The effect of hyaluronan hydrogel on fat graft survival

Liposomes Affect Protein Release and Stability of ITA-Modified PLGA-PEG-PLGA Hydrogel Carriers for Controlled Drug Delivery

Fat grafting, a key regenerative medicine technique, often requires repeat procedures due to high-fat reabsorption and volume loss. Addressing this, a novel drug delivery system uniquely combines a thermosensitive, FDA-approved hydrogel (itaconic acid-modified PLGA-PEG-PLGA copolymer) with FGF2-STAB, a stable fibroblast growth factor 2 with a 21-day stability, far exceeding a few hours of wild-type FGF2's stability. Additionally, the growth factor was encapsulated in "green" liposomes prepared via the Mozafari method, ensuring pH protection. The system, characterized by first-order FGF2-STAB release, employs green chemistry for biocompatibility, bioactivity, and eco-friendliness. The liposomes, with diameters of 85.73 ± 3.85 nm and 68.6 ± 2.2% encapsulation efficiency, allowed controlled FGF2-STAB release from the hydrogel compared to the unencapsulated FGF2-STAB. Yet, the protein compromised the carrier's hydrolytic stability. Prior tests were conducted on model proteins human albumin (efficiency 80.8 ± 3.2%) and lysozyme (efficiency 81.0 ± 2.7%). This injectable thermosensitive system could advance reconstructive medicine and cosmetic procedures.

Fatter Is Better: Boosting the Vascularization of Adipose Tissue Grafts

Adipose tissue resorption after fat grafting is a major drawback in plastic and reconstructive surgery, which is primarily caused by the insufficient blood perfusion of the grafts in the initial phase after transplantation. To overcome this problem, several promising strategies to boost the vascularization and, thus, increase survival rates of fat grafts have been developed in preclinical studies in recent years. These include the angiogenic stimulation of the grafts by growth factors and botulinum neurotoxin A, biologically active gels, and cellular enrichment, as well as the physical and pharmacological stimulation of the transplantation site. To transfer these approaches into future clinical practice, it will be necessary to establish standardized procedures for their safe application in humans. If this succeeds, the surgical outcomes of fat grafting may be markedly improved, resulting in a significant reduction of the physical and psychological stress for the patients.

Injectable In Situ Crosslinking Hydrogel for Autologous Fat Grafting

Autologous fat grafting is hampered by unpredictable outcomes due to high tissue resorption. Hydrogels based on enzymatically pretreated tunicate nanocellulose (ETC) and alginate (ALG) are biocompatible, safe, and present physiochemical properties capable of promoting cell survival. Here, we compared in situ and ex situ crosslinking of ETC/ALG hydrogels combined with lipoaspirate human adipose tissue (LAT) to generate an injectable formulation capable of retaining dimensional stability in vivo. We performed in situ crosslinking using two different approaches; inducing Ca2+ release from CaCO3 microparticles (CMPs) and physiologically available Ca2+ in vivo. Additionally, we generated ex situ-crosslinked, 3D-bioprinted hydrogel-fat grafts. We found that in vitro optimization generated a CMP-crosslinking system with comparable stiffness to ex situ-crosslinked gels. Comparison of outcomes following in vivo injection of each respective crosslinked hydrogel revealed that after 30 days, in situ crosslinking generated fat grafts with less shape retention than 3D-bioprinted constructs that had undergone ex situ crosslinking. However, CMP addition improved fat-cell distribution and cell survival relative to grafts dependent on physiological Ca2+ alone. These findings suggested that in situ crosslinking using CMP might promote the dimensional stability of injectable fat-hydrogel grafts, although 3D bioprinting with ex situ crosslinking more effectively ensured proper shape stability in vivo.

