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Tran VVT, Jin X, Hong KY, Chang H. Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review. Plast Reconstr Surg 2024; 154:451e-464e. [PMID: 37400953 DOI: 10.1097/prs.0000000000010905] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Since nanofat was first introduced by Tonnard in 2013, numerous studies have reported positive findings with its use; however, concerns exist regarding its effects and mechanisms, and the various methods used to generate nanofat also remain unclear. The authors conducted a systematic review to evaluate the efficacy of nanofat grafting alone in plastic and reconstructive surgery. METHODS The MEDLINE, Embase, Cochrane Central, Web of Science, and Scopus databases were searched for studies related to the use of nanofat grafting alone in plastic and reconstructive surgery. Outcomes of interest were all clinical results in humans or animals. RESULTS Twelve studies were included. No meta-analysis was conducted due to the clinical heterogeneity of the studies. In general, included studies had a low level of evidence. Six studies ( n = 253 patients) showed significant improvements in scar characteristics based on Patient and Observer Scar Assessment Scale, FACE-Q scale, physician assessment, patient satisfaction, and Vancouver Scar Scale scores. Four studies described the benefits of nanofat in skin rejuvenation (wrinkles, fine rhytides, pigmentation, and discoloration) through photographs, questionnaires, and indentation indices. Histologic evaluation illustrated overall increases in skin thickness, collagen, and elastic fibers. Three experimental studies showed the beneficial effects of nanofat on fat grafting, diabetic wound healing, and hair growth, with compelling histological evidence. No severe complication was reported. CONCLUSIONS Nanofat grafting shows potential benefits in scar and antiaging treatments, with conclusive histological evidence. Clinical studies of fat grafting, wound healing, and hair growth should be conducted, based on the results of this systematic review. Nanofat grafting could be a practical and safe procedure.
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Affiliation(s)
- Vinh Vuong The Tran
- From the Hi-Tech Center, Vinmec Healthcare System
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine
| | - Xian Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine
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Strong AL, Rohrich RJ, Tonnard PL, Vargo JD, Cederna PS. Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science. Plast Reconstr Surg 2024; 153:360-377. [PMID: 37159906 DOI: 10.1097/prs.0000000000010643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
SUMMARY The scientific study of facial aging has transformed modern facial rejuvenation. As people age, fat loss in specific fat compartments is a major contributor to structural aging of the face. Autologous fat grafting is safe, abundant, readily available, and completely biocompatible, which makes it the preferred soft-tissue filler in the correction of facial atrophy. The addition of volume through fat grafting gives an aging face a more youthful, healthy, and aesthetic appearance. Harvesting and preparation with different cannula sizes and filter-cartridge techniques have allowed for fat grafts to be divided based on parcel size and cell type into three major subtypes: macrofat, microfat, and nanofat. Macrofat and microfat have the benefit of providing volume to restore areas of facial deflation and atrophy in addition to improving skin quality; nanofat has been shown to improve skin texture and pigmentation. In this article, the authors discuss the current opinions regarding fat grafting and how the evolving science of fat grafting has led to the clinical utility of each type of fat to optimize facial rejuvenation. The opportunity exists to individualize the use of autologous fat grafting with the various subtypes of fat for the targeted correction of aging in different anatomic areas of the face. Fat grafting has become a powerful tool that has revolutionized facial rejuvenation, and developing precise, individualized plans for autologous fat grafting for each patient is an important advancement in the evolution of facial rejuvenation.
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Affiliation(s)
- Amy L Strong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
| | - Rod J Rohrich
- Dallas Plastic Surgery Institute
- Baylor College of Medicine
| | | | - James D Vargo
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
| | - Paul S Cederna
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
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3
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Hajimortezayi Z, Daei N, Gholizadeh N, Zakeri M, Alhili F, Hasanzadeh S, Hormozi A, Ebrahimi F, Zamani M. Fat transplant: Amazing growth and regeneration of cells and rebirth with the miracle of fat cells. J Cosmet Dermatol 2023. [PMID: 38010992 DOI: 10.1111/jocd.16103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 10/20/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUNDS AND OBJECTIVE During fat transplantation, adipose tissue is removed from the body and injected into different areas under the skin. The goal of this review article is to look into the efficacy and applicability of fat transplantation in regenerative medicine and rejuvenation, including Nanofat, Microfat, and Millifat. METHODS As a search strategy and study selection, we searched the PubMed and Medline databases until 2023 using related keywords (e.g., Nanofat, Microfat and Millifat, Regenerative Medicine, and Rejuvenation). RESULTS Autologous fat transplantation has no risk of an allergic reaction or rejection of the transplant by the individual. Autologous adipose tissue is considered an ideal filler for facial rejuvenation and is suggested as the most biocompatible and non-immunogenic skin filler. Adipose tissue transplant may have semi-permanent to permanent effects. According to recent reports, adipose tissues possess a high percentage of mature stem cells. The effect of regenerating adipose tissue and its intrinsic cells can be described as an obvious process. Variations in the sizes of adipose tissues can result in different results depending on the surgical site. Based on topographic assessment, graft fats are assigned depending on the anatomical locations and the size such as Millifat (2-2.5 mm), Microfat (1 mm), and Nanofat (500 μm or less). CONCLUSION Some characteristics of fat tissue increase its effectiveness, such as increasing stem cells, growth factors, cytokines, and compounds effective in repair, regeneration, and rejuvenation.
