Adult stem cell lines in regenerative medicine and reconstructive surgery

Effects of an Ultra-Polished Scalpel on Incisional Wounds in a Diabetic Model

Inflammation after surgical incisions is related to the degree of tissue damage. Healing with low inflammation is desirable, especially in patients with compromised healing potential. This experimental study was conducted to assess the degree of inflammatory reaction and scar formation from incisions made by an ultra-polished scalpel (UPS). Two paravertebral incisions were made with a conventional scalpel (CS) and a UPS in 18 individual rats with diabetes. The fibrotic tissue (scar) area and expression levels of collagen, transforming growth factor, and matrix metalloproteinases were quantified on postoperative days 3, 7, and 30. The scar widths and areas were significantly lower in the UPS group than in the CS group. The scar widths were 64.3 ± 14.7 µm and 86.8 ± 12.1 µm in the UPS and CS groups, respectively (P = 0.03). The scar areas were 11,398 ± 1595 µm2 in the UPS group and 17,433 ± 3487 µm2 in the CS group (P = 0.014). The UPS group had less inflammation on day 3, less transforming growth factor synthesis on days 3 and 7, lower levels of matrix metalloproteinases, and less collagen synthesis on day 7 than did the CS group. The UPS achieved less local inflammation by reducing the local tissue damage in diabetic rat models, enabling better healing, and resulting in less scar formation. The UPS warrants further clinical study as it may bring beneficial outcomes for patients with impaired healing capability and patients who seek to reduce scarring.

Oncologic Safety and Efficacy of Cell-Assisted Lipotransfer for Breast Reconstruction in a Murine Model of Residual Breast Cancer

BACKGROUND

Cell-assisted lipotransfer (CAL) is a novel technique for fat grafting that combines the grafting of autologous fat and adipose-derived stromal cells (ASCs) to enhance fat graft retention; however, its oncologic safety is controversial.

METHODS

Herein, we investigated the oncologic safety of CAL for breast reconstruction using a murine model of residual breast cancer. Various concentrations of 4T1 cells (murine breast cancer cells) were injected into female mastectomized BALB/c mice to determine the appropriate concentration for injection. One week after injection, mice were divided into control (100 μL fat), low CAL (2.5 × 10⁵ ASCs/100 μL fat), and high CAL (1.0 × 10⁶ ASCs/100 μL fat) groups, and fat grafting was performed. The injection of 5.0 × 10³ 4T1 cells was appropriate to produce a murine model of residual breast cancer.

RESULTS

The weight of the fat tumor mass was significantly higher in the high CAL group than in the other groups (p < 0.05). However, the estimated tumor weight was not significantly different between the groups. Additionally, the fat graft survival rate was significantly higher in the high CAL group than in the control and low CAL groups (p < 0.05). No significant difference was noted in the percentage of Ki-67-positive cells, suggesting that tumor proliferation was not significantly different between the groups.

CONCLUSION

In summary, CAL significantly improved fat graft survival without affecting tumor size and proliferation in a murine model of residual breast cancer. These results highlight the oncologic safety of CAL for breast reconstruction.

NO LEVEL ASSIGNED

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Cell-Based Transplantation versus Cell Homing Approaches for Pulp-Dentin Complex Regeneration

Regenerative dentistry has paved the way for a new era for the replacement of damaged dental tissues. Whether the causative factor is dental caries, trauma, or chemical insult, the loss of the pulp vitality constitutes one of the major health problems worldwide. Two regenerative therapies were introduced for a fully functional pulp-dentin complex regeneration, namely, cell-based (cell transplantation) and cell homing (through revascularization or homing by injection of stem cells in situ or intravenously) therapies, with each demonstrating advantages as well as drawbacks, especially in clinical application. The present review is aimed at elaborating on these two techniques in the treatment of irreversibly inflamed or necrotic pulp, which is aimed at regenerating a fully functional pulp-dentin complex.

Reconstruction of parietal bone defects with adiposederived mesenchymal stem cells. Experimental study

Purpose:

This study assessed the regeneration potential of mesenchymal stem cells (MSC) from adipose tissue associated with platelet-rich plasma (PRP) in bone regeneration.

Methods:

Thirty Wistar rats (Rattus norvegicus albinos) were divided into five groups (according to the grafting material and time to euthanasia): (1) autograft - 14 days (control), (2) autograft - 28 days (control), (3) MSC + PRP - 14 days, (4) MSC + PRP + papaverine - 14 days and (5) MSC + PRP + papaverine - 28 days. After euthanasia, the graft was removed and histological slides were prepared. They were assessed by a blinded pathologist using a previously published histological scale as parameter.

Results:

There was some degree of neoformed bone trabeculae (NBT) in 93.3% of the samples, as well as osteoblastic activity (OA). The autograft groups (14 and 28 days) had higher levels in the formation of bone trabeculae. Nonparametric data were analyzed using the Wilcoxon-Mann-Whitney test and proved not to be statistically significant at p < 0.05.

Conclusions:

Experimental parietal bone reconstruction, combining MSC, PRP and papaverine presented regeneration in all groups with no significant difference among them.

Quantitative Proteomic Profiling of Small Molecule Treated Mesenchymal Stem Cells Using Chemical Probes

The differentiation of human adipose derived stem cells toward a neural phenotype by small molecules has been a vogue topic in the last decade. The characterization of the produced cells has been explored on a broad scale, examining morphological and specific surface protein markers; however, the lack of insight into the expression of functional proteins and their interactive partners is required to further understand the extent of the process. The phenotypic characterization by proteomic profiling allows for a substantial in-depth analysis of the molecular machinery induced and directing the cellular changes through the process. Herein we describe the temporal analysis and quantitative profiling of neural differentiating human adipose-derived stem cells after sub-proteome enrichment using a bisindolylmaleimide chemical probe. The results show that proteins enriched by the Bis-probe were identified reproducibly with 133, 118, 126 and 89 proteins identified at timepoints 0, 1, 6 and 12, respectively. Each temporal timepoint presented several shared and unique proteins relative to neural differentiation and their interactivity. The major protein classes enriched and quantified were enzymes, structural and ribosomal proteins that are integral to differentiation pathways. There were 42 uniquely identified enzymes identified in the cells, many acting as hubs in the networks with several interactions across the network modulating key biological pathways. From the cohort, it was found by gene ontology analysis that 18 enzymes had direct involvement with neurogenic differentiation.

