Systematic review: Impact of stem cells-based therapy, and platelet-rich plasma in hair loss and telogen effluvium related to COVID-19

Background

The incidence of hair loss (HL) and telogen effluvium (TE) in COVID-19 patients has been reported in several studies.

Objectives

Evaluate both the increased incidence of HL and TE in COVID-19 and the effectiveness of Platelet-Rich Plasma (PRP), Adipose-derived Mesenchymal Stem Cells (AD-MSCs), and Human Follicle Stem Cells (HFSCs) in these patients.

Methods

The protocol was developed by the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. A multistep search of PubMed, MEDLINE, Embase, Clinicaltrials. gov, Scopus, and Cochrane databases has been performed to identify papers focusing on HL and TE COVID-19 related, and papers focusing on AD-MSCs, HFSC, and PRP use.

Results

Of the 404 articles initially identified focusing on HL and TE, 44 were related to COVID-19, and finally, only 6 were analyzed. On the other way, 331 articles focusing on AD-MSCs, HFSC, and PRP were initially identified. Of these, only 6 articles PRP (n = 3), AD-MSCs, and HFSCs (n = 3) have been analyzed.

Conclusion

Collected data confirmed both an increased incidence of HL and TE in COVID-19 patients, preliminarily, the related effectiveness of AD-MSCs, HFSCs, and PRP without major side effects.

Lipofilling Enriched with Adipose-Derived Mesenchymal Stem Cells Improves Soft Tissue Deformities and Reduces Scar Pigmentation: Clinical and Instrumental Evaluation in Plastic Surgery

BACKGROUND

Scars and soft tissue deformities (S-STDs), often resulting from hemifacial atrophy, trauma, and outcomes of burns, were usually associated with hyperpigmentation of overlying skin.

OBJECTIVES

This study aimed to evaluate the long-term effects of fat grafting commonly called "Lipofilling" enhanced with adipose-derived mesenchymal stem cells (Lipofilling-AD-MSCs) for treating S-STDs with pigmentary changes.

METHODS

A cohort study has been performed. 50 patients affected by S-STDs with hyperpigmentation treated with Lipofilling-AD-MSCs and 50 patients treated with Lipofilling not enhanced (Lipofilling-NE) were prospectively assessed. The pre-op evaluation included a clinical evaluation, a photographic assessment, magnetic resonance imaging, and ultrasound. Post-op follow-up was performed at 1, 3, 7, 12, 24, 48, weeks, and then annually.

RESULTS

Improvement in volume contours and pigmentation was clinically assessed. All people who underwent the treatments (Lipofilling-AD-MSCs and Lipofilling-NE) were satisfied with the improving pigmentation, texture, and volume contours with some differences. However, the results reported displaying a better trend in patients treated with Lipofilling-AD-MSCs to be more satisfied than patients treated with Lipofilling-NE (p < 0.0001).

CONCLUSIONS

In conclusion, Lipofilling-AD-MSCs was the preferred option for improving the contour deformities related to increased pigmentation of scars.

LEVEL OF EVIDENCE IV

Evidence obtained from cohort studies.

Mechanical and Enzymatic Digestion of Autologous Fat Grafting (A-FG): Fat Volume Maintenance and AD-SVFs Amount in Comparison

BACKGROUND

Currently, several techniques for autologous fat graft (A-FG) preparation aimed at obtaining purified tissue exist. Both mechanical digestions via centrifugation, filtration, and enzymatic digestion were considered the most effective with different impacts in terms of adult adipose-derived stromal vascular fraction cells (AD-SVFs) amount that volume maintenance.

OBJECTIVES

This article aimed to report the in vivo and in vitro results, represented by fat volume maintenance and AD-SVFs amount, obtained by four different procedures of AD-SVFs isolation and A-FG purification based on centrifugation, filtration, centrifugation with filtration, and enzymatic digestion.

METHODS

A prospective, case-control study was conducted. In total, 80 patients affected by face and breast soft tissue defects were treated with A-FG and divided into four groups: n=20 were treated with A-FG enhanced with AD-SVFs obtained by enzymatic digestion (study group 1 [SG-1]); n=20 were treated with A-FG enhanced with AD-SVFs obtained by centrifugation with filtration (SG-2); n=20 were treated with A-FG enhanced with AD-SVFs obtained by only filtration (SG-3); n=20 were treated with A-FG obtained by only centrifugation according to the Coleman technique (control group [CG]). Twelve months after the last A-FG session, the volume maintenance percentage was analyzed by magnetic resonance imaging (MRI). Isolated AD-SVF populations were counted using a hemocytometer, and cell yield was reported as cell number/mL of fat.

RESULTS

Starting with the same amount of fat analyzed (20 mL), 50,000 ± 6956 AD-SVFs/mL were obtained in SG-1; 30,250 ± 5100 AD-SVFs/mL in SG-2; 33.333 ± 5650 AD-SVFs/mL in SG-3, while 500 AD-SVFs/mL were obtained in CG. In patients treated with A-FG enhanced with AD-SVFs obtained by automatic enzymatic digestion, a 63% ± 6.2% maintenance of fat volume restoring after 1 year was observed compared with 52% ± 4.6% using centrifugation with filtration, 39% ± 4.4% using only centrifugation (Coleman), and 60% ± 5.0% using only filtration.

CONCLUSIONS

In vitro AD-SVFs cell analysis indicated that filtration was the most efficient system-between mechanical digestion procedures-thanks to the highest amount of cells obtained with fewer cell structure damage, producing in vivo, the most volume maintenance after 1 year. Enzymatic digestion produced the best number of AD-SVFs and the best fat volume maintenance.

LEVEL OF EVIDENCE III

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 http://www.springer.com/00266 .

Tuberous Breast, Deformities, and Asymmetries: A Retrospective Analysis Comparing Fat Grafting Versus Mastopexy and Breast Implants

BACKGROUND

The tuberous breast is considered a breast deformity characterized by varying degrees of herniation of the parenchyma, widened nipple-areolar complex (NAC), absence of the lower quadrants, and may involve several degrees of hypoplasia and asymmetry causing significant psychosocial distress.

OBJECTIVES

The paper aimed to compare the results obtained in patients suffering tuberous breast treated with fat grafting (FG), with those of patients treated with a mastopexy and silicone implants (M-SI) also analyzing the influence of breast and chest deformities (degrees of hypoplasia and tuberous breast, volume and NAC asymmetry, pectus excavatum, and carinatum) in the reconstructive outcomes.

METHODS

A retrospective, case-control study was conducted. Thirty-five patients affected by tuberous breast with several degrees of hypoplasia and asymmetry were treated with FG, comparing results with those of 30 patients treated with M-SI. Postoperative follow-up took place at 1, 3, 7, 12, 24, 48, weeks, and then annually for 2 years.

RESULTS

77% (n = 27) of patients treated with two FG procedures showed excellent results after 1 year compared with the patients treated with only one M-SI procedure, who showed the same results in 73% (n = 22) of cases, but the naturalness and the satisfaction degree in the FG group were higher than that in the M-SI group (p < .0001 vs. M-SI group).

CONCLUSIONS

Patients treated with FG showed natural breasts without scars and excellent cosmetic results after two procedures. Patients treated with M-SI showed more evident and lasting results after only one procedure, presenting though scars and less natural results.

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.

Reply to "Letter on Rhinofiller: Fat Grafting (Surgical) Versus Hyaluronic Acid (Non-surgical)"

Level of Evidence V 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 .

