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Tee CA, Roxby DN, Othman R, Denslin V, Bhat KS, Yang Z, Han J, Tucker-Kellogg L, Boyer LA. Metabolic modulation to improve MSC expansion and therapeutic potential for articular cartilage repair. Stem Cell Res Ther 2024; 15:308. [PMID: 39285485 PMCID: PMC11406821 DOI: 10.1186/s13287-024-03923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 09/04/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND Articular cartilage degeneration can result from injury, age, or arthritis, causing significant joint pain and disability without surgical intervention. Currently, the only FDA cell-based therapy for articular cartilage injury is Autologous Chondrocyte Implantation (ACI); however, this procedure is costly, time-intensive, and requires multiple treatments. Mesenchymal stromal cells (MSCs) are an attractive alternative autologous therapy due to their availability and ability to robustly differentiate into chondrocytes for transplantation with good safety profiles. However, treatment outcomes are variable due to donor-to-donor variability as well as intrapopulation heterogeneity and unstandardized MSC manufacturing protocols. Process improvements that reduce cell heterogeneity while increasing donor cell numbers with improved chondrogenic potential during expansion culture are needed to realize the full potential of MSC therapy. METHODS In this study, we investigated the potential of MSC metabolic modulation during expansion to enhance their chondrogenic commitment by varying the nutrient composition, including glucose, pyruvate, glutamine, and ascorbic acid in culture media. We tested the effect of metabolic modulation in short-term (one passage) and long-term (up to seven passages). We measured metabolic state, cell size, population doubling time, and senescence and employed novel tools including micro-magnetic resonance relaxometry (µMRR) relaxation time (T2) to characterize the effects of AA on improved MSC expansion and chondrogenic potential. RESULTS Our data show that the addition of 1 mM L-ascorbic acid-2-phosphate (AA) to cultures for one passage during MSC expansion prior to initiation of differentiation improves chondrogenic differentiation. We further demonstrate that AA treatment reduced the proportion of senescent cells and cell heterogeneity also allowing for long-term expansion that led to a > 300-fold increase in yield of MSCs with enhanced chondrogenic potential compared to untreated cells. AA-treated MSCs with improved chondrogenic potential showed a robust shift in metabolic profile to OXPHOS and higher µMRR T2 values, identifying critical quality attributes that could be implemented in MSC manufacturing for articular cartilage repair. CONCLUSIONS Our results suggest an improved MSC manufacturing process that can enhance chondrogenic potential by targeting MSC metabolism and integrating process analytic tools during expansion.
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Affiliation(s)
- Ching Ann Tee
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
| | - Daniel Ninio Roxby
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
| | - Rashidah Othman
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
| | - Vinitha Denslin
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, 27 Medical Drive, DSO (Kent Ridge) Building, Level 4, Singapore, 117510, Republic of Singapore
| | - Kiseer Sideeq Bhat
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
- Department of Bioresources, University of Kashmir, Hazratbal, Srinagar, 190006, India
| | - Zheng Yang
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, 27 Medical Drive, DSO (Kent Ridge) Building, Level 4, Singapore, 117510, Republic of Singapore
- Department of Orthopaedic Surgery, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block 11, Singapore, 119288, Republic of Singapore
| | - Jongyoon Han
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, 50 Vassar St, Cambridge, MA, 02139, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Lisa Tucker-Kellogg
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore.
- Cancer and Stem Cell Biology and Centre for Computational Biology, Duke-NUS Medical School, 8 College Rd, Singapore, 169857, Republic of Singapore.
| | - Laurie A Boyer
- Critical Analytics for Manufacturing Personalised-medicine (CAMP) Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology (SMART) Centre, 1 Create Way, Enterprise Wing, #04-13/14, Singapore, 138602, Republic of Singapore.
- Department of Biological Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.
- Department of Biology, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.