Biomimetic Aspects of Restorative Dentistry Biomaterials

Biomimetic has emerged as a multi-disciplinary science in several biomedical subjects in recent decades, including biomaterials and dentistry. In restorative dentistry, biomimetic approaches have been applied for a range of applications, such as restoring tooth defects using bioinspired peptides to achieve remineralization, bioactive and biomimetic biomaterials, and tissue engineering for regeneration. Advancements in the modern adhesive restorative materials, understanding of biomaterial–tissue interaction at the nano and microscale further enhanced the restorative materials’ properties (such as color, morphology, and strength) to mimic natural teeth. In addition, the tissue-engineering approaches resulted in regeneration of lost or damaged dental tissues mimicking their natural counterpart. The aim of the present article is to review various biomimetic approaches used to replace lost or damaged dental tissues using restorative biomaterials and tissue-engineering techniques. In addition, tooth structure, and various biomimetic properties of dental restorative materials and tissue-engineering scaffold materials, are discussed.

Insulin-dependent Non-canonical Activation of Notch in Drosophila: A Story of Notch-Induced Muscle Stem Cell Proliferation

Notch plays multiple roles both in development and in adult tissue homeostasis. Notch was first identified in Drosophila in which it has then been extensively studied. Among the flag-ship Notch functions we could mention its capacity to keep precursor and stem cells in a nondifferentiated state but also its ability to activate cell proliferation that in some contexts could led to cancer. In general, both these functions involve, canonical, ligand-dependent Notch activation. However, a ligand-independent Notch activation has also been described in a few cellular contexts. Here, we focus on one of such contexts, Drosophila muscle stem cells, called AMPs, and discuss how insulin-dependent noncanonical activation of Notch pushes quiescent AMPs to proliferation.

Design, construction and characterisation of a novel nanovibrational bioreactor and cultureware for osteogenesis

In regenerative medicine, techniques which control stem cell lineage commitment are a rapidly expanding field of interest. Recently, nanoscale mechanical stimulation of mesenchymal stem cells (MSCs) has been shown to activate mechanotransduction pathways stimulating osteogenesis in 2D and 3D culture. This has the potential to revolutionise bone graft procedures by creating cellular graft material from autologous or allogeneic sources of MSCs without using chemical induction. With the increased interest in mechanical stimulation of cells and huge potential for clinical use, it is apparent that researchers and clinicians require a scalable bioreactor system that provides consistently reproducible results with a simple turnkey approach. A novel bioreactor system is presented that consists of: a bioreactor vibration plate, calibrated and optimised for nanometre vibrations at 1 kHz, a power supply unit, which supplies a 1 kHz sine wave signal necessary to generate approximately 30 nm of vibration amplitude, and custom 6-well cultureware with toroidal shaped magnets incorporated in the base of each well for conformal attachment to the bioreactor’s magnetic vibration plate. The cultureware and vibration plate were designed using finite element analysis to determine the modal and harmonic responses, and validated by interferometric measurement. This helps ensure that the vibration plate and cultureware, and thus collagen and MSCs, all move as a rigid body, avoiding large deformations close to the resonant frequency of the vibration plate and vibration damping beyond the resonance. Assessment of osteogenic protein expression was performed to confirm differentiation of MSCs after initial biological experiments with the system, as well as atomic force microscopy of the 3D gel constructs during vibrational stimulation to verify that strain hardening of the gel did not occur. This shows that cell differentiation was the result of the nanovibrational stimulation provided by the bioreactor alone, and that other cell differentiating factors, such as stiffening of the collagen gel, did not contribute.

Amyloid-like peptide nanofibrils as scaffolds for tissue engineering: Progress and challenges (Review)

Networks of amyloid-like nanofibrils assembled from short peptide sequences have the ability to form scaffolds that can encapsulate clinically relevant stem cells encouraging their attachment, growth, and differentiation into various lineages which can be used in tissue engineering applications to treat a range of diseases and traumas. In this review, the author highlights a selection of important proof-of-principle papers that show how this class of self-assembled networks is highly suited to biomaterial scaffold development. The author highlights recent studies which have shown that these scaffolds can be used to promote cell and tissue regeneration both in vitro and in vivo. The author also presents some fundamental knowledge gaps which are preventing the widespread translation of such scaffolds. Finally, the author outlines a selection of studies that elucidate molecular assembly mechanisms and biophysical properties of amyloid-like peptide nanofibrils and suggests how studies like these might lead to the ability to generate nanofibril scaffolds with bespoke properties for tissue engineering.

Use of adipose tissue and stromal vascular fraction in hand surgery

Adipose tissue is an abundant source of various cell types including not only adipocytes, but also progenitor and endothelial cells from thestroma. Interest in adipose tissue has surged since the identification in 2001 of adipose-derived stem cells (ADSCs) and of the stromal vascular fraction (SVF) obtained from adipose tissue by enzymatic digestion and centrifugation. SVF has been proven effective in ensuring tissue regeneration, thus improving tissue trophicityand vascularisation. These effects have generated strong interest among both physicians and surgeons, particularly in the field of hand surgery. Several applications have been developed and used, for instance to treat Dupuytren's contracture, systemic sclerosis-related hand lesions, and skin ageing at the hand. Other uses are being evaluated in clinical or animal studies. The objective of this article is to review the capabilities of adipose tissue and their current and potential applications in hand surgery.

Effects of Metal Micro and Nano-Particles on hASCs: An In Vitro Model

As the knowledge about the interferences of nanomaterials on human staminal cells are scarce and contradictory, we undertook a comparative multidisciplinary study based on the size effect of zero-valent iron, cobalt, and nickel microparticles (MPs) and nanoparticles (NPs) using human adipose stem cells (hASCs) as a model, and evaluating cytotoxicity, morphology, cellular uptake, and gene expression. Our results suggested that the medium did not influence the cell sensitivity but, surprisingly, the iron microparticles (FeMPs) resulted in being toxic. These data were supported by modifications in mRNA expression of some genes implicated in the inflammatory response. Microscopic analysis confirmed that NPs, mainly internalized by endocytosis, persist in the vesicles without any apparent cell damage. Conversely, MPs are not internalized, and the effects on hASCs have to be ascribed to the release of ions in the culture medium, or to the reduced oxygen and nutrient exchange efficiency due to the presence of MP agglomerating around the cells. Notwithstanding the results depicting a heterogeneous scene that does not allow drawing a general conclusion, this work reiterates the importance of comparative investigations on MPs, NPs, and corresponding ions, and the need to continue the thorough verification of NP and MP innocuousness to ensure unaffected stem cell physiology and differentiation.