Preliminary Investigation on Micro-Needling with Low-Level LED Therapy and Growth Factors in Hair Loss Related to COVID-19

The incidence of hair loss (HL) and telogen effluvium (TE) has increased due to the spread of the coronavirus disease (COVID-19) induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). New biotechnologies based on micro-needling (MND) with Low-Level LED Therapy (LLLT) and Growth Factors (GFs) used for hair re-growth (HR-G) in Androgenetic Alopecia (AGA) need to be standardized also in HL and TE related to COVID-19. This article aims to describe the preliminary clinical results obtained from an open-label case-series observational study. MND with LLLT and GFs was used in patients affected by HL and TE-related to COVID-19. In total, 10 patients (6 men were identified in stage I–III vertex according to the Norwood–Hamilton scale, and 4 women were identified in stage I–II according to the Ludwig scale) were enrolled and analyzed after screening (exclusion and inclusion criteria evaluation). HR-G assessment was analyzed through photography, physician’s and patient’s global assessment scale, and standardized phototrichograms during a short follow-up: T0—baseline; T1—20 weeks (wks). In the targeted area computerized trichograms showed encouraging results with a hair density increase of 11 ± 2 hairs/cm2 at T1 after 20 wks (20 wks vs. 0 wks) compared with baseline (58 ± 2 hairs/cm2 at T1 versus 47 ± 2 hairs/cm2 at baseline) with a not quite statistically significant difference in HR-G (p = 0.0690). The preliminary effectiveness of MND with LLLT and GFs use has been demonstrated in mild-to-moderate HL and TE related to COVID-19. Further controlled trials are required to confirm these preliminary results.

Systematic review: The platelet-rich plasma use in female androgenetic alopecia as effective autologous treatment of regenerative plastic surgery

BACKGROUND

The number of clinical trials evaluating platelet-rich plasma (PRP) efficacy in female androgenetic alopecia (F-AGA) has exponentially increased during the last five years. A systematic review focused on this specific field has been performed by assessing the local infiltrations of PRP compared with any control for F-AGA in the selected studies.

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of the use of PRP in F-AGA.

METHODS

The protocol was developed in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. A multistep search of PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov, Scopus database, and Cochrane databases has been performed to identify papers on female pattern hair loss (FPHL) treatment with PRP. Of the 63 articles initially identified, 11 articles focusing on AGA were selected and, consequently, only 5 articles focused exclusively on F-AGA were analyzed. Of this amount, 3 articles were randomized-controlled trials (RCTs), 1 clinical trial, and 1 double-blind placebo-controlled pilot study (DBPCPS). The studies included had to match predetermined criteria according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach.

RESULTS

Eight percent of the articles selected and analyzed, reported a positive effect of PRP for F-AGA treatment. The information analyzed highlights the positive effects of PRP on F-AGA, without major side effects and thus, it may be considered as a safe and effective alternative procedure to treat hair loss compared with traditional drugs as Minoxidil® and Finasteride®.

CONCLUSIONS

The use of PRP in F-AGA was safe and effective for F-AGA.

Breast Silicone Gel Implants versus Autologous Fat Grafting: Biomaterials and Bioactive Materials in Comparison

In the last 20 years, surgical procedures in breast remodeling during mammoplasty have been deeply modified with a gradual shifting from an invasive intervention using definitive implants (DIs) to a more conservative autologous fat grafting (AFG). AFG has been used for many years as bioactive material through the Lipofilling technique and as a bioactive scaffold when it was enriched with adipose-derived stem cells (ASCs), while DIs have been considered physiologically inert biomaterials with low toxicity. The paper aimed to compare the breast remodeling results obtained in the DI group (55 patients) for hypoplasia correction with those of the ASC-enhanced AFG group (50 patients), also analyzing the influence of breast and chest deformities (tuberous breast, volume, and nipple–areola complex asymmetry, pectus excavatum and carinatum) in the cosmetic outcome. A retrospective, case-control study was conducted. The pre-operative analysis was performed with an accurate clinical evaluation, a photographic assessment, and an instrumental evaluation based on magnetic resonance imaging, mammography, and ultrasound. Of patients treated with DIs 89% (n = 49) showed excellent cosmetic results after 1 year compared with the patients treated with AFG, who showed the same results in 64% (n = 32) of cases. The naturalness of the results in the AFG group was higher than that in the DI group (p < 0.0001 vs. DI group). DIs and AFG were safe and effective in this case series treated. The AFG group showed more natural results, allowing the treatment of patients with pectus excavatum, while DIs showed the more evident and lasting result.

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.

Titanium-coated polypropylene mesh as innovative bioactive material in conservatives mastectomies and pre-pectoral breast reconstruction

Breast reconstruction is rapidly evolving, thanks to the growing acceptance of synthetic meshes as innovative biomaterials. 276 patients undergoing mastectomy (total of 328 mastectomies) were analyzed in a retrospective observational study to evaluate the pre-pectoral immediate breast reconstruction (IBR) using an implant wrapped with Titanium-Coated Polypropylene Mesh (TCPM) vs. patients treated with tissue expander (TE), equally placed pre-pectorally (and wrapped with the same TCPM in 74.3% of the control group’ breasts). 163 patients, of the study group (SG), underwent mastectomy and pre-pectoral IBR with implant wrapped with TCPM, in a one-step surgery, called direct-to-implant technique (DTI), while 113 patients control group (CG) underwent mastectomy and TE. DTI technique has been performed in 192 breasts of the SG while TE procedure in 136 breasts of the CG. The BREAST-Q questionnaire has been provided before the treatment and 2 years later. Baker scale has been used to evaluate capsular contracture. Oncologic, surgical, and aesthetic outcomes along with BREAST-Q scores were analyzed. Additionally, a histologic evaluation was conducted in 11 capsules' samples randomly chosen (6 derived from SG patients and 5 derived from CG). Complications were recorded in 43 cases (29SG-14CG): 8 skin-nipple necrosis (5SG-3CG), 8 wound dehiscence (6SG-2CG), 3 hematomas (1SG-2CG), and 24 infections (8SG-16CG). Grade IV capsular contracture was detected in 9 breasts (1SG-8CG), whereas 254 breasts were grade I (110SG-144CG), 33 (10SG-23CG) grade II, and 32 (4SG-28CG) grade III. Implant wrinkling was detected in 18 cases (10SG-8CG) after 30 months. The local tumor recurrence rate was 5.8%. Three recurrences were on the nipple-areola complex (1.9%). SG patients showed significantly higher rates in the BREAST-Q overall Satisfaction with Outcome (74.1), overall Satisfaction with Breasts (69.1), Psychosocial Well-being (81.9), and Sexual Well-being (63.1), versus CG's patients (p < 0.05). Histological analysis showed a process of normal tissue repair with a complete mesh integration and normal healing. Conservative mastectomies with pre-pectoral IBR assisted by TCPM proved themselves oncologically safe, biologically integrated into native tissues, and highly accepted in terms of quality of life guaranteeing a more natural and aesthetic breast appearance.

Core tip

This retrospective observational study provided clinical and histological outcomes of the pre-pectoral IBR using an implant wrapped with TCPM vs. patients treated with TE, equally placed pre-pectorally. The efficacy of IBR using an implant wrapped with TCPM was confirmed by the cosmetic results obtained and by a rate of side effects comparable to TE. All the histological analyses performed confirmed the TCPM mesh complete integration with the physiological aspects of healing: The Collagen 1 and 3 expressions did not differ, between TCPM and NO TCPM samples to confirm a process of healing overlapping to perfect device incorporation and normal healing.

•

This retrospective observational study, reports the results of pre-pectoral immediate breast reconstruction (IBR) using a prosthesis wrapped with Titanium-Coated Polypropylene Mesh (TCPM) vs. patients treated with tissue expander (TE) equally placed pre-pectorally (and wrapped with the same TCPM in 74% of the control group), with the aim to reduce the risk of reconstruction failure after conservative mastectomy.

•

The primary end-points of the study were the clinical outcomes. These outcomes were: the incidence of perioperative and postoperative complications (safety profile), quality of life (QoL) at 2 years after surgery, measured as the change between the pre- and post-op BREAST-Q scores, the aesthetic outcomes, and the capsular contracture grade. Two methods for the clinical analysis of the results have been used: Surgical-Team and patient self-evaluation. The Surgical-team evaluation was an objective evaluation based on clinical assessment, using a scale of six degrees (excellent, good, discreet, enough, poor, inadequate). The subjective patient-based self-evaluation applied the same six degrees. Moreover, secondary end-point of the study, was a histopathological capsule assessment to evaluate the integration of the TCPM in the mastectomy flap as a bioactive material.