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Sevimli M, Inan U, Seyidova N, Guluzade L, Ahmadova Z, Gulec K, Topal AE, Semerci Sevimli T. In vitro Chondrogenic Induction Promotes the Expression Level of IL-10 via the TGF-β/SMAD and Canonical Wnt/β-catenin Signaling Pathways in Exosomes Secreted by Human Adipose Tissue-derived Mesenchymal Stem Cells. Cell Biochem Biophys 2024:10.1007/s12013-024-01461-z. [PMID: 39266872 DOI: 10.1007/s12013-024-01461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 09/14/2024]
Abstract
Current treatment approaches cannot exactly regenerate cartilage tissue. Regarding some problems encountered with cell therapy, exosomes are advantageous because of their "cell-free" nature. This study examines the relationship between IL-10 and TGF-β and Canonical Wnt/β-catenin signal pathways in human adipose tissue-derived MSCs exosomes (hAT-MSCs-Exos) after in vitro chondrogenic differentiation. Human adipose tissue-derived mesenchymal stem cells (hAT-MSCs) and, as a control group, human fetal chondroblast cells (hfCCs) were differentiated chondrogenically in vitro. Exosome isolation and characterization analyses were performed. Chondrogenic differentiation was shown by Alcian Blue and Safranin O stainings. The expression levels of IL-10, TGF-β/SMAD signaling pathway genes, and Canonical Wnt/β-catenin signaling pathway genes, which play an essential role in chondrogenesis, were analyzed by RT-qPCR. Conditioned media cytokine levels were measured by using the TGF-β and IL-10 ELISA kits. IL-10 expression was upregulated in both chondrogenic differentiated hAT-MSC-Exos (dhAT-MSC-Exos) (p < 0.0001). In the TGF-β signaling pathway, TGF-β (p < 0.0001), SMAD2 (p < 0.0001), SMAD4 (p < 0.001), ACAN (p < 0.0001), SOX9 (p < 0.05) and COL1A2 (p < 0.0001) expressions were upregulated in dhAT-MSC-Exos. SMAD3 expression was upregulated in non-differentiated hAT-MSC-Exos. In the Canonical Wnt/β-catenin signaling pathway, WNT (p < 0.0001) and CTNNB1(p < 0.0001) expressions were upregulated in dhAT-MSC-Exos. AXIN (p < 0.0001) expression was upregulated in non-differentiated hAT-MSC-Exos. TGF-β and IL-10 levels were higher in dhAT-MSCs) (p < 0.0001). Related to these results, IL-10 may induce TGF-β/SMAD and Canonical Wnt/β-catenin signaling pathways in hAT-MSC exosomes obtained after chondrogenic differentiation. Therefore, using these exosomes for cartilage regeneration can lead to the development of treatment methods.
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Affiliation(s)
- Murat Sevimli
- Department of Histology and Embryology, Faculty of Medicine, Eskisehir Osmangazi University, 26040, Eskisehir, Turkey
| | - Ulukan Inan
- Department of Orthopedics and Traumatology, Faculty of Medicine, Eskisehir Osmangazi University, 26040, Eskisehir, Turkey
| | - Nigar Seyidova
- Cellular Therapy and Stem Cell Production Application and Research Center (ESTEM), Eskisehir Osmangazi University, 26040, Eskisehir, Turkey
| | - Laman Guluzade
- Cellular Therapy and Stem Cell Production Application and Research Center (ESTEM), Eskisehir Osmangazi University, 26040, Eskisehir, Turkey
| | - Zarifa Ahmadova
- Department of Surgery, Medical Faculty Mannheim, Heidelberg University, 68167, Mannheim, Germany
| | - Kadri Gulec
- Department of Analytical Chemistry, Faculty of Pharmacy, Anadolu University, 26470, Eskisehir, Turkey
| | - Ahmet Emin Topal
- Department of Biochemistry, School of Pharmacy, Bahcesehir University, Istanbul, Turkey
| | - Tugba Semerci Sevimli
- Cellular Therapy and Stem Cell Production Application and Research Center (ESTEM), Eskisehir Osmangazi University, 26040, Eskisehir, Turkey.
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Younesi FS, Hinz B. The Myofibroblast Fate of Therapeutic Mesenchymal Stromal Cells: Regeneration, Repair, or Despair? Int J Mol Sci 2024; 25:8712. [PMID: 39201399 PMCID: PMC11354465 DOI: 10.3390/ijms25168712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
Mesenchymal stromal cells (MSCs) can be isolated from various tissues of healthy or patient donors to be retransplanted in cell therapies. Because the number of MSCs obtained from biopsies is typically too low for direct clinical application, MSC expansion in cell culture is required. However, ex vivo amplification often reduces the desired MSC regenerative potential and enhances undesired traits, such as activation into fibrogenic myofibroblasts. Transiently activated myofibroblasts restore tissue integrity after organ injury by producing and contracting extracellular matrix into scar tissue. In contrast, persistent myofibroblasts cause excessive scarring-called fibrosis-that destroys organ function. In this review, we focus on the relevance and molecular mechanisms of myofibroblast activation upon contact with stiff cell culture plastic or recipient scar tissue, such as hypertrophic scars of large skin burns. We discuss cell mechanoperception mechanisms such as integrins and stretch-activated channels, mechanotransduction through the contractile actin cytoskeleton, and conversion of mechanical signals into transcriptional programs via mechanosensitive co-transcription factors, such as YAP, TAZ, and MRTF. We further elaborate how prolonged mechanical stress can create persistent myofibroblast memory by direct mechanotransduction to the nucleus that can evoke lasting epigenetic modifications at the DNA level, such as histone methylation and acetylation. We conclude by projecting how cell culture mechanics can be modulated to generate MSCs, which epigenetically protected against myofibroblast activation and transport desired regeneration potential to the recipient tissue environment in clinical therapies.
