DAM retention was, nonetheless, appreciated at irradiated sites. Improvement in both mouse and human irradiated skin overlying fat and DAM grafts was observed in terms of biomechanical stiffness, dermal thickness, collagen density, collagen fiber networks, and skin vascularity. Innovation: This is the first demonstration of the use of DAMs for augmenting the regenerative potential of irradiated mouse and human skin. Conclusions: These findings support the use of DAMs to address soft tissue atrophy after radiation therapy. Morphological characteristics of the irradiated skin can also be improved with DAM grafting.

Inflammation-mediated matrix remodeling of extracellular matrix-mimicking biomaterials in tissue engineering and regenerative medicine

Extracellular matrix (ECM)-mimicking biomaterials are considered effective tissue-engineered scaffolds for regenerative medicine because of their biocompatibility, biodegradability, and bioactivity. ECM-mimicking biomaterials preserve natural microstructures and matrix-related bioactive components and undergo continuous matrix remodeling upon transplantation. The interaction between host immune cells and transplanted ECM-mimicking biomaterials has attracted considerable attention in recent years. Transplantation of biomaterials may initiate injuries and early pro-inflammation reactions characterized by infiltration of neutrophils and M1 macrophages. Pro-inflammation reactions may lead to degradation of the transplanted biomaterial and drive the matrix into a fetal-like state. ECM degradation leads to the release of matrix-related bioactive components that act as signals for cell migration, proliferation, and differentiation. In late stages, pro-inflammatory cells fade away, and anti-inflammatory cells emerge, which involves macrophage polarization to the M2 phenotype and leukocyte activation to T helper 2 (Th2) cells. These anti-inflammatory cells interact with each other to facilitate matrix deposition and tissue reconstruction. Deposited ECM molecules serve as vital components of the mature tissue and influence tissue homeostasis. However, dysregulation of matrix remodeling results in several pathological conditions, such as aggressive inflammation, difficult healing, and non-functional fibrosis. In this review, we summarize the characteristics of inflammatory responses in matrix remodeling after transplantation of ECM-mimicking biomaterials. Additionally, we discuss the intrinsic linkages between matrix remodeling and tissue regeneration. STATEMENT OF SIGNIFICANCE: Extracellular matrix (ECM)-mimicking biomaterials are effectively used as scaffolds in tissue engineering and regenerative medicine. However, dysregulation of matrix remodeling can cause various pathological conditions. Here, the review describes the characteristics of inflammatory responses in matrix remodeling after transplantation of ECM-mimicking biomaterials. Additionally, we discuss the intrinsic linkages between matrix remodeling and tissue regeneration. We believe that understanding host immune responses to matrix remodeling of transplanted biomaterials is important for directing effective tissue regeneration of ECM-mimicking biomaterials. Considering the close relationship between immune response and matrix remodeling results, we highlight the need for studies of the effects of clinical characteristics on matrix remodeling of transplanted biomaterials.

Research Progress on the Immunogenicity and Regeneration of Acellular Adipose Matrix: A Mini Review

Acellular adipose matrix (AAM) has received increasing attention for soft tissue reconstruction, due to its abundant source, high long-term retention rate and in vivo adipogenic induction ability. However, the current decellularization methods inevitably affect native extracellular matrix (ECM) properties, and the residual antigens can trigger adverse immune reactions after transplantation. The behavior of host inflammatory cells mainly decides the regeneration of AAM after transplantation. In this review, recent knowledge of inflammatory cells for acellular matrix regeneration will be discussed. These advancements will inform further development of AAM products with better properties.

An immunologically active, adipose-derived extracellular matrix biomaterial for soft tissue reconstruction: concept to clinical trial

Soft tissue reconstruction remains an intractable clinical challenge as current surgical options and synthetic implants may produce inadequate outcomes. Soft tissue deficits may be surgically reconstructed using autologous adipose tissue, but these procedures can lead to donor site morbidity, require multiple procedures, and have highly variable outcomes. To address this clinical need, we developed an "off-the-shelf" adipose extracellular matrix (ECM) biomaterial from allograft human tissue (Acellular Adipose Tissue, AAT). We applied physical and chemical processing methods to remove lipids and create an injectable matrix that mimicked the properties of lipoaspirate. Biological activity was assessed using cell migration and adipogenesis assays. Characterization of regenerative immune properties in a murine muscle injury model revealed that allograft and xenograft AAT induced pro-regenerative CD4⁺ T cells and macrophages with xenograft AAT additionally attracting eosinophils secreting interleukin 4 (Il4). In immunocompromised mice, AAT injections retained similar volumes as human fat grafts but lacked cysts and calcifications seen in the fat grafts. The combination of AAT with human adipose-derived stem cells (ASCs) resulted in lower implant volumes. However, tissue remodeling and adipogenesis increased significantly in combination with ASCs. Larger injected volumes of porcine-derived AAT demonstrated biocompatibility and greater retention when applied allogeneicly in Yorkshire cross pigs. AAT was implanted in healthy volunteers in abdominal tissue that was later removed by elective procedures. AAT implants were well tolerated in all human subjects. Implants removed between 1 and 18 weeks demonstrated increasing cellular infiltration and immune populations, suggesting continued tissue remodeling and the potential for long-term tissue replacement.

The Emerging Field of Regenerative Aesthetics-Where We Are Now

BACKGROUND

Regenerative aesthetics is an emerging branch of regenerative medicine with therapies aimed at recapturing youthful structure and function using the body's own systems.

OBJECTIVE

To introduce the field of regenerative aesthetics, and to explore themes and evidence surrounding current and emerging therapies in the field.

MATERIALS AND METHODS

A review of the literature was performed for each of the 3 pillars of regeneration; namely, stem cells, biochemical cues, and scaffolds.

RESULTS

Herein, we provide an overview of the field of regenerative aesthetics, a discussion surrounding the 3 pillars of regeneration, and an overview of the evidence supporting current and emerging therapeutic modalities that could play a pivotal role in the future of aesthetic treatments.

CONCLUSION

An enhanced understanding of this field can serve to further enhance our awareness about the regenerative effects of therapies we already offer, in addition to providing inspiration for future innovation.

The role of a shelf-ready, human-derived, soft tissue injectable adipose matrix for facial volume correction

BACKGROUND

Synthetic soft tissue fillers frequently used to restore facial volume do not provide a regenerative framework, limiting their sustained efficacy. Autologous fat transfer for facial rejuvenation supports tissue regeneration but has unpredictable outcomes depending on the quality of harvesting, processing, and implantation.

AIMS

Exploration of the pros and cons of available tissue fillers and the role of an injectable Allograft Adipose Matrix (AAM) for facial rejuvenation.

METHODS

The results of a literature review conducted by two clinicians with extensive experience in this field were discussed by a panel of dermatologists and surgeons who regularly treat patients with signs and symptoms of facial aging. A manuscript was prepared and reviewed by the panel taking into account the evidence and their clinical experience treating patients for facial rejuvenation.

RESULTS

Facial rejuvenation needs to address the volume deficiency and repositioning of ptotic soft tissues. Frequently used synthetic fillers are suitable candidates for improving the facial appearance of fine lines and for molding. A better understanding of facial volume loss has allowed the use of adipose fat cells for facial rejuvenation. The injectable AAM is readily available and provides a regenerative framework for sustainable results. Prospective clinical and randomized studies support the effective and safe use of AAM for facial rejuvenation.

CONCLUSION

AAM may offer an alternative to synthetic fillers and autologous fat implantation in the face without the cumbersome process of fat harvesting and processing. More robust studies are to confirm the positive results obtained in smaller studies using the soft tissue bio stimulatory injectable.