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Background: Midface reconstruction is challenging because the structures and deformities involved are complicated. In this study, we present a strategy for integrally reconstructing nasal and midfa...

Tissue ischemia usually leads to necrosis and is a threatening condition associated with reconstructive surgery. Promoting the survival of ischemic tissue is critical for improving clinical outcomes. Although various solutions based on stem cells have been reported, there are still limitations to clinical translation. The aim of this study was to develop an effective method to promote the survival of ischemic tissue. Adipose-derived CD34 + and CD34- cells were obtained by magnetic bead sorting from the stromal vascular faction (SVF). Adipose-derived stem cells (ADSCs) were collected by subculture. The angiogenic capacities of CD34 + cells, CD34- cells and ADSCs were evaluated in vitro by comparing mRNA and protein expression. Random axial flaps in nude mice were used to evaluate the efficacy of these cells in protecting tissue from necrosis. The effect of these cells in preventing inflammation was also evaluated. Our data suggest that CD34 + cells expressed higher levels of angiogenetic factors and lower levels of inflammatory factors than the other cell types. More vessel branches were formed when human umbilical vein endothelial cells (HUVECs) were treated with conditioned medium from CD34 + cells than conditioned medium from the other cell types. Compared to ADSCs, CD34 + cells showed significantly higher efficacy in promoting tissue survival. More CD31 + cells and higher levels of angiogenic factors were observed in tissues from the CD34 + group than in those from the other groups. Lower levels of the proinflammatory factors TNF-α and IL-1b and higher levels of anti-inflammatory factors were found in the CD34 + group than in the other groups. Adipose-derived CD34 + cells showed better efficacy in improving ischemic tissue survival than ADSCs by reducing tissue inflammation and promoting angiogenesis. CD34 + cells can be obtained easily and may be suitable for clinical applications.

Background: Minoxidil (MXD) is an U.S. Food and Drug Administration-approved drug for the topical treatment of androgenetic alopecia (AGA) with minor side effects, but its hair growth (HG) effect is unsatisfactory. Methods: A double-blinded within-subjects randomized clinical trial was conducted on 16 male AGA patients who showed limited improvement after MXD treatment. Eligible participants received three concentrated growth factor (CGF) injections on half of the scalp and the placebo on the other side at 4-week intervals, and MXD was applied twice daily on both sides throughout the follow-up period. The primary endpoint was the HG ratio at V4. The secondary endpoints included the HG ratios at V2, V3, and V5; hair density and T/V ratio at V2, V3, V4, and V5; Global Aesthetic Improvement Scale (GAIS) scores at V4 and V5; and participant satisfaction at V4. Results: Each group included 16 subjects; each half of the scalp was randomly assigned to the MXD+CGF or MXD group. The HG ratio at V4 was higher in the MXD+CGF group than in the MXD group. The MXD+CGF group had significant improvements in hair density, HG ratio, and T/V ratio compared with the MXD group over the follow-up period. The GAIS scores and participant satisfaction were higher in the MXD+CGF group than in the MXD group. Unexpectedly, the MXD+CGF treatment hastened HG, which was sustained for 3 months after discontinuation. No severe adverse events occurred. Conclusions: The combined treatment of MXD and CGF is safe and more efficient for AGA patients. Combining CGF can expedite the potency of MXD and provide patients with fast and lasting HG.