Injectable Pectin-Alginate Hydrogels for Improving Vascularization and Adipogenesis of Human Fat Graft

Autologous fat grafting (AFG) is the most prevailing tool for soft tissue regeneration in clinics, although efficiency is limited to unpredictable volume resorption due to poor vascularization and eventual necrosis. This study sought to improve the AFG efficiency using a hydrogel as a carrier for human fat graft (F) with and without platelet-rich plasma (PRP). PRP is clinically well known for the local release of several endogenous growth factors and has been in clinical use already. A human-fat-graft-encapsulated pectin-alginate hydrogel (FG) was developed and characterized. PRP was added to F to develop a human fat graft with PRP (FP). FP was admixed with a pectin-alginate hydrogel to develop FGP. FG and FGP showed the smooth injectable, elastic, and shear-thinning properties. FG and FGP groups showed enhanced cell viability and proliferation compared to the control F in vitro. We also investigated the in vivo angiogenesis and neo-adipogenesis ability of F, FG, FGP, and FP in nude mice after subcutaneous injection. After 2 and 4 weeks, an MRI of the mice was conducted, followed by graft explantation. The explanted grafts were also assessed histologically and with immunohistochemistry (IHC) studies. MRI and histology results revealed better vascularity of the FG and FGP system compared to fat graft alone. Further, the IHC studies, CD 31, and perilipin staining also revealed better vasculature and adipogenesis of FG and FGP systems. These results indicate the enhanced angiogenesis and adipogenesis of FG and FGP. Thus, developed pectin-alginate hydrogel-based fat graft systems FG and FGP replenish the native microenvironment by mediating angiogenesis and adipogenesis, thereby maximizing the clinical outcomes of autologous fat grafting.

Superior Epididymal Artery-Based Paraepididymal Adipofascial Flap: An Experimental Adipofascial Flap Model in the Rat

BACKGROUND

Flap surgery is widely performed in reconstructive surgery. Experimental research is vital to improve flap viability. However, the number of flap models for animals is still limited. In this study, we define a new adipofascial flap in rats that can be used to investigate pedicled flap and/or adipofascial flap physiology.

METHODS

Eight Wistar male rats were used. Under deep anesthesia, paraepididymal adipofascial flaps were harvested. Flap perfusion was assessed using a near-infrared fluorescence imaging system. The length of the flap and the diameter of the flap pedicle were measured.

RESULTS

All animals (n = 8) had sufficient sizes of paraepididymal fat pad, and no animals were lost. The only postoperative complication was testicular hematoma, which was observed in 2 animals. The maximum length of the harvested paraepididymal adipofascial flap was 9.7 cm with a mean of 6.6 cm. The maximum width of the flap was 3.3 cm with a mean of 2.6 cm. The mean pedicle diameter of the paraepididymal adipofascial flap was 1.1 mm. Near-infrared fluorescence imaging revealed adequate perfusion in all flaps.

CONCLUSIONS

The number of reported adipofascial flap models in animals is low, and they are mostly limited to flaps based on epigastric vessels. Superior epididymal artery-based paraepididymal adipofascial flap can be used as a pedicled flap model for studies focusing on adipofascial and/or pedicled flap physiology. Uncomplicated surgical technique and short operative time make this flap a valuable alternative to other flap models.

Changes in Human Fat Injected Alongside Hyaluronic Acid in the Backs of Nude Mice

BACKGROUND

Cross-linked hyaluronic acid (HA) is an active anti-aging cosmetic filler. The combination of cross-linked HA and preadipocytes or adipose-derived stem cells has been previously investigated, but the effects of agglomerated cross-linked HA injection on the vascularization of fat grafts remain unclear.

OBJECTIVES

The aim of this study was to explore the effects of agglomerated cross-linked HA injection on the vascularization of fat grafts.

METHODS

The backs of nude mice were divided into 4 regions that received different treatments: nothing (control group), agglomerated Biohyalux (HA group), agglomerated fat (FAT group), and lumps formed by the sequential injection of Biohyalux and fat (HA/FAT group). Samples were collected after 1 month for weighing and hematoxylin and eosin staining, immunohistochemistry, image analysis, and Western blotting.

RESULTS

The weight of fat and the mean number of adipocytes in the HA/FAT group did not significantly differ from those in the FAT group. No living tissue was found in agglomerated HA. Some tiny HA particles were surrounded by tissue rich in blood vessels. The expression levels of CD31 and vascular endothelial growth factor (VEGF) in the HA/FAT group were higher than those in the FAT group, but the difference was only significant for VEGF expression.