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Affiliation(s)
- Fereshteh Sadat Younesi
- Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1G6, Canada;
- Keenan Research Institute for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
| | - Boris Hinz
- Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1G6, Canada;
- Keenan Research Institute for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
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Yang Z, Wu Y, Neo SH, Yang D, Jeon H, Tee CA, Denslin V, Lin DJ, Lee EH, Boyer LA, Han J. Size-Based Microfluidic-Enriched Mesenchymal Stem Cell Subpopulations Enhance Articular Cartilage Repair. Am J Sports Med 2024; 52:503-515. [PMID: 38186352 DOI: 10.1177/03635465231214431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND The functional heterogeneity of culture-expanded mesenchymal stem cells (MSCs) has hindered the clinical application of MSCs. Previous studies have shown that MSC subpopulations with superior chondrogenic capacity can be isolated using a spiral microfluidic device based on the principle of inertial cell focusing. HYPOTHESIS The delivery of microfluidic-enriched chondrogenic MSCs that are consistent in size and function will overcome the challenge of the functional heterogeneity of expanded MSCs and will significantly improve MSC-based cartilage repair. STUDY DESIGN Controlled laboratory study. METHODS A next-generation, fully automated multidimensional double spiral microfluidic device was designed to provide more refined and efficient isolation of MSC subpopulations based on size. Analysis of in vitro chondrogenic potential and RNA sequencing was performed on size-sorted MSC subpopulations. In vivo cartilage repair efficacy was demonstrated in an osteochondral injury model in 12-week-old rats. Defects were implanted with MSC subpopulations (n = 6 per group) and compared with those implanted with unsegregated MSCs (n = 6). Osteochondral repair was assessed at 6 and 12 weeks after surgery by histological, micro-computed tomography, and mechanical analysis. RESULTS A chondrogenic MSC subpopulation was efficiently isolated using the multidimensional double spiral device. RNA sequencing revealed distinct transcriptomic profiles and identified differential gene expression between subpopulations. The delivery of a chondrogenic MSC subpopulation resulted in improved cartilage repair, as indicated by histological scoring, the compression modulus, and micro-computed tomography of the subchondral bone. CONCLUSION We have established a rapid, label-free, and reliable microfluidic protocol for more efficient size-based enrichment of a chondrogenic MSC subpopulation. Our proof-of-concept in vivo study demonstrates the enhanced cartilage repair efficacy of these enriched chondrogenic MSCs. CLINICAL RELEVANCE The delivery of microfluidic-enriched chondrogenic MSCs that are consistent in size and function can overcome the challenge of the functional heterogeneity of expanded MSCs, resulting in significant improvement in MSC-based cartilage repair. The availability of such rapid, label-free enriched chondrogenic MSCs can enable better cell therapy products for cartilage repair with improved treatment outcomes.
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Affiliation(s)
- Zheng Yang
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
- Department of Orthopaedic Surgery, National University of Singapore, Singapore, Singapore
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Yingnan Wu
- Department of Orthopaedic Surgery, National University of Singapore, Singapore, Singapore
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Shu Hui Neo
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
| | - Dahou Yang
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
| | - Hyungkook Jeon
- Department of Manufacturing Systems and Design Engineering, Seoul National University of Science and Technology, Seoul, Republic of Korea
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Ching Ann Tee
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
| | - Vinitha Denslin
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Daryl Jimian Lin
- Department of Orthopaedic Surgery, National University of Singapore, Singapore, Singapore
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Eng Hin Lee
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
- Department of Orthopaedic Surgery, National University of Singapore, Singapore, Singapore
- NUS Tissue Engineering Program, Life Sciences Institute, National University of Singapore, Singapore, Singapore
| | - Laurie A Boyer
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Jongyoon Han
- Critical Analytics for Manufacturing Personalized-Medicine Interdisciplinary Research Group, Singapore-MIT Alliance for Research and Technology, Singapore, Singapore