Background The regeneration response of the skin to mechanical stretching in vivo has been explored in reconstructive surgery to repair large-scale deformities. The ability of the skin to regenerate limits the reconstructive outcome. Here, we propose an approach in which autologous stromal vascular fraction (SVF) cells and mechanical stretching are combined to overcome this limitation and promote skin regeneration. Methods This randomized, blinded, placebo-controlled clinical trial screened 22 participants undergoing tissue expansion with exhausted regeneration. Twenty eligible participants received intradermal injections of the SVF or placebo treatments. Follow-ups were conducted at 4, 8, and 12 weeks to assess efficacy and at 2 years to assess safety. The primary endpoint was the expanded skin thickness at 12 weeks. The secondary endpoints included skin thickness at 4 and 8 weeks, the expansion index (EI), and the skin texture score at 12 weeks. Results The skin thickness of the SVF group was significantly higher than that of the control group at both 8 weeks (mean difference 0.78 [95% CI − 1.43 to − 0.11]; p = 0.018) and 12 weeks (0.65 [95% CI − 1.30 to − 0.01]; p = 0.046). In the SVF group, the increase in skin thickness was significant at 4 weeks (0.49 [95% CI − 0.80 to − 0.06]; p = 0.010) to 8 weeks (0.45 [95% CI − 0.92 to 0.02]; p = 0.026) and maintained after 12 weeks, whereas that in the control group was reduced after 8 weeks (0.42 [95% CI − 0.07 to 0.91]; p = 0.037). The SVF group showed greater EI increases than the control group (0.50 [95% CI − 0.00 to 0.99]; p = 0.047). The skin texture scores in the SVF group were greater than those in the control group at 12 weeks. Histologically, SVF-treated expanded skin showed more proliferating cells and blood vessels, and the extracellular matrix volume increased. No severe adverse events occurred. Conclusions Transplantation of SVF cells can expedite the potency of mechanical stretch-induced skin regeneration and provide clinical reconstruction with plentiful tissue. Trial registration This trial was registered with the Chinese Clinical Trial Registry, ChiCTR2000039317 (registered 23 October 2020—retrospectively registered).

Background Long-term preservation of adipose tissue is crucial for clinical applications. Researchers should consider both efficiency and biosafety when choosing a cryoprotective agent (CPA) for adipose tissue preservation. Glycerol has been applied as a nontoxic CPA for multiple tissues but not adipose tissue. We aimed to evaluate the efficacy of glycerol as a CPA for adipose tissue cryopreservation. Methods Fresh human adipose tissues were obtained from patients who underwent liposuction and divided into 1 mL samples. Each sample was randomly mixed with 1 mL of CPA: 60–100% glycerol, 0.25 mol/L trehalose or DMSO + FBS and cryopreserved in − 196 °C liquid nitrogen for one month. After thawing and elution, the tissues were immediately evaluated for activity and structural integrity in vitro. Then, 0.2 mL of each sample was transplanted subdermally to the nude mouse dorsum and harvested after one month for histological examination to assess the effect of the cryopreserved fat in transplantation. Results After cryopreservation, the samples treated with DMSO + FBS, trehalose, 60% and 70% glycerol had a more integrated structure than the samples in other groups. Tissues preserved with 70% glycerol had the highest G3PDH activity of 24.41 ± 0.70, comparable to 24.76 ± 0.48 in fresh tissue (p > 0.05). Adipose-derived stem cells (ASC) viability, proliferation and differentiation capability were also better preserved in 70% glycerol group. In vivo analysis showed that tissue preserved with 70% glycerol had a retention rate of 52.37 ± 7.53%, significantly higher than other groups. Histological observation demonstrated better structural integrity and viability in 70% glycerol group. Compared to the DMSO + FBS and trehalose groups, the glycerol groups showed lower tissue inflammation. Conclusion Glycerol (70%) is efficient in adipose tissue cryopreservation. Glycerol-based CPAs, which are nontoxic and show biosafety, are a promising solution for clinical tissue cryopreservation.