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Histological, and bio-molecular evaluation of TCPM samples were analyzed. In particular, Hematoxylin-eosin staining of post-operative biopsies of wrapping tissue TCPM mesh was performed focusing on the collagen presence and fibroblasts amount and specifically, on the complete healing and TCPM incorporation without side effects. Additionally, the immunofluorescence using specific markers CD 45 and Collagen 1, and immunohistochemistry using CD 45 on paraffin samples were performed. The endpoint was to evaluate the grade of inflammation represented by the number of lymphocytes in the treated site, and the eventual different collagen type expression (Collagen 1 and Collagen 3) in tissues underwent and not to radiotherapy and during the use of TCPM.

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Analyzing the side effects with the use of t-test, the complication rate between SG and CG did not showed statistically significant differences (p=0,8472), although it was slightly higher in the SG. Despite the study group was bigger than the control group (+42%) the side effects' number did not statistically differ, confirming the safety and reliability of the TCPM procedure during DTI. Overall Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being scores were all significantly increased after sub-cutaneous pre-pectoral DTI immediate reconstruction with TCPM mesh (p < 0.05) compared to CG. Mean satisfaction with the overall aesthetic result was high after breast reconstruction (8.72) in patients who underwent DTI pre-pectoral immediate reconstruction (SG) after 2 years from surgery.

•

The histological analysis of fragments of implant's wrapping tissue incorporating TCPM mesh displayed complete incorporation of the mesh with physiological aspects of healing. The immunochemistry concluded the Collagen 1, and 3 expressions did not differ, with statistical significance, between TCPM and NO TCPM samples, showing a process of physiological healing overlapping to perfect device incorporation, confirming that TCPM was a bioactive material. Conservative mastectomies with pre-pectoral IBR assisted by TCPM are resulted oncologically safe preserving breast appearance.

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.

Malignant Skin Cancer Excision in Combined Therapy with Electro-Chemotherapy and Dermal Substitute

Squamous cell carcinoma (SCC) is the second most common malignancy skin cancer. It is characterized by abnormal, accelerated growth of squamous cells (SCs). SCC occurs when DNA damage from exposure to ultraviolet radiation or other damaging agents trigger abnormal changes in the SCs, presenting as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. For most skin SCC, the surgical excision alone is standard practice. However, recent efforts in new treatment strategies have involved around adjuvant or concomitant electrochemotherapy (ECT). ECT is a non-thermal tumor ablation modality, safe and effective on any type of solid tumor. An 87-year-old patient affected by hand SCC with invasion of deep structures including tendons was treated with neoadjuvant intra-tumoral ECT sessions followed by a selective surgical removal and reconstruction of the substance loss with collagen dermal template (CDT). Two neoadjuvant intra-tumoral ECT procedures, at distance of 3 months, with the aim to reduce the tumor size before a selective surgery, were performed. This study shows that combined surgical selective excision with ECT and CDT is a valid technique for the extended-deep dorsal hand tumor lesions reconstruction.

SARS-CoV-2: the "Uncensored" Truth about Its Origin and Adipose-Derived Mesenchymal Stem Cells as New Potential Immune-Modulatory Weapon

In this second return of the pandemic, January 2021, it appears to be clear that a Nano-sized organism, the SARS-CoV-2, has rendered the human race helpless, made the global health status decline, and drowned the world economy. However, it does not appear clear the real origin of the SARS-CoV-2 and the aim of this work is to report and discuss, maybe for the first time since the pandemic began, the scientific data published in this specific field, analyzing the potentially available weapons against the SARS-CoV-2. About this last point, a ray of hope comes from the potential of Mesenchymal Stem Cells (MSCs) that has already been established in Coronavirus Disease 2019 (COVID-19), and in particular from the Adipose-Derived Mesenchymal Stem Cells (AD-MSCs). However, cell-based therapy has its own limits, especially represented by the know-how in this field and by the rules of applications. It was suggested a biological therapy using AD-MSCs as a weapon against COVID-19, as they can be a game-changer owing to their immuno-modulatory nature, which combats the cytokine storm characterizing this disease, and their practical efficiency, which will realistically aid large access to therapy worldwide.

Systematic Review: Adipose-Derived Mesenchymal Stem Cells, Platelet-Rich Plasma and Biomaterials as New Regenerative Strategies in Chronic Skin Wounds and Soft Tissue Defects

The number of clinical trials evaluating adipose-derived mesenchymal stem cells (AD-MSCs), platelet-rich plasma (PRP), and biomaterials efficacy in regenerative plastic surgery has exponentially increased during the last ten years. AD-MSCs are easily accessible from various fat depots and show intrinsic plasticity in giving rise to cell types involved in wound healing and angiogenesis. AD-MSCs have been used in the treatment of soft tissue defects and chronic wounds, employed in conjunction with a fat grafting technique or with dermal substitute scaffolds and platelet-rich plasma. In this systematic review, an overview of the current knowledge on this topic has been provided, based on existing studies and the authors’ experience. 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, PRP, and biomaterials used in soft tissue defects and chronic wounds. Of the 2136 articles initially identified, 422 articles focusing on regenerative strategies in wound healing were selected and, consequently, only 278 articles apparently related to AD-MSC, PRP, and biomaterials were initially assessed for eligibility. Of these, 85 articles were excluded as pre-clinical, experimental, and in vitro studies. For the above-mentioned reasons, 193 articles were selected; of this amount, 121 letters, expert opinions, commentary, and editorials were removed. The remaining 72 articles, strictly regarding the use of AD-MSCs, PRP, and biomaterials in chronic skin wounds and soft tissue defects, were analyzed. The studies included had to match predetermined criteria according to the patients, intervention, comparator, outcomes, and study design (PICOS) approach. The information analyzed highlights the safety and efficacy of AD-MSCs, PRP, and biomaterials on soft tissue defects and chronic wounds, without major side effects.

Silver Sulfadiazine Eradicates Antibiotic-Tolerant Staphylococcus aureus and Pseudomonas aeruginosa Biofilms in Patients with Infected Diabetic Foot Ulcers

Infections are among the most frequent and challenging events in diabetic foot ulcers (DFUs). Pathogenic bacteria growing in biofilms within host tissue are highly tolerant to environmental and chemical agents, including antibiotics. The present study was aimed at assessing the use of silver sulfadiazine (SSD) for wound healing and infection control in 16 patients with DFUs harboring biofilm-growing Staphylococcus aureus and Pseudomonas aeruginosa. All patients received a treatment based on a dressing protocol including disinfection, cleansing, application of SSD, and application of nonadherent gauze, followed by sterile gauze and tibio-breech bandage, in preparation for toilet surgery after 30 days of treatment. Clinical parameters were analyzed by the T.I.M.E. classification system. In addition, the activity of SSD against biofilm-growing S. aureus and P. aeruginosa isolates was assessed in vitro. A total of 16 patients with S. aureus and P. aeruginosa infected DFUs were included in the study. Clinical data showed a statistically significant (p < 0.002) improvement of patients’ DFUs after 30 days of treatment with SSD with significant amelioration of all the parameters analyzed. Notably, after 30 days of treatment, resolution of infection was observed in all DFUs. In vitro analysis showed that both S. aureus and P. aeruginosa isolates developed complex and highly structured biofilms. Antibiotic susceptibility profiles indicated that biofilm cultures were significantly (p ≤ 0.002) more tolerant to all tested antimicrobials than their planktonic counterparts. However, SSD was found to be effective against fully developed biofilms of both S. aureus and P. aeruginosa at concentrations below those normally used in clinical preparations (10 mg/mL). These results strongly suggest that the topical administration of SSD may represent an effective alternative to conventional antibiotics for the successful treatment of DFUs infected by biofilm-growing S. aureus and P. aeruginosa.