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Affiliation(s)
- Zahra Hajimortezayi
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Narges Daei
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Nasim Gholizadeh
- Department of Dermatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mana Zakeri
- Department of Biology, Tehran Medical Branch, Islamic Azad University, Tehran, Iran
| | - Farah Alhili
- Medical Technical College, Al-Farahidi University, Baghdad, Iraq
| | - Sajedeh Hasanzadeh
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Arezoo Hormozi
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Faezeh Ebrahimi
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Majid Zamani
- Department of Hematology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Neiva-Sousa M, Carracha C, Nunes da Silva L, Valejo Coelho P. Does Platelet-Rich Plasma Promote Facial Rejuvenation? Revising the Latest Evidence in a Narrative Review. J Cutan Aesthet Surg 2023; 16:263-269. [PMID: 38314356 PMCID: PMC10833488 DOI: 10.4103/jcas.jcas_210_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Facial aging is characterized by progressive macroscopic, histological, and molecular changes. Due to its regenerative and rejuvenating properties, the use of platelet-rich plasma (PRP) as a facial antiaging agent has gained popularity over the last decade. In order to gather and evaluate the latest evidence focusing on the effect of PRP on facial skin rejuvenating, a search through MEDLINE (PubMed) using relevant keywords, inclusion, and exclusion criteria was performed. A total of 539 articles were initially retrieved, and from those, 16 were included in the review. Treatment protocols comprised the use of PRP both in monotherapy and in combination with other substances and by means of direct injection or topical application following skin permeation. The selected studies presented high variability regarding PRP preparation methods, administration protocols, and results assessment. In most studies, PRP seemed to improve to some degree the signs of facial aging, such has wrinkles, skin quality, and pigmentation, accompanied by significant histological and molecular responses. Optimizing treatment protocols should be the next step in assessing the full potential of PRP.
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Affiliation(s)
| | - Clara Carracha
- Department of Maxillofacial Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Luis Nunes da Silva
- Department of Maxillofacial Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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5
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Rahman E, Philip-Dormston WG, Webb WR, Rao P, Carruthers JD, Carruthers A, Swift A, Goodman GJ, Mosahebi A, Nahai F. Developing Consensus-Based Guidelines for Case Reporting in Aesthetic Medicine: Enhancing Transparency and Standardization. Aesthet Surg J Open Forum 2023; 5:ojad076. [PMID: 37694226 PMCID: PMC10483583 DOI: 10.1093/asjof/ojad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Clinical case reporting plays a vital role in sharing detailed patient narratives, providing insights into rare conditions, innovative treatments, and unexpected outcomes. However, existing reporting guidelines in aesthetic medicine fail to capture the specific nuances of procedures and outcomes in this field. The authors' objectives were to develop comprehensive guidelines for Case REporting in Aesthetic Medicine (CREAM). The study employed a 3-phase consensus process, including a literature review, expert interviews, and a consensus meeting. A diverse group of 10 expert participants (plastic surgeons, dermatologists, noncore specialists, evidence-based medicine expert, and research scientist) in Phase I and 30 experienced aesthetic practitioners in Phase II contributed to the research. Statistical analysis was conducted to assess agreement levels among participants and explore associations and variations within the data. The participants represented various specialties, genders, LGBTQ+ identities, and ethnic backgrounds. The research resulted in the development of the CREAM guidelines, consisting of a 16-item checklist. The guidelines covered essential aspects of case reporting, such as patient and practice information, procedure details, clinical assessment and outcomes, adverse events, and ethical considerations. Statistical analysis indicated a high level of consensus among participants, as well as significant associations between checklist items. CREAM guidelines represent a step toward enhancing transparency and standardization in case reporting in aesthetic medicine. Adhering to these guidelines will allow authors to contribute to a robust evidence base, prioritize patient safety, and drive advancements aesthetic medicine.