CONCLUSIONS

Cross-linked HA had minimal effect on the early retention rate of surrounding fat grafts, but enhanced their vascularization. Fat grafts should be not injected into lumps of cross-linked HA. Therefore, agglomerated cross-linked HA should be dissolved before fat transplantation.

Hydrogel from acellular porcine adipose tissue promotes survival of adipose tissue transplantation

Lipofilling is a popular technique for soft tissue augmentation, limited by unpredictable graft survival. This study aimed at exploring the effect of hydrogel from acellular porcine adipose tissue (HAPA) on angiogenesis and survival of adipose tissue used for lipofilling. The effect of HAPA on adipose-derived stem cells (ADSCs) proliferation, adipogenic differentiation, and vascular endothelial growth factor (VEGF) secretion were evaluated in hypoxia and normoxiain vitro. For thein vivostudy, adipose tissue with phosphate buffered saline, ADSCs, and HAPA (with or without ADSCs) were co-injected subcutaneously into nude mice. HAPA-ADSCs mixture (tissue engineering adipose tissue) was also grafted. Gross observation, volume measurement, and ultrasound observation were assessed. For histological assessment, hematoxylin and eosin, perilipin, cluster of differentiation 31 (CD31), Ki67, and transferase-mediated d-UTP nick end labelling (TUNEL) staining were performed. HAPA improved ADSCs proliferation, VEGF secretion, and adipogenic differentiation under normoxia and hypoxia conditionsin vitrostudy. For thein vivostudy, HAPA showed improved volume retention and angiogenesis, and reduced cell apoptosis when compared to ADSCs-assisted lipofilling and pure lipofilling. In conclusion, HAPA could maintain ADSCs viability and improve cell resistant to hypoxia and might be a promising biomaterial to assist lipofilling.

[Preliminary exploration on the application of hydrogel from acellular porcine adipose tissue to assist lipofilling]

OBJECTIVE

To investigate the effect of hydrogel from acellular porcine adipose tissue (HAPA) on the survival of transplanted adipose tissue.

METHODS

For in vitro study, adipose tissue and HAPA-adipose tissue complex were cultured in normoxia and hypoxia atmospheres for 24 and 72 hours. TUNEL and Perilipin immunofluorescence staining were performed to observe the effect of HAPA on apoptosis and survival of adipocities. For in vivo study, 42 healthy male nude mice (4-6 weeks old) weighing 15-18 g were randomly divided into adipose group (group A), 10%HAPA group (group B), 20%HAPA group (group C), 30%HAPA group (group D), 40%HAPA group (group E), and 50%HAPA group (group F) according to different HAPA/adipose tissue volume ratio ( n=7). For each group, 1 mL adipose tissue or HAPA-adipose tissue complex was injected subcutaneously into the dorsum of the nude mice. At 4 weeks after transplantation, 7 nude mice in each group were sacrificed and grafts were harvested, gross observation, volume measurement, ultrasound examination, and histologic staining (HE staining, CD31 and Perilipin immunofluorescence stainings) were applied.

RESULTS

Hypoxia showed a tendency of promoting adipose tissue necrosis and apoptosis, while HAPA exhibited an obvious effect of inhibiting cell apoptosis in vitro study ( P<0.05). For in vivo study, grafts of all groups had intact fibrocapsule. No obvious signs of infection and necrosis were observed at 4 weeks. Volume shrinkage was observed in all groups, however, the groups A-D had significantly higher volume retention rate than groups E and F ( P<0.05). Ultrasound examination showed that there were no significant difference in the number and volume of liquify area of the grafts in each group ( P>0.05). With the increase of HAPA's volume ratio, HE staining proved an improved fat integrity while a gradually decreased vacuoles and fibrosis. CD31 immunohistochemical staining showed that the number of neo-vascularisation in groups E and F were significantly higher than those in groups A-D ( P<0.05). Perilipin immunofluorescence staining showed that with the increase of HAPA volume ratio, the number of living adipocytes increased gradually, and more new adipocytes could be seen in the field of vision.

CONCLUSION

As the volume ratio of HAPA gradually increased, the survival of transplanted adipose tissue also increased, but the volume retention rate decreased gradually. 30%HAPA was considered the relative optimal volume ratio for its superior adipose tissue survival and volume retation rate.