Research progress on Mesenchymal Stem Cells (MSCs), Adipose-Derived Mesenchymal Stem Cells (AD-MSCs), Drugs, and Vaccines in Inhibiting COVID-19 Disease

Mesenchymal Stem Cells (MSCs), and Adipose-Derived Mesenchymal Stem Cells (AD-MSCs) have been used for many years in regenerative medicine for clinical and surgical applications. Additionally, recent studies reported improved respiratory activity after intravenous administration of MSCs into patients affected by coronavirus disease 2019 (COVID-19) caused by the Coronavirus 2 (SARS-CoV-2) suggesting their role as anti-viral therapy. Severe COVID-19 patients usually progress to acute respiratory distress syndrome, sepsis, metabolic acidosis that is difficult to correct, coagulation dysfunction, multiple organ failure, and even death in a short period after onset. Currently, there is still a lack of clinically effective drugs for such patients. The high secretory activity, the immune-modulatory effect, and the homing ability make MSCs and in particular AD-MSCs both a potential tool for the anti-viral drug-delivery in the virus microenvironment and potential cellular therapy. AD-MSCs as the most important exponent of MSCs are expected to reduce the risk of complications and death of patients due to their strong anti-inflammatory and immune-modulatory capabilities, which can improve microenvironment, promote neovascularization and enhance tissue repair capabilities. In this literature review, the role of regenerative strategies through MSCs, AD-MSCs, and adipocyte-secreted exosomal microRNAs (A-SE-miRs) as a potential antiviral therapy was reported, comparing the results found with current research progress on drugs and vaccines in COVID-19 disease.

Regenerative application of stromal vascular fraction cells enhanced fat graft maintenance: clinical assessment in face rejuvenation

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of the use of FG-SVFs in face rejuvenation for esthetic improvement.

METHODS

33 female patients affected by face's soft-tissue defects with loss of volume, study group (SG), were treated with FG-SVFs, comparing results with a control group (CG) (n = 30) treated with fat graft not enhanced (FG). Clinical evaluation, a photographic assessment, magnetic resonance imaging (MRI), and ultrasound (US) were performed. Post-operative follow-up was performed at 1, 3, 7, 12, 24, 48, weeks, and then annually.

RESULTS

SG patients showed 61% maintenance of the contour restoring and of volume after 3 years compared with the CG treated with FG, who showed 31% maintenance. 60.7% (n = 20) of SG patients, presented an increase of 6.6 mm in the soft tissue volume after 36 months, which was reported in only 33,3% (n = 10) of the CG. Volumetric persistence in the SG was higher than that in the CG (p <. 0001 vs. CG). MRI and US moreover confirmed the absence of important side effects, as fat necrosis, and cytosteatonecrotic areas.

CONCLUSIONS

The use of FG-SVFs was safe and effective in this series of a case treated.

Fat Graft Enhanced With Adipose-Derived Stem Cells in Aesthetic Breast Augmentation: Clinical, Histological, and Instrumental Evaluation

BACKGROUND

Fat graft enhanced with adipose-derived stem cells (FG-e-ASCs) has been utilized in outcomes of radiotherapy after mastectomy, breast soft tissue defects, ulcers, and loss of substance. The authors present their experience utilizing FG-e-ASCs in breast augmentation.

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of a study group (SG) regarding utilization of FG-e-ASCs in breast augmentation for aesthetic improvement, comparing the results with a control group (CG).

METHODS

A total of 46 patients affected by breast hypoplasia were treated with FG-e-ASCs, comparing results with those of a CG (n = 30) treated with fat graft not enhanced with adipose-derived stem cells (FG-ne-ASCs). The preoperative evaluation included a complete clinical evaluation, a photographic assessment, magnetic resonance imaging of the soft tissue, ultrasound, and mammography. Postoperative follow-up took place at 1, 3, 7, 12, 24, and 48 weeks and then annually.

RESULTS

The patients treated with FG-e-ASCs showed 58% maintenance of the contour restoring and of 3-dimensional (3D) volume after 3 years compared with the patients of the CG treated with FG-ne-ASCs, who showed 29% maintenance. In 67.4% (n = 31) of breast augmentations treated with FG-e-ASCs, we observed a restoration of the breast contour and an increase of 10.3 mm in the 3D volume after 36 months, which was observed in only 20.0% (n = 6) of patients in the CG treated with FG-ne-ASCs. Volumetric persistence in the SG was higher than that in the CG (P < 0.0001 SG vs CG).

CONCLUSIONS

Utilization of FG-e-ASCs was safe and effective in this series of cases performed.

LEVEL OF EVIDENCE: 4

Systematic Review-The Potential Implications of Different Platelet-Rich Plasma (PRP) Concentrations in Regenerative Medicine for Tissue Repair. Int J Mol Sci. 2020;21. [PMID: 32784862 PMCID: PMC7460839 DOI: 10.3390/ijms21165702]

The number of studies evaluating platelet-rich plasma (PRP) concentration has substantially grown in the last fifteen years. A systematic review on this field has been realized by evaluating in the identified studies the in vitro PRP concentration—also analyzing the platelet amount—and the in vivo PRP effects in tissue regeneration compared to any control. The protocol has been developed in agreement with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. Multistep research of the PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov, Scopus database and Cochrane databases has permitted to identify articles on different concentrations of PRP in vitro and related in vivo impact for tissue repair. Of the 965 articles initially identified, 30 articles focusing on PRP concentration have been selected and, consequently, only 15 articles have been analyzed. In total, 40% (n = 6) of the studies were related to the fixed PRP Concentration Group used a fixed PRP concentration and altered the platelet concentration by adding the different volumes of the PRP (lysate) to the culture. This technique led to a substantial decrease in nutrition available at higher concentrations. Sixty percent (n = 9) of the studies were related to the fixed PRP Volume Group that used a fixed PRP-to-media ratio (Vol/Vol) throughout the experiment and altered the concentration within the PRP volume. For both groups, when the volume of medium (nutrition) decreases, a lower rate of cell proliferation is observed. A PRP concentration of 1.0 × 10⁶ plt/μL, appears to be optimal thanks to the constant and plentiful capillary nutrition supply and rapid diffusion of growth factors that happen in vivo and it also respects the blood decree-law. The PRP/media ratio should provide a sufficient nutrition supply to prevent cellular starvation, that is, PRP ≤ 10% (Vol/Vol) and thus best mimic the conditions in vivo.

A randomized blinded retrospective study: the combined use of micro-needling technique, low-level laser therapy and autologous non-activated platelet-rich plasma improves hair re-growth in patients with androgenic alopecia

INTRODUCTION

Mini-invasive therapies based on autologous non-activated Platelet-Rich Plasma (ANA-PRP), Low-Level Laser Therapy (LLL-T), and Micro-Needling Technique (MN-T) used in combining for hair re-growth need to be standardized.

OBJECTIVES

The work aims to show in vivo outcomes resulted from retrospective case-series study in which ANA-PRP + MN-T + LLL-T were used in combined in patients affected by Androgenic alopecia.

METHODS

23 patients were treated, of which 13 males were classified in stage I-V by the Norwood-Hamilton scale, and 10 females were classified in stage I-III by the Ludwig scale. Assessment of hair re-growth was evaluated with photography, physician's and patient's global assessment scale, and standardized phototrichograms during a follow-up: T0 - baseline, T1 - 12 weeks, T2 - 23 weeks, T3 - 44 weeks, T4 - 58 weeks.

RESULTS

Interesting outcomes represented by a hair density increase of 81 ± 5 hairs/cm² and 57 ± 7 hairs/cm² respectively at T1 and T2 compared with baseline (173 ± 5 hairs/cm² at T1 and 149 ± 9 hairs/cm² at T2 versus 92 ± 2 hairs/cm² at baseline) were observed using computerized trichograms.

EXPERT OPINION

The main limitation in the autologous regenerative therapies and biotechnologies in hair-regrowth is the extreme variability of PRP products used, in the absence of standardized protocols and widely shared. Appropriate PRP preparations have to be pick after carefully thinking about their bio-molecular specifications and intended indications for use in patients. This approach will aid in matching the optimal PRP product to specific patient factors, leading to improved outcomes and the elucidation of the cost-effectiveness of this treatment. The combined use of biotechnologies as the association of PRP with micro-needling and low-level laser therapy may improve the results in terms of hair count and hair density compared with those obtained by alone PRP. All the procedures must be performed in the full respect of international and local rules.

CONCLUSIONS

The effect of the combined use of MN-T, LLL-T, and ANA-PRP has been demonstrated.