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Affiliation(s)
- Eqram Rahman
- Corresponding Author: Dr Eqram Rahman, Pond Street, Hampstead NW3 2QG, UK. E-mail: ; Instagram: @Beyond_border_Aesthetics
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Koptyug A, Sukhovei Y, Kostolomova E, Unger I, Kozlov V. Novel Strategy in Searching for Natural Compounds with Anti-Aging and Rejuvenating Potential. Int J Mol Sci 2023; 24:ijms24098020. [PMID: 37175723 PMCID: PMC10178965 DOI: 10.3390/ijms24098020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
We suggest a novel approach for searching natural compounds with anti-aging and rejuvenation potential using cell cultures, with a high potential for the further in vivo applications. The present paper discusses ways of defining age for cell populations with large numbers of cells and suggests a method of assessing how young or old a cell population is based on a cell age profile approach. This approach uses experimental distributions of the cells over the cell cycle stages, acquired using flow cytometry. This paper discusses how such a profile should evolve under homeostatic maintenance of cell numbers in the proliferation niches. We describe promising results from experiments on a commercial substance claiming rejuvenating and anti-aging activity acting upon the cultures of human mononuclear cells and dermal fibroblasts. The chosen substance promotes a shift towards larger proportion of cells in synthesis and proliferation stages, and increases cell culture longevity. Further, we describe promising in vivo testing results of a selected food supplement. Based on the described concept of cell age profile and available test results, a strategy to search for natural compounds with regenerative, anti-aging and rejuvenation potential is suggested and proposed for wider and thorough testing. Proposed methodology of age assessment is rather generic and can be used for quantitative assessment of the anti-aging and rejuvenation potential of different interventions. Further research aimed at the tests of the suggested strategy using more substances and different interventions, and the thorough studies of molecular mechanisms related to the action of the substance used for testing the suggested search methodology, are needed.
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Affiliation(s)
- Andrey Koptyug
- SportsTech Research Center, Department of Engineering, Mathematics and Science Education, Mid Sweden University, Akademigatan 1, 831 25 Östersund, Sweden
| | - Yurij Sukhovei
- Institute of Fundamental and Clinical Immunology, Tyumen Branch, Kotovskogo Str. 5, 625027 Tyumen, Russia
| | - Elena Kostolomova
- Department of Microbiology, Tyumen State Medical University, Kotovskogo Str. 5/2, 625023 Tyumen, Russia
| | - Irina Unger
- Institute of Fundamental and Clinical Immunology, Tyumen Branch, Kotovskogo Str. 5, 625027 Tyumen, Russia
| | - Vladimir Kozlov
- Institute of Fundamental and Clinical Immunology, Department of Clinical Immunology, Yadrintcevskaya Str. 14, 630099 Novosibirsk, Russia
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Hu H, Shi Y, Qian Y, Yu X, Liu A, Li F, Jiang H, Wang H. Pyramidal multiple-theory (multi-type, multi-method and multi-layer) for facial fat grafting. J Cosmet Dermatol 2023; 22:937-944. [PMID: 36575894 DOI: 10.1111/jocd.15525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/08/2022] [Accepted: 11/08/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Age-related changes to the face pertinent anatomy and important aspects of autologous fat grafting have been widely applied in facial rejuvenation. Various types of autologous fat products (Macrofat, Microfat, SEFF, nanofat, and SVF-gel) with different properties and applicabilities have been introduced and available for surgeons. METHODS Key differences between common techniques for fat processing and infiltration. Develop a plan for patients based on site-specific facial anatomical zones, we suggested a pyramidal multiple-theory (multi-type, multi-method and multi-layer) for facial fat grafting. Based on the complicated mechanism of the face decrepitude in different layers of facial soft tissue, autologous fat products with various particle sizes and components into different layers. RESULTS Fifty-eight patients underwent this facial fat grafting strategy from June 2020 to Jan 2022. All achieved cosmetic improvements, with higher patients' satisfaction, and minor complications. Our facial fat grafting strategy takes advantage of different fat products and is able to address the physiological tissue changes during aging, more properly and targetedly, than the traditional facial fat grafting. CONCLUSIONS Fat grafting to the face aids in volume restoration and rejuvenation, thereby addressing soft-tissue atrophy associated with the aging face, acquired conditions, or congenital malformations. The technique described as "lipo-tumescence" has been successfully used in the breast and other regions of the body that have radiation damage and is discussed in this article specifically for the face and neck.