Fat Graft Enrichment Strategies: A Systematic Review

BACKGROUND

Autologous fat grafting is a dynamic modality used in plastic surgery as an adjunct to improve functional and aesthetic form. However, current practices in fat grafting for soft-tissue augmentation are plagued by tremendous variability in long-term graft retention, resulting in suboptimal outcomes and repetitive procedures. This systematic review identifies and critically appraises the evidence for various enrichment strategies that can be used to augment and improve the viability of fat grafts.

METHODS

A comprehensive literature search of the Medline and PubMed databases was conducted for animal and human studies published through October of 2017 with multiple search terms related to adipose graft enrichment agents encompassing growth factors, platelet-rich plasma, adipose-derived and bone marrow stem cells, gene therapy, tissue engineering, and other strategies. Data on level of evidence, techniques, complications, and outcomes were collected.

RESULTS

A total of 1382 articles were identified, of which 147 met inclusion criteria. The majority of enrichment strategies demonstrated positive benefit for fat graft survival, particularly with growth factors and adipose-derived stem cell enrichment. Platelet-rich plasma and adipose-derived stem cells had the strongest evidence to support efficacy in human studies and may demonstrate a dose-dependent effect.

CONCLUSIONS

Improved understanding of enrichment strategies contributing to fat graft survival can help to optimize safety and outcomes. Controlled clinical studies are lacking, and future studies should examine factors influencing graft survival through controlled clinical trials in order to establish safety and to obtain consistent outcomes.

Microfibrous scaffolds from poly(l-lactide-co-ε-caprolactone) blended with xeno-free collagen/hyaluronic acid for improvement of vascularization in tissue engineering applications

Success of 3D tissue substitutes in clinical applications depends on the presence of vascular networks in their structure. Accordingly, research in tissue engineering is focused on the stimulation of angiogenesis or generation of a vascular network in the scaffolds prior to implantation. A novel, xeno-free, collagen/hyaluronic acid-based poly(l-lactide-co-ε-caprolactone) (PLC/COL/HA) (20/9.5/0.5 w/w/w) microfibrous scaffold was produced by electrospinning. Collagen types I and III, and hyaluronic acid were isolated from human umbilical cords and blended with the GMP grade PLC. When compared with PLC scaffolds the PLC/COL/HA had higher water uptake capacity (103% vs 66%) which may have contributed to the decrease in its Young's Modulus (from 1.31 to 0.89 MPa). The PLC/COL/HA better supported adipose tissue-derived mesenchymal stem cell (AT MSC) adhesion; within 24 h the cell number on the PLC/COL/HA scaffolds was 3 fold higher. Co-culture of human umbilical vein endothelial cells and AT MSCs induced capillary formation on both scaffold types, but the PLC/COL/HA led to formation of interconnected vessels whose total length was 1.6 fold of the total vessel length on PLC. Clinical use of this scaffold would eliminate the immune response triggered by xenogeneic collagen and transmission of animal-borne diseases while promoting a better vascular network formation.

Application of Epineural Sheath as a Novel Approach for Fat Volume Maintenance

INTRODUCTION

Various methods have been suggested to improve fat graft survival and decrease graft loss. The exact mechanism of fat graft survival is still unclear, and new strategies are needed to further investigate it.

MATERIALS AND METHODS

The efficacy of epineural sheath in fat volume maintenance was tested in rat model. Five experimental groups were created: group 1, fat graft without any coverage; group 2, epineural sheath tube alone; group 3, epineural sheath tube filled with fat graft; group 4, fat graft mixed with minced epineural sheath without any coverage; and group 5, fat graft covered with the epineural sheath patch. All grafts were implanted into the dorsal subcutaneous region and were followed for up to 12 weeks, when samples were harvested for hematoxylin and eosin and immunostaining for vascular endothelial growth factor expression and perilipin evaluation of fat viability.