Systematic Review: Allogenic Use of Stromal Vascular Fraction (SVF) and Decellularized Extracellular Matrices (ECM) as Advanced Therapy Medicinal Products (ATMP) in Tissue Regeneration

Stromal vascular fraction (SVF) containing adipose stem cells (ASCs) has been used for many years in regenerative plastic surgery for autologous applications, without any focus on their potential allogenic role. Allogenic SVF transplants could be based on the possibility to use decellularized extracellular matrix (ECM) as a scaffold from a donor then re-cellularized by ASCs of the recipient, in order to develop the advanced therapy medicinal products (ATMP) in fully personalized clinical approaches. A systematic review of this field has been realized in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. Multistep research of the PubMed, Embase, MEDLINE, Pre-MEDLINE, PsycINFO, CINAHL, Clinicaltrials.gov, Scopus database, and Cochrane databases has been conducted to identify articles and investigations on human allogenic ASCs transplant for clinical use. Of the 341 articles identified, 313 were initially assessed for eligibility on the basis of the abstract. Of these, only 29 met all the predetermined criteria for inclusion according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach, and 19 have been included in quantitative synthesis (meta-analysis). Ninety-one percent of the studies previously screened (284 papers) were focused on the in vitro results and pre-clinical experiments. The allogenic use regarded the treatment of perianal fistulas, diabetic foot ulcers, knee osteoarthritis, acute respiratory distress syndrome, refractory rheumatoid arthritis, pediatrics disease, fecal incontinence, ischemic heart disease, autoimmune encephalomyelitis, lateral epicondylitis, and soft tissue defects. The information analyzed suggested the safety and efficacy of allogenic ASCs and ECM transplants without major side effects.

Adipose Stem Cells (ASCs) and Stromal Vascular Fraction (SVF) as a Potential Therapy in Combating (COVID-19)-Disease

A recent and interesting study reported improved respiratory activity after intravenous administration of mesenchymal stem cells (MSCs) into patients affected by coronavirus disease 2019 (COVID-19). These outcomes displayed that intravenous infiltration of MSCs is a safe and efficacy treatment for COVID-19 pneumonia, a severe acute respiratory illness caused by the coronavirus 2 (SARS-CoV-2). Only 7 patients were treated, but with extraordinary results, opening a new strategy in COVID-19 therapy. Currently, no specific therapies against SARS-CoV-2 are available. The MSCs therapy outcomes reported, are striking, as these cells inhibit the over-activation of the immune system, promoting endogenous repair, by improving the lung microenvironment after the SARS-CoV-2 infection. The MSCs could represent an effective, autologous and safe therapy, and therefore, sharing these published results, here is reported the potential use possibilities in COVID-19 of the most common MSCs represented by Adipose Stem Cells (ASCs).

Systematic Review of Platelet-Rich Plasma Use in Androgenetic Alopecia Compared with Minoxidil®, Finasteride®, and Adult Stem Cell-Based Therapy

The number of articles evaluating platelet-rich plasma (PRP) efficacy in androgenic alopecia (AGA) have exponentially increased during the last decade. A systematic review on this field was performed by assessing in the selected studies the local injections of PRP compared to any control for AGA. The protocol was developed in accordance with 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 was performed to identify studies on hair loss treatment with platelet-rich plasma. Of the 163 articles initially identified, 123 articles focusing on AGA were selected and, consequently, only 12 clinical trials were analyzed. The studies included had to match predetermined criteria according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach. In total, 84% of the studies reported a positive effect of PRP for AGA treatment. Among them, 50% of the studies demonstrated a statistically significant improvement using objective measures and 34% of the studies showed hair density and hair thickness improvement, although no p values or statistical analysis was described. In total, 17% of the studies reported greater improvement in lower-grade AGA, while 8% noted increased improvement in higher-grade AGA. Only 17% of the studies reported that PRP was not effective in treating AGA. The information analyzed highlights the positive effects of PRP on AGA, without major side effects and thus it be may considered as a safe and effective alternative procedure to treat hair loss compared with Minoxidil^® and Finasteride^®.

Autologous activated platelet-rich plasma (AA-PRP) and non-activated (A-PRP) in hair growth: a retrospective, blinded, randomized evaluation in androgenetic alopecia

Objectives: A retrospective case-series study comparing autologous activated platelet-rich plasma (AA-PRP) versus autologous non-activated platelet-rich plasma (A-PRP) in hair re-growth was reported.Methods: 90 patients, 63 males showing AGA in stage I-V by the Norwood-Hamilton scale and 27 females with AGA in stage I-III by the Ludwig scale, treated since 2013, were analyzed. 57 patients were treated with A-PRP injections and 33 patients were treated with AA-PRP in three sessions spaced 30 days average. Assessment of hair re-growth was evaluated in different weeks (Ws) after the treatment, summarized in four phases: T0, before the first infusion, T1 - 12 Ws, T2 - 23 Ws, T3 - 44 Ws, T4 - 58 Ws after the last treatment.Results: 12 Ws, 23 Ws, 44 Ws, and 58Ws after the last treatment, hair density measurements for patients treated with A-PRP and AA-PRP were 65 ± 5 and 28 ± 4 hairs/cm2 at T1, 28 ± 2 and 15 ± 3 hairs/cm2 at T2, 25 ± 3 and 14 ± 3 hairs/cm2 at T3, 23 ± 3 and 13 ± 3 hairs/cm² at T4.Conclusion: The effects of A-PRP and AA-PRP in hair re-growth during a long-term follow-up, was demonstrated.

Autologous Micrografts from Scalp Tissue: Trichoscopic and Long-Term Clinical Evaluation in Male and Female Androgenetic Alopecia. Biomed Res Int. 2020;2020:7397162. [PMID: 32071919 PMCID: PMC7007958 DOI: 10.1155/2020/7397162]

Tissue engineering in hair regrowth aims to develop innovative and not-invasive procedures to advance the hair regrowth. A placebo-controlled, randomized, evaluator-blinded, half-head group study to compare hair regrowth with micrografts containing human hair follicle mesenchymal stem cells (HF-MSCs) vs. placebo was reported. After 58 weeks, 27 patients displayed in the targeted area an increase of hair count and hair density, respectively, of 18.0 hairs per 0.65 cm² and 23.3 hairs per cm² compared with baseline, while the control area displayed a mean decrease of 1.1 hairs per 0.65 cm² and 0.7 hairs per cm² (control vs. treatment: P < 0.0001). After 26 months, 6 patients revealed dynamic hair loss and were retreated. More broad controlled examinations are required. HF-MSCs contained in micrografts may represent a safe and viable treatment alternative against hair loss.

Impact of the Different Preparation Methods to Obtain Autologous Non-Activated Platelet-Rich Plasma (A-PRP) and Activated Platelet-Rich Plasma (AA-PRP) in Plastic Surgery: Wound Healing and Hair Regrowth Evaluation. Int J Mol Sci. 2020;21. [PMID: 31936605 PMCID: PMC7014364 DOI: 10.3390/ijms21020431]

Autologous therapies using platelet-rich plasma (PRP) need meticulous preparation—currently, no standardised preparation technique exists. Processing Quantitative Standards (PQSs) define manufacturing quantitative variables (such as time, volume and pressure). Processing Qualitative Standards (PQLSs) define the quality of the materials and methods of manufacturing. The aim of this review is to use existing PQSs and PQLs to report the in vivo/in vitro results obtained by using different Kits, that utilise different procedures (classified as Closed-Technique and Opened-Technique) to isolate autologous human activated (AA-PRP) or non-activated PRP (A-PRP). PQSs included the volumes of blood collected as well as the reagents used, the time/gravity of centrifugation, and the duration, temperature and tilt level/speed of centrifugation. PQLSs included the use of Calcium Chloride CaCl_2, Kit weight, transparency of Kit components, the maintenance of a closed sterile processing environment and the use of a small centrifuge. Eight CE marked devices for PRP extraction were evaluated: Angel^®, Biomed^®, Cascade^® and Selphyl^®, Mag-18^®, i-Stem^®, MyCells^® and Regenlab^®. Using a Kit with the PQSs and PQLSs described in this study enables the isolation of A-PRP, thereby meeting consensus quality criteria. As our understanding of Critical Quality Attributes (CQAs) of A-PRP continues to evolve, especially with respect to purity and potency, adjustments to these benchmark PQSs and PQLs will hopefully help isolate A-PRP of desired CQAs with greater reproducibility, quality, and safety. Confirmatory studies will no doubt need to be completed.