BMP-2 can promote the osteogenic differentiation of human endometrial stem cells

Background: Human endometrial-derived stem cells (hEnSCs) as multipotent accessible source of cells are known as useful cell candidates in the field of bone tissue engineering. However, the effect of bone morphogenic protein-2 (BMP-2) as an osteoinductive growth factor has not been clearly ascertained.

Objective: To evaluate the effect of the remarkable osteoinductive growth factor BMP-2, on promotion of osteogenic differentiation in hEnSCs.

Methods: Endometrial biopsies were obtained from healthy women referred to the hospital for infertility treatment. After tissue digestion in collagenase, the isolated endometrial cells were expanded in Dulbecco’s modified Eagle medium (DMEM) supplemented with 10% FBS. The propagated cells were characterized based on the expression of endometrial (CD90, CD105), endothelial (CD31), and hematopoietic (CD34, CD133) stem cell markers. Cells were differentiated in osteogenic medium containing DMEM supplemented with 10% FBS, 10 nM dexamethasone, 50 μg/ml Ascorbic acid, and 10 mM β-glycerophosphate in the presence or absence of BMP-2 for 21 days. Alizarin red staining was performed to verify the matrix mineralization. Immunocytochemical staining was conducted to detect the expression of OCT-4, CD133, and osteopontin as well as osteocalcin. The expression of osteoblast transcripts, including osteopontin, osteonectin, and alkaline phosphatase (ALP) were analyzed by semi quantitative PCR.

Results: The expanded EnSCs were spindle shaped. They were positive for the expression of Oct-4, CD90, and CD105, while they were negative for endothelial and hematopoietic markers. The matrix mineralization was confirmed by Alizarin red in both groups at day 21. Although the expression of osteopontin and osteocalcin was detected in both groups by immunological staining, the expression of osteocalcin was more intense in the presence of BMP-2. ALP, Osteonectin and osteopontin transcripts were expressed in all groups; however, the expression of ALP and osteopontin was upregulated in the presence of BMP-2.

Conclusion: BMP-2 as an osteoinductive growth factor, could promote the osteogenic differentiation of EnSCs in vitro.

Human Adipose-Derived Mesenchymal Stromal Cells May Promote Breast Cancer Progression and Metastatic Spread

BACKGROUND

Stem cell-enriched fat grafting has been proposed as a potential therapy for reconstructive, restorative, or enhancement-related procedures of the breast. Its role in postoncologic breast reconstruction is still emerging, with concerns about safety. The authors investigated the dose-dependent interaction between human adipose-derived mesenchymal stromal cells (AD-MSCs) and human breast cancer cell (BCC) lines [MDA-MB-231 (MDA) and MCF-7 (MCF)] focusing on tumor microenvironment, tumor growth, and metastatic spread.

METHODS

Adipose-derived mesenchymal stromal cell influence on viability and factor expression [regulated on activation, normal T cell expressed and secreted (RANTES), tumor necrosis factor-α, and eotaxin) of breast cancer cells was studied in vitro using direct and indirect co-culture systems. Groups were formed according to adipose-derived mesenchymal stromal cell-to-cancer cell number ratio [MDA/MCF only, AD-MSC/(MDA/MCF), and AD-MSC/(MDA/MCF)]. A humanized orthotopic murine cancer model was used to evaluate breast cancer progression and metastasis (n = 10/group). Cells were injected into the mammary pad in different ratios and animals were monitored over 42 days. Microdialysis was performed to analyze RANTES levels in the tumor microenvironment (days 21 and 42). Primary and metastatic tumors were weighed and analyzed for oncogene, growth factor, and metastatic marker expression.

RESULTS

MDA cell viability increased from 45.5 percent to 95.5 percent in presence of adipose-derived mesenchymal stromal cells in vitro. In vivo, animals with AD-MSC showed increased mean tumor weight (MDA, p < 0.01; MCF versus controls, p < 0.05) and metastatic occurrence (40 percent in MDA; 30 percent in MCF versus 0 percent in controls). Cytokine analysis revealed switching of MCF tumor phenotype to a more malignant type in the presence of adipose-derived mesenchymal stromal cells.

CONCLUSION

Human adipose-derived mesenchymal stromal cells may promote progression and metastatic spread in breast cancer through a switch to a more malignant phenotype with worse prognosis.

Reforming craniofacial orthodontics via stem cells

Stem cells are the most interesting cells in cell biology. They have the potential to evolve as one of the most powerful technologies in the future. The future refers to an age where it will be used extensively in various fields of medical and dental sciences. Researchers have discovered a number of sources from which stem cells can be derived. Craniofacial problems are very common and occur at all ages. Stem cells can be used therapeutically in almost every field of health science. In fact, many procedures will be reformed after stem cells come into play. This article is an insight into the review of the current researches being carried out on stem cells and its use in the field of orthodontics, which is a specialized branch of dentistry. Although the future is uncertain, there is a great possibility that stem cells will be used extensively in almost all major procedures of orthodontics.

Nanoscale stimulation of osteoblastogenesis from mesenchymal stem cells: nanotopography and nanokicking

AIM

Mesenchymal stem cells (MSCs) have large regenerative potential to replace damaged cells from several tissues along the mesodermal lineage. The potency of these cells promises to change the longer term prognosis for many degenerative conditions currently suffered by our aging population. We have endeavored to demonstrate our ability to induce osteoblatogenesis in MSCs using high-frequency (1000-5000 Hz) piezo-driven nanodisplacements (16-30 nm displacements) in a vertical direction.

MATERIALS & METHODS

Osteoblastogenesis has been determined by the upregulation of osteoblasic genes such as osteonectin (ONN), RUNX2 and Osterix, assessed via quantitative real-time PCR; the increase of osteocalcin (OCN) and osteopontin (OPN) at the protein level and the deposition of calcium phosphate determined by histological staining.

RESULTS

Intriguingly, we have observed a relationship between nanotopography and piezo-stimulated mechanotransduction and possibly see evidence of two differing osteogenic mechanisms at work. These data provide confidence in nanomechanotransduction for stem cell differentiation without dependence on soluble factors and complex chemistries.