RESULTS

In groups 1 and 4, over 25% of graft loss was observed at first week, over 50% at third week, and 100% at sixth week postimplantation. The weight of fat graft within the epineural sheath tube and the weight of epineural tube (ET) alone were maintained up to 12 weeks postimplantation. The weight of fat graft within the epineural patch was maintained up to 6 weeks, but 50% of weight loss was observed between 6 and 12 weeks. Structure of the epineural sheath tubes and patches was intact, and no leakage of fat graft was observed. Based on hematoxylin and eosin staining, normal structure and integrity of the fat graft within the ET were preserved up to 12 weeks postimplantation. Characteristic adipocyte morphology was confirmed by perilipin staining, showing viable fat cells in groups 3 and 5 at 12 weeks. Increased vascular endothelial growth factor expression was observed in groups 2, 3, 4, and 5.

CONCLUSIONS

Both, the ETs and epineural patches maintained 100% and 50% of fat graft weight at 12 weeks postimplantation, respectively. These results were confirmed by histology and immunostaining showing viable adipocytes within the epineural patches (6 weeks) and tubes (12 weeks). These results are encouraging and justify further evaluation of fat volume maintenance in preclinical large animal model in preparation to clinical application.

Exosome-Like Vesicles Derived from Adipose Tissue Provide Biochemical Cues for Adipose Tissue Regeneration

There is an emerging need for soft tissue replacements in the field of reconstructive surgery for the treatment of congenital deformities, posttraumatic repair, and cancer rehabilitation. Previous studies have shown that the bioactive adipose tissue extract can induce adipogenesis without additional stem cells or growth factors. In this study, we innovatively investigated whether exosome-like vesicles derived from adipose tissue (ELV-AT) could direct stem cell differentiation and trigger adipose tissue regeneration. In vitro, ELV-AT can induce adipogenesis of adipose-derived stem cells and promote proliferation, migration, and angiogenic potential of the aorta endothelial cells. In vivo, ELV-AT were transplanted to a chamber on the back of nude mice and neoadipose tissues were formed. Our findings indicated that ELV-AT could be used as a cell-free therapeutic approach for adipose tissue regeneration.

Adipose Tissue and Extracellular Matrix Development by Injectable Decellularized Adipose Matrix Loaded with Basic Fibroblast Growth Factor

BACKGROUND

There is a significant need for soft-tissue replacements in the field of reconstructive surgery. Decellularized adipose tissues were heparin crosslinked and loaded with basic fibroblast growth factor (bFGF). This injectable system was evaluated for its adipogenic and angiogenic capabilities for in vivo adipose tissue regeneration.

METHODS

Decellularized adipose tissues were harvested from the inguinal fat pads of C57BL/6J mice, minced, and heparinized before being loaded with bFGF. Decellularized adipose tissues without bFGF served as a control. In vivo adipose neotissue formation, neovascularization, and volume stability were evaluated over a period of 12 weeks. After 6 or 12 weeks, mice were killed and the newly formed adipose tissues, together with the contralateral endogenous adipose tissues, were harvested for gross, volumetric, histologic, and immunohistochemical analysis.

RESULTS

Decellularized adipose tissues that were heparinized and loaded with bFGF induced significant de novo adipose neotissue formation, with progressive tissue growth and neovascularization from 6 to 12 weeks. The adipose neotissues exhibited mature adipose morphology and extracellular matrix that closely resembled that of the endogenous adipose tissue. In contrast, decellularized adipose tissues without bFGF induced limited adipose neotissue formation and were completely resorbed by the end of 12 weeks.

CONCLUSION

This study demonstrates the high efficiency of heparinized decellularized adipose tissue matrix loaded with bFGF in promoting adipose neotissue formation and neovascularization with long-term volume stability.