Impact of the Different Preparation Methods to Obtain Human Adipose-Derived Stromal Vascular Fraction Cells (AD-SVFs) and Human Adipose-Derived Mesenchymal Stem Cells (AD-MSCs): Enzymatic Digestion Versus Mechanical Centrifugation

Autologous therapies using adipose-derived stromal vascular fraction (AD-SVFs) and adult adipose-derived mesenchymal stem cells (AD-MSCs) warrant careful preparation of the harvested adipose tissue. Currently, no standardized technique for this preparation exists. Processing quantitative standards (PQSs) define manufacturing quantitative variables (such as time, volume, and pressure). Processing qualitative standards (PQLSs) define the quality of the materials and methods in manufacturing. The purpose of the review was to use PQSs and PQLSs to report the in vivo and in vitro results obtained by different processing kits that use different procedures (enzymatic vs. non-enzymatic) to isolate human AD-SVFs/AD-MSCs. PQSs included the volume of fat tissue harvested and reagents used, the time/gravity of centrifugation, and the time, temperature, and tilt level/speed of incubation and/or centrifugation. PQLSs included the use of a collagenase, a processing time of 30 min, kit weight, transparency of the kit components, the maintenance of a closed sterile processing environment, and the use of a small centrifuge and incubating rocker. Using a kit with the PQSs and PQLSs described in this study enables the isolation of AD-MSCs that meet the consensus quality criteria. As the discovery of new critical quality attributes (CQAs) of AD-MSCs evolve with respect to purity and potency, adjustments to these benchmark PQSs and PQLs will hopefully isolate AD-MSCs of various CQAs with greater reproducibility, quality, and safety. Confirmatory studies will no doubt need to be completed.

Wound Healing: In Vitro and In Vivo Evaluation of a Bio-Functionalized Scaffold Based on Hyaluronic Acid and Platelet-Rich Plasma in Chronic Ulcers

Chronic ulcers are characterized by loss of substance without a normal tendency towards spontaneous healing. The Wound Bed Preparation Guideline advises that after diagnosis, the expert should correct the biological state of the ulcer micro-environment based on TIME principles (Tissue, Infection, Moisture balance, Epidermal). There are many ways to treat such ulcers, for example through use of advanced dressings, negative pressure, surgical toilets, dermal substitutes, autologous skin grafting, and free or local flaps. In vitro and in vivo pre-clinical models hold widely acknowledged potential yet complex limitations. Tissue bioengineering could be an ideal approach to foster innovative strategies in wound healing. Our observational study reports on an in vitro and in vivo evaluation of a bio-functionalized scaffold composed of platelet-rich plasma (PRP) and hyaluronic acid (HA) used in 182 patients affected by chronic ulcers (diabetic and vascular), comparing the results with a control group of 182 patients treated with traditional dressings (HA alone). After 30 days the patients who had undergone the combined treatment (PRP + HA), showed 96.8% ± 1.5% re-epithelialization, as compared to 78.4% ± 4.4% in the control group (HA only). Within 80 days, they had 98.4% ± 1.3% re-epithelialization as compared to 87.8% ± 4.1% in the control group (HA only; p < 0.05). No local recurrence was observed during the follow-up period. PRP + HA treatment showed stronger regenerative potential in terms of epidermal proliferation and dermal renewal compared with HA alone.

Medial Thigh Contouring in Massive Weight Loss: A Liposuction-Assisted Medial Thigh Lift

BACKGROUND

Thigh’s lifting can be associated with significant complications, if the medial thigh excess is removed en bloc. In this study, the liposuction-assisted medial thigh’s lift (LAMeT) procedure, outcomes and complications were assessed.

METHODS

Twenty four females between 25 and 61 years with grade 2 or 3 on Pittsburgh Rating Scale (PRS) treated with medial thigh’s reduction were enrolled. Medial thigh’s reduction was performed in three different procedures of vertical, horizontal and LAMeT. Vertical thigh’s lift with fascia suspension was conducted in 13 patients with grade 3 of ptosis on PRS; horizontal thigh’s lift with fascia suspension was undertaken in 3 patients with grade 2 on PRS; vertical and horizontal thigh’s lift considered as control group was described as excision-only group; and LAMeT was performed in 8 patients with grade 2 and 3 on PRS.

RESULTS

Complications were observed in 62.5% of patients who underwent vertical or horizontal thigh’s lift with fascia suspension and in 16.7% who experienced the LAMeT without fascia suspension. The most frequent complication was seroma. Hospital stay was significantly lower in the LAMeT.

CONCLUSION

Medial thigh’s lift is a safe and satisfying procedure because it provides aesthetic improvement in massive weight loss patients. The complication rate is higher when skin excess and laxity are removed en bloc, as the resection of excess tissue is poorly selective. The LAMeT preserves lymphatic and blood vessels and allows a more anatomical resection of the excess skin. Thus postoperative complications incidence is lower and the patient heals faster.

Autologous Cellular Method Using Micrografts of Human Adipose Tissue Derived Follicle Stem Cells in Androgenic Alopecia

Hair bio-engineering has risen at the crossing point of various manipulations to meet a clinical requirement for innovations to advance hair growth. The authors reported the microscopic and trichoscopic results of an autologous cell biological technique to compare, through histological, immunocytochemistry, and cytospin analysis, hair re-growth obtained by micro-grafts from scalp tissue containing Human Intra- and Extra-Dermal Adipose Tissue-Derived Hair Follicle Stem Cells (HD-AFSCs) versus placebo (saline solution). An autologous solution of micro-grafts was obtained from mechanical fragmentation and centrifugation of scalp biopsy’s (2 × 2 mm) using “Gentile protocol”. The micro-grafts solution was mechanically infiltrated on half of the selected patients’ scalps with Androgenic Alopecia (Norwood–Hamilton 2–5 and Ludwig 1–2). The other half was infiltrated with saline solution. Three injections were performed to each patient at 45-day intervals. Of the 35 patients who were enrolled, 1 was excluded and 1 was rejected. 23 and 44 weeks after the last micro graft’s injections, the patients displayed a hair density improvement, with a mean increment of 33% ± 7.5% and 27% ± 3.5% respectively, contrasted with baseline values, for the treated region. Microscopic assessment appeared, in scalp biopsies, to show an expansion in the number of hair follicles per mm² following 11 months from the last micro-grafts application compared with baseline (1.4 + 0.27 versus 0.46 + 0.15, respectively; p < 0.05). HD-AFSCs contained in micro-grafts may represent a safe and effective alternative therapy option against hair loss.

Concise Review: Adipose-Derived Stem Cells (ASCs) and Adipocyte-Secreted Exosomal microRNA (A-SE-miR) Modulate Cancer Growth and proMote Wound Repair

Adipose-derived stem cells (ASCs) have been routinely used from several years in regenerative surgery without any definitive statement about their potential pro-oncogenic or anti-oncogenic role. ASCs has proven to favor tumor progression in several experimental cancer models, playing a central role in regulating tumor invasiveness and metastatic potential through several mechanisms, such as the paracrine release of exosomes containing pro-oncogenic molecules and the induction of epithelial-mesenchymal transition. However, the high secretory activity and the preferential tumor-targeting make also ASCs a potentially suitable vehicle for delivery of new anti-cancer molecules in tumor microenvironment. Nanotechnologies, viral vectors, drug-loaded exosomes, and micro-RNAs (MiR) represent additional new tools that can be applied for cell-mediated drug delivery in a tumor microenvironment. Recent studies revealed that the MiR play important roles in paracrine actions on adipose-resident macrophages, and their dysregulation has been implicated in the pathogenesis of obesity, diabetes, and diabetic complications as wounds. Numerous MiR are present in adipose tissues, actively participating in the regulation of adipogenesis, adipokine secretion, inflammation, and inter-cellular communications in the local tissues. These results provide important insights into Adipocyte-secreted exosomal microRNA (A-SE-MiR) function and they suggest evaluating the potential role of A-SE-MiR in tumor progression, the mechanisms underlying ASCs-cancer cell interplay and clinical safety of ASCs-based therapies.