CONCLUSION

In the future it is envisaged that this technology may have beneficial therapeutic applications in the healthcare industry, for conditions whose overall phenotype maybe characterized by weak or damaged bones (e.g., osteoporosis and bone fractures), and which can benefit from having an increased number of osteoblastic cells in vivo.

Activation of cannabinoid receptor 2 enhances osteogenic differentiation of bone marrow derived mesenchymal stem cells

Bone marrow derived mesenchymal stem cells (BM-MSCs) are considered as the most promising cells source for bone engineering. Cannabinoid (CB) receptors play important roles in bone mass turnover. The aim of this study is to test if activation of CB₂ receptor by chemical agonist could enhance the osteogenic differentiation and mineralization in bone BM-MSCs. Alkaline phosphatase (ALP) activity staining and real time PCR were performed to test the osteogenic differentiation. Alizarin red staining was carried out to examine the mineralization. Small interference RNA (siRNA) was used to study the role of CB₂ receptor in osteogenic differentiation. Results showed activation of CB₂ receptor increased ALP activity, promoted expression of osteogenic genes, and enhanced deposition of calcium in extracellular matrix. Knockdown of CB₂ receptor by siRNA inhibited ALP activity and mineralization. Results of immunofluorescent staining showed that phosphorylation of p38 MAP kinase is reduced by knocking down of CB₂ receptor. Finally, bone marrow samples demonstrated that expression of CB₂ receptor is much lower in osteoporotic patients than in healthy donors. Taken together, data from this study suggested that activation of CB₂ receptor plays important role in osteogenic differentiation of BM-MSCs. Lack of CB₂ receptor may be related to osteoporosis.

Stress urinary incontinence in women and cell therapy: What can we expect from the future?

Stress urinary incontinence (SUI) is a common disorder that affects a large number of women and their quality of life. The aim of SUI therapy is to restore the existing urethral function via physical therapy, biofeedback, pelvic floor rehabilitation, pharmacological therapy, bulking agents and surgical approaches. Currently, the gold standard for the management of SUI is the tension-free vaginal sling, which provides structural support to the female urethra. However, even minimally invasive surgical procedure such as “slings” carries risks for the patients, lost efficacy over the time and has long-term complications. For this reason, new therapeutic modalities are needed. Cell therapy has been emerged as an alternative to be used on the treatment of different diseases. The use of stem cells as a therapeutic option for SUI is an attractive alternative because, theoretically, injected cells could restore functional muscle cells and aid in sphincter closure in women with sphincter-associated incontinence. This study aims to review the current literature regarding evidences for using stem cell therapy on stress urinary incontinence in women.

Skin regeneration: the complexities of translation into clinical practise

The integration of engineering into biological science has resulted in the capacity to provide tissue engineered solutions for tissue damage. Skin regeneration remains the goal of skin repair to reduce the long term consequences of scarring to the individual. A scar is abnormal in its architecture, chemistry and cell phenotype, tissue engineering of scaffolds and cells opens up the potential of tissue regeneration into the future. Tissue engineering solutions have been applied to skin many decades despite technical success the clinical application has been modest. To realise the potential of the developing technologies needs alignment of not only the science and engineering but also the commercial upscaling of production in a safe and regulated framework for clinical use. In addition the education and training for the introduction of new technology within the health system is essential, bringing together the technology and systems for utilisation to optimise the patient outcome. This article is part of a Directed Issue entitled: Regenerative Medicine: The challenge of translation.

Effects of bone morphogenetic protein-4 (BMP-4) on adipocyte differentiation from mouse adipose-derived stem cells

OBJECTIVES

As mesenchymal stem cells (MSCs) can be isolated easily from adipose tissues while retaining their self-renewal and multi-potential differentiation capacities, they hold promising possibilities for being applied extensively in tissue engineering. Bone morphogenetic protein (BMP) family members have been reported to provide instructive signals to MSCs for them to differentiate into several different cell lineages. The study described here aims to investigate whether BMP-4 could promote adipose-derived stem cell (ASC) differentiation into adipocytes under various concentrations.

MATERIALS AND METHODS

ASCs were isolated from mouse inguinal adipose pads and cultured in vitro. 10 ng/ml and 50 ng/ml BMP-4 were added to adipogenic media for 8 days. Oil red-O staining, reverse transcription/polymerase chain reaction and immunocytofluorescence staining were performed to examine differentiation of the ASCs.

RESULTS

As indicated by increased expression of adipogenic and lipogenic genes (PPAR-γ, APN and LPL) and proteins, 50 ng/ml BMP-4 seemed to induce mASCs to differentiate into the adipo-lineage compared to 10 ng/ml BMP-4, and control groups. In addition, lipid droplets accumulated within the adipocytes under 50 ng/ml BMP-4 stimulation, as shown by oil red-O staining.

CONCLUSIONS

Our present study suggests that BMP-4, as an adipo-inducing factor, promoted adipogenesis of ASCs at higher concentrations (50 ng/ml) and can perhaps be considered as a candidate for use in adipose tissue engineering.

Fat grafting and stem cell enhanced fat grafting to the breast under oncological aspects--recommendations for patient selection

Reconstructive and aesthetic fat grafting has been introduced to the breast level over the last years. The safety of such procedures has so far not been completely clarified. The concept has now been refined to stem cell enhanced fat grafting. However beside the promise of using adult stem cells in terms of tissue rejuvenation and augmentation, scar treatment and reconstruction, the variance of adipose stem cell function--including angiogenetic, antiapoptotic, immunomodulatory, chemotactic and anti-scarring potential--raises new scepsis about oncological safety. Herein we reviewed experimental and clinical data on fat grafting and stem cell enhanced fat grafting addressing surgical promise and oncological concerns. Based on these data we suggest clinical criteria for patient selection undergoing fat grafting for aesthetic or reconstructive reasons based on their individual breast cancer risk.

The role of adipose derived stem cells, smooth muscle cells and low intensity laser irradiation (LILI) in tissue engineering and regenerative medicine

Tissue engineering and regenerative medicine has become the treatment of choice for several degenerative diseases. It involves the repairing or replacing of diseased or damaged cells or tissues. Stem cells have a key role to play in this multidisciplinary science because of their capacity to differentiate into several lineages. Adipose derived stem cells (ADSCs) are adult mesenchymal stem cells that are easily harvested and have the capacity to differentiate into cartilage, bone, smooth muscle, fat, liver and nerve cells. ADSCs have been found to differentiate into smooth muscle cells which play major roles in diseases such as asthma, hypertension, cancer and arteriosclerosis. Low Intensity Laser Irradiation (LILI), which involves the application of monochromatic light, has been found to increase viability, proliferation and differentiation in several types of cells including ADSCs. This review discusses the role of ADSCs, smooth muscle cells and LILI in the science of tissue engineering and regenerative medicine.