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Affiliation(s)
- Hao Hu
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingshen Shi
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuxin Qian
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoyan Yu
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Antang Liu
- Department of Plastic and Reconstructive Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Facheng Li
- Plastic Surgery Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Hua Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hui Wang
- Department of Plastic and Reconstructive Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
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Shi J, Zeng Q, Wang P, Chang Q, Huang J, Wu M, Wang X, Wang H. A novel chlorin e6 derivative-mediated photodynamic therapy STBF-PDT reverses photoaging via the TGF-β pathway. Photodiagnosis Photodyn Ther 2023; 41:103321. [PMID: 36738905 DOI: 10.1016/j.pdpdt.2023.103321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Photoaging is characterized by wrinkles in the skin and the deterioration of the skin barrier function, mainly caused by long-term exposure to ultraviolet (UV) radiation. Photodynamic therapy (PDT) has been shown to treat photoaging. The novel photosensitizer ShengTaiBuFen(STBF) is a derived substance of Chlorin e6(Ce6) that can exert photodynamic effects directly. In this study, we investigated the availability and the mechanism of STBF-PDT in the treatment of photoaging. METHODS Fluorophotometer was used to determine therapeutic parameters for in vivo experiments. Camera photographs, dermoscopy, HE and Masson staining, skin pH, trans epidermal water loss (TEWL), epidermal water content, and sebum testing were used together to evaluate the results of the treatment. Dark toxicity and therapeutic parameters for in vitro experiments were determined by CCK8 analysis. Scratch assay was used to identify the cell migration of STBF-PDT on HaCaT cells. qPCR and Western blot were used to evaluate the TGF-β/Smad signaling pathway in human dermal fibroblast (HDF) cells. RESULTS We investigated the optimal STBF concentration and time of incubation in vivo and in vitro experiments. STBF-PDT improved the skin phenotype of photoaged mice. The skin of photoaged mice treated with 80 J/cm2 STBF-PDT became smooth, while skin flakes were reduced. The epidermis of STBF-PDT-treated mice was thinner, and the cells were neatly arranged, with increased dermal collagen. In vitro, STBF-PDT promoted the migration of HaCaT cells below a light dose of 0.1 J/cm2. HDF cells co-cultured with HaCaT cells treated with low-dose STBF-PDT showed activation of the TGF-β pathway. CONCLUSION As a novel photosensitizer, STBF-mediated low-dose PDT could reverse photoaging via the TGF-β pathway.
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Affiliation(s)
- Jingjuan Shi
- Department of Dermatology, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - Qingyu Zeng
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai 200050, China
| | - Peiru Wang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai 200050, China
| | - Qihang Chang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai 200050, China
| | - Jianhua Huang
- Department of Dermatology, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - Minfeng Wu
- Department of Dermatology, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - Xiuli Wang
- Institute of Photomedicine, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai 200050, China.
| | - Hongwei Wang
- Department of Dermatology, Huadong Hospital, Fudan University, Shanghai 200040, China.
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Dayal A, Bhatia A, Hsu JTS. Fat grafting in aesthetics. Clin Dermatol 2022; 40:35-44. [DOI: 10.1016/j.clindermatol.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Semsarzadeh N, Khetarpal S. Rise of stem cell therapies in aesthetics. Clin Dermatol 2022; 40:49-56. [DOI: 10.1016/j.clindermatol.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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Wang JV, Saedi N. Reflections on debates in aesthetic dermatology: Part I. Clin Dermatol 2022; 40:1-3. [DOI: 10.1016/j.clindermatol.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Atiyeh B, Ghieh F, Oneisi A. Nanofat Cell-Mediated Anti-Aging Therapy: Evidence-Based Analysis of Efficacy and an Update of Stem Cell Facelift. Aesthetic Plast Surg 2021; 45:2939-2947. [PMID: 34085105 DOI: 10.1007/s00266-021-02353-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/09/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Fat grafting has been extensively applied as natural filler and has been very promising in restoring volume loss. Lipografting has also been credited to reduce age-related skin changes due to the regenerative potential of adipose derived stem cells. Cell-mediated therapies in plastic surgery are rapidly evolving with growing applications. Nanofat, a bio-regenerative liquid suspension rich in stromal vascular fraction cells without viable adipocytes, has been described as an efficient cutaneous anti-aging therapy. We have published in 2013 a review entitled "stem cell facelift: between reality and fiction." Available clinical evidence at that time did not substantiate marketing and promotional claims of "stem cell facelift". The same year, the report about nanofat was published demonstrating striking clinical outcome. The current literature search is aimed at reviewing any evidence that has emerged since then regarding clinical efficacy of this modality. METHODS A thorough PICO tool-based comprehensive literature search of PubMed database for "the efficacy of nanofat cell-mediated anti-aging therapy" was conducted with a time frame from 2013 till present. RESULTS Despite apparent increasing popularity of stem cell rejuvenation, well-controlled clinical studies about this modality are surprisingly very scarce. Only seven papers published after 2013 were identified and were included in this review CONCLUSION: Though considered to be a safe procedure, and despite documented histologic improvement and striking clinical outcome in some reports, available evidence can hardly support clinical improvement of skin quality. Before cell-mediated aesthetic rejuvenation applications can be routinely undertaken, more robust evidence with well-defined primary outcome end points and objective outcome measures is required. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bishara Atiyeh
- Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Ghieh
- Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Oneisi
- Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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