Application of Hydrogel in Reconstruction Surgery: Hydrogel/Fat Graft Complex Filler for Volume Reconstruction in Critical Sized Muscle Defects

Autogenic fat graft usually suffers from degeneration and volume shrinkage in volume reconstruction applications. How to maintain graft viability and graft volume is an essential consideration in reconstruction therapies. In this presented investigation, a new fat graft transplantation method was developed aiming to improve long term graft viability and volume reconstruction effect by incorporation of hydrogel. The harvested fat graft is dissociated into small fragments and incorporated into a collagen based hydrogel to form a hydrogel/fat graft complex for volume reconstruction purpose. In vitro results indicate that the collagen based hydrogel can significantly improve the survivability of cells inside isolated graft. In a 6-month investigation on artificial created defect model, this hydrogel/fat graft complex filler has demonstrated the ability of promoting fat pad formation inside the targeted defect area. The newly generated fat pad can cover the whole defect and restore its original dimension in 6-month time point. Compared to simple fat transplantation, this hydrogel/fat graft complex system provides much improvement on long term volume restoration effect against degeneration and volume shrinkage. One notable effect is that there is continuous proliferation of adipose tissue throughout the 6-month period. In summary, the hydrogel/fat graft system presented in this investigation demonstrated a better and more significant effect on volume reconstruction in large sized volume defect than simple fat transplantation.

Magnetic Resonance Imaging of Human Tissue-Engineered Adipose Substitutes

Adipose tissue (AT) substitutes are being developed to answer the strong demand in reconstructive surgery. To facilitate the validation of their functional performance in vivo, and to avoid resorting to excessive number of animals, it is crucial at this stage to develop biomedical imaging methodologies, enabling the follow-up of reconstructed AT substitutes. Until now, biomedical imaging of AT substitutes has scarcely been reported in the literature. Therefore, the optimal parameters enabling good resolution, appropriate contrast, and graft delineation, as well as blood perfusion validation, must be studied and reported. In this study, human adipose substitutes produced from adipose-derived stem/stromal cells using the self-assembly approach of tissue engineering were implanted into athymic mice. The fate of the reconstructed AT substitutes implanted in vivo was successfully followed by magnetic resonance imaging (MRI), which is the imaging modality of choice for visualizing soft ATs. T1-weighted images allowed clear delineation of the grafts, followed by volume integration. The magnetic resonance (MR) signal of reconstructed AT was studied in vitro by proton nuclear magnetic resonance ((1)H-NMR). This confirmed the presence of a strong triglyceride peak of short longitudinal proton relaxation time (T1) values (200 ± 53 ms) in reconstructed AT substitutes (total T1=813 ± 76 ms), which establishes a clear signal difference between adjacent muscle, connective tissue, and native fat (total T1 ~300 ms). Graft volume retention was followed up to 6 weeks after implantation, revealing a gradual resorption rate averaging at 44% of initial substitute's volume. In addition, vascular perfusion measured by dynamic contrast-enhanced-MRI confirmed the graft's vascularization postimplantation (14 and 21 days after grafting). Histological analysis of the grafted tissues revealed the persistence of numerous adipocytes without evidence of cysts or tissue necrosis. This study describes the in vivo grafting of human adipose substitutes devoid of exogenous matrix components, and for the first time, the optimal parameters necessary to achieve efficient MRI visualization of grafted tissue-engineered adipose substitutes.

Lymphedema fat graft: an ideal filler for facial rejuvenation

Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.

Adipose stromal/stem cells assist fat transplantation reducing necrosis and increasing graft performance

Autologous fat transfer (AFT) is a procedure for adipose tissue (AT) repair after trauma, burns, post-tumor resections and lipodystrophies still negatively impacted by the lack of graft persistence. The reasons behind this poor outcome are unclear and seem to involve damages in either harvested/transplanted mature adipocytes or on their mesenchymal progenitors, namely adipose stromal/stem cells (ASC), and due to post-transplant AT apoptosis and involution. A rabbit subcutaneous AT regeneration model was here developed to first evaluate graft quality at different times after implant focusing on related parameters, such as necrosis and vasculogenesis. Standard AFT was compared with a strategy where purified autologous ASC, combined with hyaluronic acid (HA), assisted AFT. Five million of autologous ex vivo isolated CD29+, CD90+, CD49e+ ASC, loaded into HA, enriched 1 ml of AT generating an early significant protective effect in reducing AFT necrosis and increasing vasculogenesis with a preservation of transplanted AT architecture. This beneficial impact of ASC assisted AFT was then confirmed at three months with a robust lipopreservation and no signs of cellular transformation. By a novel ASC assisted AFT approach we ensure a reduction in early cell death favoring an enduring graft performance possibly for a more stable benefit in patients.