Novel aspects of parenchymal-mesenchymal interactions: from cell types to molecules and beyond

Mesenchymal stem or stromal cells (MSCs) were initially isolated from the bone marrow and received their name on the basis of their ability to differentiate into multiple lineages such as bone, cartilage, fat and muscle. However, more recent studies suggest that MSCs residing in perivascular compartments of the small and large blood vessels play a regulatory function supporting physiologic and pathologic responses of parenchymal cells, which define the functional representation of an organ or tissue. MSCs secrete or express factors that reach neighbouring parenchymal cells via either a paracrine effect or a direct cell-to-cell interaction promoting functional activity, survival and proliferation of the parenchymal cells. Previous concept of 'epithelial-stromal' interactions can now be widened. Given that MSC can also support hematopoietic, neuronal and other non-epithelial parenchymal lineages, terms 'parenchymal-stromal' or 'parenchymal-mesenchymal' interactions may better describe the supportive or 'trophic' functions of MSC. Importantly, in many cases, MSCs specifically provide supportive microenvironment for the most primitive stem or progenitor populations and therefore can play a role as 'stem/progenitor niche' forming cells. So far, regulatory roles of MSCs have been reported in many tissues. In this review article, we summarize the latest studies that focused on the supportive function of MSC. This thread of research leads to a new perspective on the interactions between parenchymal and mesenchymal cells and justifies a principally novel approach for regenerative medicine based on co-application of MSC and parenchymal cell for the most efficient tissue repair.

Cyclic tensile loading regulates human mesenchymal stem cell differentiation into neuron-like phenotype

Mechanical loading has been utilized as an effective tool to direct mesenchymal stem cells (MSCs) commitment into cell lineages of mesodermal origin. However, the use of this tool to induce transdifferentiation of MSCs into the neural lineage has never been attempted. In this study, we examined the potential of uniaxial cyclic tensile loading in promoting neuronal differentiation of human MSCs (hMSCs) on modified biodegradable poly(ε-caprolactone) (PCL). The stem cell morphology, tissue-specific gene and protein expression, microfilament structure and, subsequently, Rho GTPase activity were analysed after cyclically stretching the cells at a range of amplitudes (0.5%, 2% or 3.5%) and frequencies (0.5, 1 or 1.5 Hz) for 8 h. hMSCs responded to these stimuli and displayed distinctly different microfilament organization. However, only those stretched at 0.5% strain amplitude and 0.5 Hz frequency showed promoted outgrowth of filopodia with significant upregulation of neurogenic genes expression. Positive staining of the neurogenic protein markers Nestin and Tuj1 suggested that the hMSCs had been committed to early neuronal progenitors. In addition, Rac1 but not RhoA was activated at this particular loading parameter. Furthermore, inhibition of Rac1 activity with NSC23766 disrupted the effect of cyclic loading. The results suggest that cyclic tensile loading at low amplitude and frequency is capable of triggering neuron-like differentiation through the regulation of Rho GTPases activity, even in the absence of neurogenic induction medium.

Diferenciação in vitro de células-tronco mesenquimais da medula óssea de cães em precursores osteogênicos

O objetivo principal da nossa pesquisa foi avaliar o potencial de diferenciação osteogênica de células-tronco mesenquimais (MSC) obtidas da medula óssea do cão. As MSC foram separadas pelo método Ficoll e cultivadas sob duas condições distintas: DMEM baixa glicose ou DMEM/F12, ambos contendo L-glutamina, 20% de SFB e antibióticos. Marcadores de MSC foram testados, confirmando células CD44+ e CD34- através da citometria de fluxo. Para a diferenciação osteogênica, as células foram submetidas a quatro diferentes condições: Grupo 1, as mesmas condições utilizadas para a cultura de células primárias com os meios DMEM baixa glicose suplementado; Grupo 2, as mesmas condições do Grupo 1, mais os indutores de diferenciação dexametasona, ácido ascórbico e b-glicerolfosfato; Grupo 3, células cultivadas com meios DMEM/F12 suplementado; e Grupo 4, nas mesmas condições que no Grupo 3, mais indutores de diferenciação de dexametasona, ácido ascórbico e b-glicerolfosfato. A diferenciação celular foi confirmada através da coloração com alizarin red e da imunomarcação com o anticorpo SP7/Osterix. Nós observamos através da coloração com alizarin red que o depósito de cálcio foi mais evidente nas células cultivadas em DMEM/F12. Além disso, usando a imunomarcação com o anticorpo SP/7Osterix obtivemos positividade em 1:6 células para o Meio DMEM/F12 comparada com 1:12 para o meio DMEM-baixa glicose. Com base nos nossos resultados concluímos que o meio DMEM/F12 é mais eficiente para a indução da diferenciação de células-tronco mesenquimais caninas em promotores osteogênicos. Este efeito provavelmente ocorre em decorrência da maior quantidade de glicose neste meio, bem como da presença de diversos aminoácidos.

Evaluation of castor oil-based polyurethane membranes in rat bone-marrow cell culture

PURPOSE: To evaluate three methods to isolate rats MSCs and to analyze the potential of a castor oil polyurethane base membrane as a scaffold for MSCs. METHODS: Four male Wistar rats, aged 20-30 days were used. Bone marrow aspirates from femur and tibia were harvested using DMEM high glucose and heparin. The cell culture was performed in three different ways: direct culture and two types of density gradients. After 15 days, was made the 1st passage and analyzed cell viability with markers Hoerscht 33342 and propidium iodide. The MSCs were characterized by surface markers with the aid of flow cytometry. After this, three types of castor oil polyurethane membranes associated with the MSCs were kept on the 6-well plate for 5 days and were analyzed by optical microscopy to confirm cell aggregation and growth. RESULTS: Separation procedures 1 and 2 allowed adequate isolation of MSCs and favored cell growth with the passage being carried out at 70% confluence after 15 days in culture. The cells could not be isolated using procedure 3. When the 3 castor oil polyurethane membrane types were compared it was possible to observe that the growth of MSCs was around 80% in membrane type 3, 20% in type 2, and 10% in type 1. CONCLUSION: Both Ficoll-Hypaque densities allow isolation of rat MSCs, and especially castor oil-based membrane type 3 may be used as a scaffold for MSCs.