Adipose-Derived Stromal Vascular Fraction Cells and Platelet-Rich Plasma: Basic and Clinical Implications for Tissue Engineering Therapies in Regenerative Surgery

Cell-based therapy and regenerative medicine offer a paradigm shift in regard to various diseases causing loss of substance or volume and tissue or organ damage. Recently, many authors have focused their attention on mesenchymal stem cells for their capacity to differentiate into many cell lineages. The most widely studied types are bone marrow mesenchymal stem cells and adipose derived stem cells (ADSCs), which display similar results. Based on the literature, we believe that the ADSCs offer advantages because of lower morbidity during the harvesting procedure. Additionally, platelet-rich plasma can be used in this field for its ability to stimulate tissue regeneration. The aim of this chapter is to describe ADSC preparation and isolation procedures, preparation of platelet-rich plasma, and the application of ADSCs in regenerative plastic surgery. We also discuss the mechanisms and future role of ADSCs in cell-based therapy and tissue engineering.

Advances in Regenerative Stem Cell Therapy in Androgenic Alopecia and Hair Loss: Wnt pathway, Growth-Factor, and Mesenchymal Stem Cell Signaling Impact Analysis on Cell Growth and Hair Follicle Development

The use of stem cells has been reported to improve hair regrowth in several therapeutic strategies, including reversing the pathological mechanisms, that contribute to hair loss, regeneration of hair follicles, or creating hair using the tissue-engineering approach. Although various promising stem cell approaches are progressing via pre-clinical models to clinical trials, intraoperative stem cell treatments with a one-step procedure offer a quicker result by incorporating an autologous cell source without manipulation, which may be injected by surgeons through a well-established clinical practice. Many authors have concentrated on adipose-derived stromal vascular cells due to their ability to separate into numerous cell genealogies, platelet-rich plasma for its ability to enhance cell multiplication and neo-angiogenesis, as well as human follicle mesenchymal stem cells. In this paper, the significant improvements in intraoperative stem cell approaches, from in vivo models to clinical investigations, are reviewed. The potential regenerative instruments and functions of various cell populaces in the hair regrowth process are discussed. The addition of Wnt signaling in dermal papilla cells is considered a key factor in stimulating hair growth. Mesenchymal stem cell-derived signaling and growth factors obtained by platelets influence hair growth through cellular proliferation to prolong the anagen phase (FGF-7), induce cell growth (ERK activation), stimulate hair follicle development (β-catenin), and suppress apoptotic cues (Bcl-2 release and Akt activation).

Vasculogenic Chronic Ulcer: Tissue Regeneration with an Innovative Dermal Substitute

The healing of venous and arterial ulcers is slow, and in some cases, they may not heal at all. This study aims to demonstrate the clinical advantage of Nevelia^®, an innovative collagen dermal template substitute (DS) in venous and arterial chronic ulcers treatment. 35 patients affected by chronic vascular ulcers with a mean area of 35.1 ± 31.8 cm² were treated with DS followed by autologous dermal epidermal graft (DEG). Follow-up was performed at 7-14-21 and 28 days after DS implant and 7-14-21 and 28 days after DEG. At 28 days after DEG, the mean values of Manchester Scar Scale was of 1.8 ± 0.7 for skin color, 1.6 ± 0.7 for skin contour, 1.7 ± 0.7 for distortion, and 1.7 ± 0.7 for skin texture, whereas skin was matte in 27 patients (77%) and shiny in the remaining eight cases (23%). Histological findings correlate with the clinical result showing a regenerated skin with reactive epidermal hyperplasia and dermal granulation tissue after two weeks (T1), and after three weeks (T2) a re-epithelialization and a formed new tissue architecture analogue to normal skin physiology. These data suggest that Nevelia^® could be useful to treat chronic venous and arterial ulcers.

Engineered Fat Graft Enhanced with Adipose-Derived Stromal Vascular Fraction Cells for Regenerative Medicine: Clinical, Histological and Instrumental Evaluation in Breast Reconstruction

The areas in which Stromal Vascular Fraction cells (SVFs) have been used include radiotherapy based tissue damage after mastectomy, breast augmentation, calvarial defects, Crohn's fistulas, and damaged skeletal muscle. Currently, the authors present their experience using regenerative cell therapy in breast reconstruction. The goal of this study was to evaluate the safety and efficacy of the use of Engineered Fat Graft Enhanced with Adipose-derived Stromal Vascular Fraction cells (EF-e-A) in breast reconstruction. 121 patients that were affected by the outcomes of breast oncoplastic surgery were treated with EF-e-A, comparing the results with the control group (n = 50) treated with not enhanced fat graft (EF-ne-A). The preoperative evaluation included a complete clinical examination, a photographic assessment, biopsy, magnetic resonance (MRI) of the soft tissue, and ultrasound (US). Postoperative follow-up took place at two, seven, 15, 21, 36 weeks, and then annually. In 72.8% (n = 88) of breast reconstruction treated with EF-e-A, we observed a restoration of the breast contour and an increase of 12.8 mm in the three-dimensional volume after 12 weeks, which was only observed in 27.3% (n = 33) of patients in the control group that was treated with EF-ne-A. Transplanted fat tissue reabsorption was analyzed with instrumental MRI and US. Volumetric persistence in the study group was higher (70.8%) than that in the control group (41.4%) (p < 0.0001 vs. control group). The use of EF-e-A was safe and effective in this series of treated cases.

Platelet-Rich Plasma and Micrografts Enriched with Autologous Human Follicle Mesenchymal Stem Cells Improve Hair Re-Growth in Androgenetic Alopecia. Biomolecular Pathway Analysis and Clinical Evaluation

Platelet rich plasma (PRP) and Micrografts containing human follicle mesenchymal stem cells (HF-MSCs) were tried as a potential treatment for androgenetic alopecia (AGA). However, little to no work has yet to be seen wherein the bio-molecular pathway of HF-MSCs or PRP treatments were analyzed. The aims of this work are to report the clinical effectiveness of HF-MSCs and platelet-rich plasma evaluating and reviewing the most updated information related to the bio-molecular pathway. Twenty-one patients were treated with HF-MSCs injections and 57 patients were treated with A-PRP. The Wnt pathway and Platelet derived-growth factors effects were analyzed. 23 weeks after the last treatment with mean hair thickness increments (29 ± 5.0%) over baseline values for the targeted area. 12 weeks after the last injection with A-PRP mean hair count and hair density (31 ± 2%) increases significantly over baseline values. The increment of Wnt signaling in Dermal Papilla Cells evidently is one of the principal factors that enhances hair growth. Signaling from mesenchymal stem cells and platelet derived growth factors positively influences hair growth through cellular proliferation to prolong the anagen phase (FGF-7), inducing cell growth (ERK activation), stimulating hair follicle development (β-catenin), and suppressing apoptotic cues (Bcl-2 release and Akt activation).

Fluid Cartilage as New Autologous Biomaterial in the Treatment of Minor Nose Defects: Clinical and Microscopic Difference Amongst Diced, Crushed, and Fluid Cartilage

Developing cartilage constructs with injectability, appropriate matrix composition, and persistent cartilaginous phenotype remains an enduring challenge in cartilage repair. Fourteen patients with minor contour deformity were treated with fluid cartilage filler gently injected as autologous fluid graft in deep planes of defect of the nose that were close to the bone or the cartilage. A computerized tomographic scan control was performed after 12 months. Pearson’s Chi-square test was used to investigate differences in cartilage density between native and newly formed cartilages. The endpoints were the possibility of using fluid cartilage as filler with aesthetic and functional improvement and versatility. Patients were followed up for two years. The constructs of fluid cartilage graft that were injected in the deep plane resulted in a persistent cartilage tissue with appropriate morphology, adequate central nutritional perfusion without central necrosis or ossification, and further augmented nasal dorsum without obvious contraction and deformation. This report demonstrated that fluid cartilage grafts are useful for cartilage regeneration in patients with outcomes of rhinoplasty, internal nasal valve collapse, and minor congenital nose aesthetics deformity.