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Tran ANT, Kim HY, Oh SY, Kim HS. CD49f and CD146: A Possible Crosstalk Modulates Adipogenic Differentiation Potential of Mesenchymal Stem Cells. Cells 2023; 13:55. [PMID: 38201259 PMCID: PMC10778538 DOI: 10.3390/cells13010055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/07/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The lack of appropriate mesenchymal stem cells (MSCs) selection methods has given the challenges for standardized harvesting, processing, and phenotyping procedures of MSCs. Genetic engineering coupled with high-throughput proteomic studies of MSC surface markers arises as a promising strategy to identify stem cell-specific markers. However, the technical limitations are the key factors making it less suitable to provide an appropriate starting material for the screening platform. A more accurate, easily accessible approach is required to solve the issues. METHODS This study established a high-throughput screening strategy with forward versus side scatter gating to identify the adipogenesis-associated markers of bone marrow-derived MSCs (BMSCs) and tonsil-derived MSCs (TMSCs). We classified the MSC-derived adipogenic differentiated cells into two clusters: lipid-rich cells as side scatter (SSC)-high population and lipid-poor cells as SSC-low population. By screening the expression of 242 cell surface proteins, we identified the surface markers which exclusively found in lipid-rich subpopulation as the specific markers for BMSCs and TMSCs. RESULTS High-throughput screening of the expression of 242 cell surface proteins indicated that CD49f and CD146 were specific for BMSCs and TMSCs. Subsequent immunostaining confirmed the consistent specific expression of CD49f and CD146 and in BMSCs and TMSCs. Enrichment of MSCs by CD49f and CD146 surface markers demonstrated that the simultaneous expression of CD49f and CD146 is required for adipogenesis and osteogenesis of mesenchymal stem cells. Furthermore, the fate decision of MSCs from different sources is regulated by distinct responses of cells to differentiation stimulations despite sharing a common CD49f+CD146+ immunophenotype. CONCLUSIONS We established an accurate, robust, transgene-free method for screening adipogenesis associated cell surface proteins. This provided a valuable tool to investigate MSC-specific markers. Additionally, we showed a possible crosstalk between CD49f and CD146 modulates the adipogenesis of MSCs.
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Affiliation(s)
- An Nguyen-Thuy Tran
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Ewha Womans University, Seoul 07985, Republic of Korea; (A.N.-T.T.); (H.Y.K.)
- Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul 03760, Republic of Korea
| | - Ha Yeong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Ewha Womans University, Seoul 07985, Republic of Korea; (A.N.-T.T.); (H.Y.K.)
| | - Se-Young Oh
- Department of Convergence Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, Seoul 07985, Republic of Korea;
| | - Han Su Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Ewha Womans University, Seoul 07985, Republic of Korea; (A.N.-T.T.); (H.Y.K.)
- Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul 03760, Republic of Korea
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De Francesco F, Zingaretti N, Parodi PC, Riccio M. The Evolution of Current Concept of the Reconstructive Ladder in Plastic Surgery: The Emerging Role of Translational Medicine. Cells 2023; 12:2567. [PMID: 37947645 PMCID: PMC10649097 DOI: 10.3390/cells12212567] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
Plastic surgeons have used the reconstructive ladder for many decades as a standard directory for complex trauma reconstruction with the goal of repairing body structures and restoring functionality. This consists of different surgical maneuvers, such as secondary intention and direct tissue closure, as well as more complex methods such as local tissue transfer and free flap. The reconstructive ladder represents widely known options achievable for tissue reconstruction and wound closure that puts at the bottom rung the simplest methods of reconstruction and strengthens the complexity by moving upward. Regenerative medicine and surgery constitute a quickly spreading area of translational research that can be employed by minimally invasive surgical strategies, with the aim of regenerating cells and tissues in vivo in order to reestablish normal function through the intrinsic potential of cells, in combination with biomaterials and appropriate biochemical stimuli. These translational procedures have the aim of creating an appropriate microenvironment capable of supporting the physiological cellular function to generate the desired cells or tissues and to generate parenchymal, stromal, and vascular components on demand, and above all to produce intelligent materials capable of determining the fate of cells. Smart technologies have been grown that give extra "rungs" on the classic reconstructive ladder to integrate a more holistic, patient-based approach with improved outcomes. This commentary presents the evolution of the traditional concept of the reconstructive ladder in the field of plastic surgery into a new course with the aim of achieving excellent results for soft tissue reconstruction by applying innovative technologies and biologically active molecules for a wide range of surgical diseases.
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Affiliation(s)
- Francesco De Francesco
- Department of Reconstructive Surgery and Hand Surgery, University Hospital (AOU Ospedali Riuniti di Ancona), Via Conca 71, Torrette di Ancona, 60123 Ancona, Italy;
| | - Nicola Zingaretti
- Department of Medical Area (DAME), Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, University of Udine, 33100 Udine, Italy; (N.Z.); (P.C.P.)
| | - Pier Camillo Parodi
- Department of Medical Area (DAME), Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, University of Udine, 33100 Udine, Italy; (N.Z.); (P.C.P.)
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, University Hospital (AOU Ospedali Riuniti di Ancona), Via Conca 71, Torrette di Ancona, 60123 Ancona, Italy;
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