Focal adhesions in osteoneogenesis

As materials technology and the field of tissue engineering advance, the role of cellular adhesive mechanisms, in particular, interactions with implantable devices, becomes more relevant in both research and clinical practice. A key tenet of medical device technology is to use the exquisite ability of biological systems to respond to the material surface or chemical stimuli in order to help to develop next-generation biomaterials. The focus of this review is on recent studies and developments concerning focal adhesion formation in osteoneogenesis, with an emphasis on the influence of synthetic constructs on integrin-mediated cellular adhesion and function.

Novel polyurethanes with interconnected porous structure induce in vivo tissue remodeling and accompanied vascularization

Tissue engineering and regenerative medicine have furnished a vast range of modalities to treat either damaged tissue or loss of soft tissue or its function. In most approaches, a temporary porous scaffold is required to support tissue regeneration. The scaffold should be designed such that the turnover synchronizes with tissue remodeling and regeneration at the implant site. Segmented polyester urethanes (PUs) used in this study were based on epsilon-caprolactone (CL) and co-monomers D,L-lactide (D,L-L) and gamma-butyrolactone (BL), and 1,4-butanediisocyanate (BDI). In vitro, the PUs were nontoxic and haemocompatible. To test in vivo biocompatibility, the PUs were further processed into porous structures and subcutaneously implanted in rats for a period up to 21 days. Tissue remodeling and scaffold turnover was associated with a mild tissue response. The tissue response was characterized by extensive vascularization through the interconnected pores, with low numbers of macrophages on the edges and stroma formation inside the pores of the implants. The tissue ingrowth appeared to be related to the extent of microphase separation of the PUs and foam morphology. By day 21, all of the PU implants were highly vascularized, confirming the pores were interconnected. Degradation of P(CL/D,L-L)-PU was observed at this time, whereas the other two PU types remained intact. The robust method reported here of manufacturing and processing, good mechanical properties, and in vivo tissue response of the porous P(CL/D,L-L)-PU and PBCL-PU makes them excellent candidates as biomaterials with an application for soft tissue remodeling, for example, for cardiovascular regeneration.

The spreading, migration and proliferation of mouse mesenchymal stem cells cultured inside hyaluronic acid hydrogels

Synthetic hydrogel scaffolds that can be used as culture systems that mimic the natural stem cell niche are of increased importance for stem cell biology and regenerative medicine. These artificial niches can be utilized to control the stem cell fate and will have potential applications for expanding/differentiating stem cells in vitro, delivering stem cells in vivo, as well as making tissue constructs. In this study, we synthesized hyaluronic acid (HA) hydrogels that could be degraded through a combination of cell-released enzymes and used them to culture mouse mesenchymal stem cells (mMSC). To form the hydrogels, HA was modified to contain acrylate groups and crosslinked through Michael addition chemistry using non-degradable, plasmin degradable or matrix metalloproteinase (MMP) degradable crosslinkers. Using this hydrogel we found that mMSC proliferation occurred in the absence of cell spreading, that mMSCs could only spread when both RGD and MMP degradation sites were present in the hydrogel and that mMSCs in hydrogels with high density of RGD (1000 μm) spread and migrated faster and more extensively than in hydrogels with low density of RGD (100 μm).

Micropatterned matrix directs differentiation of human mesenchymal stem cells towards myocardial lineage

Stem cell response can be influenced by a multitude of chemical, topological and mechanical physiochemical cues. While extensive studies have been focused on the use of soluble factors to direct stem cell differentiation, there are growing evidences illustrating the potential to modulate stem cell differentiation via precise engineering of cell shape. Fibronectin were printed on poly(lactic-co-glycolic acid) (PLGA) thin film forming spatially defined geometries as a means to control the morphology of bone marrow derived human mesenchymal stem cells (hMSCs). hMSCs that were cultured on unpatterned substrata adhered and flattened extensively (approximately 10,000 microm(2)) while cells grown on 20 microm micropatterend wide adhesive strips were highly elongated with much smaller area coverage of approximately 2000 microm(2). Gene expression analysis revealed up-regulation of several hallmark markers associated to neurogenesis and myogenesis for cells that were highly elongated while osteogenic markers were specifically down-regulated or remained at its nominal level. Even though there is clearly upregulated levels of both neuronal and myogenic lineages but at the functionally relevant level of protein expression, the myogenic lineage is dominant within the time scale studied as determined by the exclusive expression of cardiac myosin heavy chain for the micropatterned cells. Enforced cell shape distortion resulting in large scale rearrangement of cytoskeletal network and altered nucleus shape has been proposed as a physical impetus by which mechanical deformation is translated into biochemical response. These results demonstrated for the first time that cellular shape modulation in the absence of any induction factors may be a viable strategy to coax lineage-specific differentiation of stem cells.

Serum regulates adipogenesis of mesenchymal stem cells via MEK/ERK-dependent PPARgamma expression and phosphorylation

Mesenchymal stem cells (MSCs) provide us an excellent cellular model to uncover the molecular mechanisms underlying adipogenic differentiation of adult stem cells. PPARγ had been considered as an important molecular marker of cells undergoing adipogenic differentiation. Here, we demonstrated that expression and phosphorylation of PPARγ could be found in bone marrow–derived MSCs cultured in expansion medium without any adipogenic additives (dexamethasone, IBMX, insulin or indomethacin). Then, PPARγ was dephosphorylated in MSCs during the process of adipogenic differentiation. We then found that inhibition of MEK activation by specific inhibitor (PD98059) counteracted the PPARγ expression and phosphorylation. However, expression and phosphorylation of PPARγ did not present in MSCs cultured in medium with lower serum concentration. When these MSCs differentiated into adipocytes, no phosphorylation could be detected to accompany the expression of PPARγ. Moreover, exposure of MSCs to higher concentration of serum induced stronger PPARγ expression, and subsequently enhanced their adipogenesis. These data suggested that activation of the MEK/ERK signalling pathway by high serum concentration promoted PPARγ expression and phosphorylation, and subsequently enhanced adipogenic differentiation of MSCs.