Characteristics and Potentiality of Human Adipose-Derived Stem Cells (hASCs) Obtained from Enzymatic Digestion of Fat Graft. Cells. 2019;8:282. [PMID: 30934588 PMCID: PMC6469026 DOI: 10.3390/cells8030282]

Human adipose-derived stem cells localize in the stromal-vascular portion, and can be ex vivo isolated using a combination of washing steps and enzymatic digestion. For this study, we undertook a histological evaluation of traditional fat graft compared with fat graft enriched with stromal vascular fraction cells isolated by the Celution™ system to assess the interactions between cells and adipose tissue before the breast injection. In addition, we reported on histological analyses of biopsies derived from fat grafted (traditional or enriched with SVFs) in the breast in order to assess the quality of the adipose tissue, fibrosis and vessels. The hASCs derived from enzymatic digestion were systematically characterized for growth features, phenotype and multi-potent differentiation potential. They fulfill the definition of mesenchymal stem cells, albeit with a higher neural phenotype profile. These cells also express genes that constitute the core circuitry of self-renewal such as OCT4, SOX2, NANOG and neurogenic lineage genes such as NEUROD1, PAX6 and SOX3. Such findings support the hypothesis that hASCs may have a potential usefulness in neurodegenerative conditions. These data can be helpful for the development of new therapeutic approaches in personalized medicine to assess safety and efficacy of the breast reconstruction.

Mechanical and Controlled PRP Injections in Patients Affected by Androgenetic Alopecia

23 patients (18 male and 5 female) aged 21-70 years who displayed male pattern hair loss (MPHL) in Stage 1 to Stage 5 as determined by the Norwood-Hamilton classification scale, and female pattern hair loss (FPHL) in Stage 1 to Stage 2 as determined by the Ludwig classification scale, were treated with non-activated autologous platelet-rich plasma (A-PRP). Autologous blood (55 mL) was harvested using sodium citrate as an anticoagulant. A-PRP (23 mL) was produced for all cases using a closed system according to the transfusion service protocol. Following centrifugation (260 x g for 10 min) the A-PRP was inserted in a laser light selector device, and after the centrifugation, 9 mL of A-PRP was collected. The scalp of the patients affected by androgenetic alopecia (AGA) was divided into four areas (frontal, parietal, vertex, and occipital); local anesthesia was not performed. Interfollicular A-PRP injections (0.2 mL x cm²) were performed by controlled and mechanical injections scheduled at a depth of 5 mm using a medical injector gun. Treatment sessions were performed with a 30-day interval. For each patient, three treatment sessions were performed. PRP was injected in the androgen-related areas of scalp affected by hair loss. Placebo (normal saline solution) was loaded in another syringe (10 mL) and injected on the adjacent side in a similar fashion.

Gentle Is Better: The Original "Gentle Technique" for Fat Placement in Breast Lipofilling

Context

Breast lipofilling usually involves three different stages (harvesting, processing, and placement), and in each of these phases, adipocyte cells can be damaged. Our technique of fat placement is quite different from the others as we focus our attention on the last stage of fat graft procedure, which could explain the better results in graft survival.

Aims

Our method is focused on eliminating any unnecessary manipulation of the graft so as to optimize graft retention and clinical outcomes: Controlled movement and slow rate of fat injection are the cornerstone of our technique and guarantee a nontraumatic fat transfer and a greater survival rate of adipocytes.

Settings and Design

This was a retrospective cohort study.

Materials and Methods

Of 120 patients (average age 41,5 years) affected by breast soft tissue defects, 60 were managed with the lipofilling procedure using fat graft injected by "Gentle technique." To establish the effects of the injection's procedure, we compared the results obtained in fat graft maintenance with a control group made up of 60 patients, treated with fat graft injection according to Coleman procedure.

Statistical Analysis Used

Values are expressed as mean plus standard error and analyzed using Student's t test.

Results

In patients treated with Gentle technique, we observed a 60.5% + 12.5% maintenance of contour restoring and three-dimensional volume after 1 year (P < 0.0001 vs. control group); we compared the results obtained with only 39% + 4.4% of the control group treated with fat graft injected according to Coleman.

Conclusions

Controlled 26 movement and slow rate of fat injection are the cornerstone of our technique and guarantee a nontraumatic fat transfer and a greater 27 survival rate of adipocytes.

Stem cells from human hair follicles: first mechanical isolation for immediate autologous clinical use in androgenetic alopecia and hair loss

BACKGROUND

Hair follicles are known to contain a well-characterized niche for adult stem cells: the bulge, which contains epithelial and melanocytic stem cells. Stem cells in the hair bulge, a clearly demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. The bulge epithelial stem cells can also reconstitute in an artificial in vivo system to a new hair follicle.

METHODS

In this study, we have developed a new method to isolate human adult stem cells by mechanical centrifugation of punch biopsy from human hair follicles without culture condition. Here, we used human follicle stem cells (HFSCs), to improve the hair density in 11 patients (38 to 61 years old) affected by AGA in stage 3-5 as determined by the Norwood-Hamilton classification scale.

RESULTS

The primary outcomes were microscopic identification and counting of HFSCs. The secondary outcomes were clinical preliminary results and safety and feasibility in HFSCs-treated scalp. Each scalp tissue suspension contained about 3,728.5±664.5 cells. The percentage of hair follicle-derived mesenchymal stem cells CD44+ [from dermal papilla (DP)] was about 5%+0.7% whereas the percentage of hair follicle epithelial stem cells CD200+ (from the bulge) was about 2.6%+0.3%. In total, 23 weeks after the last treatment with HFSCs mean hair count and hair density increases over baseline values. In particular, a 29%±5% increase in hair density for the treated area and less than a 1% increase in hair density for the placebo area.

CONCLUSIONS

We have shown that the isolated cells are capable to improve the hair density in patients affected by androgenetic alopecia (AGA). These cells appear to be located in the bulge area of human.

In Vitro and In Vivo Studies of Alar-Nasal Cartilage Using Autologous Micro-Grafts: The Use of the Rigenera® Protocol in the Treatment of an Osteochondral Lesion of the Nose

Cartilage defects represent a serious problem due to the poor regenerative properties of this tissue. Regarding the nose, nasal valve collapse is associated with nasal blockage and persistent airway obstruction associated with a significant drop in the quality of life for patients. In addition to surgical techniques, several cell-based tissue-engineering strategies are studied to improve cartilage support in the nasal wall, that is, to ameliorate wall insufficiency. Nevertheless, there are no congruent data available on the benefit for patients during the follow-up time. In this manuscript, we propose an innovative approach in the treatment of cartilage defects in the nose (nasal valve collapse) based on autologous micro-grafts obtained by mechanical disaggregation of a small portion of cartilage tissue (Rigenera® protocol). In particular, we first analyzed in vitro murine and human cartilage micro-grafts; secondly, we analyzed the clinical results of a patient with pinched nose deformity treated with autologous micro-grafts of chondrocytes obtained by Rigenera® protocol. The use of autologous micro-graft produced promising results in surgery treatment of cartilage injuries and could be safely and easily administrated to patients with cartilage tissue defects.

Evaluation of Not-Activated and Activated PRP in Hair Loss Treatment: Role of Growth Factor and Cytokine Concentrations Obtained by Different Collection Systems

Platelet rich plasma (PRP) was tested as a potential therapy for androgenetic alopecia (AGA) through two different clinical protocols in which one population (18 participants) received half-head treatment with autologous non-activated PRP (A-PRP) produced by CPunT Preparation System (Biomed Device, Modena, Italy) and the other half-head with placebo, and a second separated population in which all participants (n = 6, 3 participants per group) received treatment with calcium-activated PRP (AA-PRP) produced from one of two different PRP collection devices (Regen Blood Cell Therapy or Arthrex Angel System). For the A-PRP study, three treatments were administered over 30-day intervals. Trichoscan analysis of patients, three months post-treatment, showed a clinical improvement in the number of hairs in the target area (36 ± 3 hairs) and in total hair density (65 ± 5 hair cm²), whereas negligible improvements in hair count (1.1 ± 1.4 hairs) and density (1.9 ± 10.2 hair cm²) were seen in the region of the scalp that received placebo. Microscopic evaluation conducted two weeks after treatment showed also an increase in epidermal thickness, Ki67⁺ keratinocytes, and in the number of follicles. The AA-PRP treatment groups received a singular set of injections, and six months after the treatments were administered, notable differences in clinical outcomes were obtained from the two PRP collection devices (+90 ± 6 hair cm² versus −73 ± 30 hair cm² hair densities, Regen versus Arthrex). Growth factor concentrations in AA-PRP prepared from the two collection devices did not differ significantly upon calcium activation.