Engineered adipose tissue of predefined shape and dimensions from human adipose-derived mesenchymal stem cells

Human adipose-derived mesenchymal stem cells (hAD-MSCs) were cultured in growth medium of low calcium concentration to which antioxidants had been added. Large numbers of hAD-MSCs could be obtained within 2 weeks. Scaffolding was made with 3 commonly used biomaterials. Gelatin sponges and polyglycolic acid meshes were cut into small pieces and put into the scaffold pocket, which was made of polypropylene mesh and measured 1.5 x 1.0 x 0.5 cm3. Immune-deficient mice were divided into 3 groups. In Group I, only hAD-MSCs were injected. In Group II, the scaffold alone was implanted and harvested after 2 months in vivo. In Group III, scaffolds were cultured with hAD-MSCs in adipogenic medium for 2 weeks before implantation, and 2 implanted scaffolds were harvested after 2, 4, and 6 months in vivo. All of the successfully harvested scaffolds were filled with newly formed adipose tissue and had retained their predefined shape and dimensions. New blood vessels had also grown into the newly formed adipose tissue. Adipose tissue of specific shape and 3 dimensions was regenerated in vivo using tissue engineering of hAD-MSCs and scaffolding made with 3 common biomaterials.

Time-lapse analysis and microdissection of living 3D melanoma cell cultures for genomics and proteomics

A novel technique is presented for the monitoring and morphological characterization of 3D cell cultures targeted for laser capture microdissection (LCM). A custom-made chamber enables time-lapse topography and pre-selection of cell targets in order to minimize microdissection time, optimizing the quality of biomolecules for downstream analyses. The method complements the recently presented novel application of LCM in living 3D cultures, whose compatibility with standard genomics and proteomics assays such as microarrays, real-time PCR, and 2D gel electrophoresis is further corroborated here. Specifically, the above techniques are employed in tandem to study, as a proof of principle, the dynamics of in vitro vasculogenic mimicry. It was shown previously that aggressive melanoma cells spontaneously differentiate on collagen gels into vascular-like networks with strong endogenous angiogenic potential. Here the evolution of vasculogenic mimicry was quantified by three time-dependent variables: the distribution of the vascular-like network lengths, widths, and area coverage. Based on these morphological descriptors the networks were locally classified over time as "early" or "mature" stage. LCM of networks and randomly oriented cells followed by real-time PCR for select genes revealed that differential expression was time-dependent and increased with network maturity. The method is widely applicable for microgenomics and microproteomics analyses in phenotypically evolving 3D cultures (i.e., of stem cells), under spontaneous or directed differentiation. Therefore beyond enabling future rigorous analyses on the mechanistics of vasculogenic mimicry, it provides a practical discovery engine for a range of developmental studies and tissue regenerative engineering applications.

Treatment with bone marrow-derived stromal cells accelerates wound healing in diabetic rats

Bone marrow stem cells participate in tissue repair processes and may have a role in wound healing. Diabetes is characterised by delayed and poor wound healing. We investigated the potential of bone marrow-derived mesenchymal stromal cells (BMSCs) to promote healing of fascial wounds in diabetic rats. After manifestation of streptozotocin (STZ)-induced diabetic state for 5 weeks in male adult Sprague-Dawley rats, healing of fascial wounds was severely compromised. Compromised wound healing in diabetic rats was characterised by excessive polymorphonuclear cell infiltration, lack of granulation tissue formation, deficit of collagen and growth factor [transforming growth factor (TGF-beta), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), platelet-derived growth factor PDGF-BB and keratinocyte growth factor (KGF)] expression in the wound tissue and significant decrease in biomechanical strength of wounds. Treatment with BMSC systemically or locally at the wound site improved the wound-breaking strength (WBS) of fascial wounds. The improvement in WBS was associated with an immediate and significant increase in collagen levels (types I-V) in the wound bed. In addition, treatment with BMSCs increased the expression of growth factors critical to proper repair and regeneration of the damaged tissue moderately (TGF-beta, KGF) to markedly (EGF, VEGF, PDGF-BB). These data suggest that cell therapy with BMSCs has the potential to augment healing of the diabetic wounds.

Alkaline phosphatase, glutathione-S-transferase-P, and cofilin-1 distinguish multipotent mesenchymal stromal cell lines derived from the bone marrow versus peripheral blood

Multipotent mesenchymal stromal cells (MSCs) can be isolated from bone marrow or peripheral blood. To identify phenotypical and functional differences between MSCs derived from these sources, the human bone marrow-derived, fibroblast-like cell line L87/4 was compared with the peripheral blood-derived, fibroblast-like cell line V54/2. Both cell lines expressed similar levels of SH3+, CD45(-), CD68(-), CD133(-), and HLA-DR(-). The bone marrow-derived cells expressed higher surface levels of CD105, CD10, and CD117 and preferentially expressed alkaline phosphatase, glutathione S-transferase P, and cofilin-1. The peripheral blood-derived line showed a higher number of CD34+/CD105+ double-positive and side population (SP) cells. The results demonstrate the more multipotent, yet quiescent, stromal phenotype of bone marrow MSCs, whereas MSCs isolated from the circulation display more hematopoietic-lineage characteristics. Importantly, potential marker genes that distinguish the two stages of MSCs are defined.

Expression of stem and germ cell markers within nonfollicle structures in adult mouse ovary

Recent studies have suggested that germline stem cells may generate new follicles in the adult murine ovary. In this study, the authors use a pou5f1-enhanced green fluorescent protein (EGFP) transgenic mouse model to study the expression of stem and germ cell markers in adult murine ovaries. Immunohistochemical analyses and reverse transcription polymerase chain reaction were performed to detect the expression of mouse vasa homologue, stem cells factor receptor, stage-specific embryonic antigen 1, synaptonemal complex proteins, disrupted meiotic, and growth differentiation factor-9 in GFP+ ovarian tissues. GFP+ cell aggregates of nonfollicle structures were identified and isolated from adult B6.CBA-Tg(pou5f1-EGFP)2Mnn/J transgenic mouse ovaries. This study shows the presence of cell aggregates that are distinct from ovarian follicles and are coexpressing germline and stem cell surface markers in adult murine ovaries. These cell aggregates may represent a mixed population of germ cells and germline stem cells. Further research is necessary to evaluate the plasticity of the potential stem cell population in these cell aggregates.

Therapeutic pathways of adult stem cell repair

The use of adult stem cells as therapeutic agents to treat disease has become increasingly prevalent. During the last decade, isolated and expanded stem and progenitor cells have demonstrated the capacity to differentiate into multiple cell types. Early optimism that in vitro differentiation capacity would translate into in vivo tissue regeneration has lessened and identifying the mechanisms that underlie the benefit of stem cell repair is an emerging area of investigation. This review considers several of the pathways and mechanisms required for adult stem cell repair. These mechanisms include the mobilization and the homing of stem cells to sites of injury, immunomodulatory effect of stem cells, and the association of stem cells with increased vascularization of injured tissue. These data suggest that the unique properties of adult stem cells can be utilized to treat a wide variety of diseases that cannot be treated with existing pharmacological agents, and prompt new paradigms for the bio-pharmacokinetics of biological expressed by efficacious stem cells.

Nonmyeloablative stem cell therapy enhances microcirculation and tissue regeneration in murine inflammatory bowel disease

BACKGROUND AND AIMS

Reduced microcirculation has been implicated in the pathogenesis of inflammatory bowel disease (IBD). Stem cells or endothelial progenitor cells are thought to contribute to tissue regeneration through neoangiogenesis or vasculogenesis in ischemia- or inflammatory-related diseases. We therefore hypothesized that adult stem cells facilitate epithelial repair in IBD.

METHODS

Moderate-severe colitis in mice was induced by dextran sulfate sodium (DSS) and 2.0 x 10(6) immortalized CD34(-) stem cells infused twice via the tail vein during an observation period of 35 days in a nonmyeloablative setting.

RESULTS

Here, we demonstrate that adult stem cells home to the damaged digestive tract in the large intestine and facilitate mucosal repair in moderate-severe colitis. Nonmyeloablative stem cell therapy resulted in increased survival in severe colitis (P < .0001). Moreover, clinical activity and histologic evaluation of the colitis severity score were reduced significantly in moderate (P = .0003 or P = .03) and severe (P < .0001 or P < .03) colitis after 35 days, in addition to the DSS-induced shortening of colon length (P = .002 and P < .0002). Genetically marked stem cells were detected predominantly in the submucosa of the damaged colon epithelium. Epithelial repair in experimental IBD was mediated either by induction of improved vasculogenesis or by the differentiation of the transplanted stem cells into endothelial cells, as demonstrated by the promotion of Tie2 activity in the infused cells at the site of the damaged mucosa.

CONCLUSIONS

Our findings indicate that systemically administered adult stem cells respond to an adequate tissue lesion in murine IBD by enhancing microcirculation, resulting in accelerated tissue repair.

Stem cells for regeneration of urological structures

OBJECTIVES

This review focuses on advances in regenerative therapies using stem cells in urology.

METHODS

A detailed literature search was performed using the PubMed database of the National Center of Biotechnology Information. Publications of experimental investigations and clinical trials using stem cells in reconstructive urology have been summarized and critically reviewed.

RESULTS

Tissue engineering and autologous cell therapy techniques have been developed to generate prostheses for different urological tissues and organ systems. During the last decade, increasing numbers of studies have described stem cells in the context of therapeutic tools. The ability of adult and embryonic stem cells as well as progenitors to improve bladder wall architecture, improve renal tubule formation, or promote restoration of spermatogenesis or recovery of continence has been investigated in several animal models. Although results have been encouraging, only a myoblast-based therapy of incontinence has reached clinical trials.

CONCLUSIONS

Several populations of adult stem cells and progenitor cells have been studied as useful cellular sources in the treatment and reconstruction of urological organs. However, considerable basic research still needs to be performed to ensure the controlled differentiation and long-term fate of stem cells following transplantation.

Development of separation technique for stem cells

In recent years, human embryonic stem cells have been established, and somatic stem cells derived from various adult organs have been identified and characterized to differentiate into various kinds of functional cells. There have been attempts to use functional cells induced from such stem cells for tissue regeneration and cell therapy. The method is expected to become an important treatment for intractable diseases in the near future. Since tissues and organs generally contain only a small quantity of somatic stem cells, and since it is necessary to separate functional cells generated from stem cells for use in therapy, an effective method for specific cell separation is crucial to the practical application of regenerative medicine. For the specific separation of cells, a fluorescence activated cell sorter using specific antibodies is a powerful tool, but the method is not suitable for large-scale processing and a special device is required. Although a magnetic cell separation system using immuno-magnetic fine particles is also commercially available, the system still needs special apparatus for large-scale processing. We developed a novel method for the separation of specific cells in an aqueous two-phase system using antibodies modified with a temperature-responsive polymer. The method enables the processing of a large quantity of cells without the requirement of a special device.

The MR tracking of transplanted ATDC5 cells using fluorinated poly-l-lysine-CF3

Magnetic resonance (MR) imaging using super-paramagnetic iron oxides (SPIOs) is a powerful tool to monitor transplanted cells in living animals. However, since SPIOs are negative contrast agents it is difficult to track transplanted cells in bone and cartilage that originally display low signals. In this study, we examined the feasibility of tracking with fluorescein isothiocyanate (FITC)-labeled poly-L-lysine-CF(3) (PLK-CF(3)) using mouse ATDC5 cells, a stem cell line of bone and cartilage cells. FITC-labeled PLK-CF(3) was easily internalized by ATDC5 cells by adding it into culture medium. No acute or long-term toxicities were seen at less than 160 microg/ml. Labeled cells transplanted into the cranial bone of mice were detected for at least 7 days by MR images. FITC-labeled PLK-CF(3) is a useful positive contrast agent for MR tracking in bone and cartilage.

Stem cells and adipose tissue engineering

A large proportion of the plastic and reconstructive surgical procedures performed each year are to repair soft tissue defects that result from traumatic injury, tumor resection, and congenital defects. These defects typically result from the loss of a large volume of adipose tissue. To date, no ideal filler material which is successful in all cases has been developed. Additionally, the success of using autologous fat tissue grafts to repair soft tissue defects has been limited. Researchers are thus investigating strategies to engineer volumes of adipose tissue that may be used in these cases. A necessary component for engineering a viable tissue construct is an appropriate cell source. Attempts to engineer adipose tissue have involved the use of preadipocytes and adipocytes as the base cell source. Increased interest surrounding the research and development of stem cells as a source of cells for tissue engineering has, however, led to a new path of investigation for developing adipose tissue-engineering strategies. This manuscript serves as a review of the current state of adipose tissue-engineering methods and describes the shift toward tissue-engineering strategies using stem cells.