OBJECTIVE The purpose of this study was to detect the yield, activity and safety of the stromal vascular fraction (SVF) isolated by a new clinical-grade collagenase with a specific process and to validate the efficacy of the method. MATERIALS AND METHODS For the in vitro study, adipose tissue specimens were obtained from women undergoing elective liposuction (n = 5). The SVF was isolated by new clinical-grade collagenase for the experimental group and research-grade collagenase NB4 for the control group. The surface markers of the SVFs isolated by the two collagenases were detected by flow cytometry. The yield, activity and morphology of the SVFs were compared, together with their proliferation, migration and differentiation. Furthermore, we conducted a clinical trial to evaluate the improvement of skin texture after transplantation of autologous SVF isolated by clinical-grade collagenase. RESULTS There were no statistically significant differences in the yield, viability or morphology of the SVFs isolated by the new collagenase and collagenase NB4. Adipose tissue-derived mesenchymal stem cells (ASCs) surface marker expression was consistent between the two products. The differentiation potential of the cells was not different, which was consistent with previously published results. The SVF isolated by the new collagenase had a higher proliferation and migration. After administration of autologous SVF isolated by the new collagenase, the VISIA score improved significantly with regard to wrinkle scores and texture scores. CONCLUSION We concluded that this new type of clinical-grade collagenase can replace current research-grade products without any negative effect on the yield or function of the SVF, which can be applied to antiaging and rejuvenation of facial skin.

Background: Tissue ischemia usually leads to necrosis and is a threatening condition associated with reconstructive surgery. Promoting the survival of ischemic tissue is critical for improving clinical outcomes. Although various solutions based on stem cells have been reported, there are still limitations to clinical translation. The aim of this study was to develop an effective method to promote the survival of ischemic tissue.Methods: Adipose-derived CD34+ and CD34- cells were obtained by magnetic bead sorting from the stromal vascular faction (SVF). Adipose-derived stem cells (ADSCs) were collected by subculture. The angiogenic capacities of CD34+ cells, CD34- cells and ADSCs were evaluated in vitro by comparing mRNA and protein expression. Random axial flaps in nude mice were used to evaluate the efficacy of these cells in protecting tissue from necrosis. The effect of these cells in preventing inflammation was also evaluated.Results: Our data suggest that CD34+ cells expressed higher levels of angiogenetic factors and lower levels of inflammatory factors than the other cell types. More vessel branches were formed when human umbilical vein endothelial cells (HUVECs) were treated with conditioned medium from CD34+ cells than conditioned medium from the other cell types. Compared to ADSCs, CD34+ cells showed significantly higher efficacy in promoting tissue survival. More CD31+ cells and higher levels of angiogenic factors were observed in tissues from the CD34+ group than in those from the other groups. Lower levels of the proinflammatory factors TNF-α and IL-1b and higher levels of anti-inflammatory factors were found in the CD34+ group than in the other groups.Conclusion: Adipose-derived CD34+ cells showed better efficacy in improving ischemic tissue survival than ADSCs by reducing tissue inflammation and promoting angiogenesis. CD34+ cells can be obtained easily and may be suitable for clinical applications.

Clinical application of mechanical stretching is a reconstructive method for skin repair. Although studies have reported dermal fibroblast heterogeneity, whether stretching affects individual fibroblast subpopulations equally remains unclear. In this study, we show the changes in dermal structure and papillary fibroblast (Fp) in regenerated human skin. Exhausted skin regeneration caused dermal‒epidermal junction flattening, papillary dermis thinning, and an increase in type III collagen-to-type I collagen ratio, with upregulated hallmarks of aging. Well-regenerated skin displayed a notable increase in the Fp population. Consistent changes were observed in the rat expansion model. Moreover, we found that TGFβ1 expression was especially increased in skin showing good regeneration. Activation of the TGFβ1/SMAD2/3 pathway improved exhausted skin regeneration and resulted in increased collagen content and Fp proliferation, whereas pharmacological inhibition of TGFβ1 action impacted well-regenerated skin. Short-term mechanical stretching that promoted skin regeneration enhanced Fp proliferation, extracellular matrix synthesis, and increased TGFβ1 expression, leading to good regeneration. Conversely, long-term stretching induced premature Fp senescence, leading to poor regeneration. This work shows the mechanism of mechanical stretching in well-skin regeneration that enhances Fp proliferation and extracellular matrix synthesis through the TGFβ1/SMAD2/3 pathway and highlights a crucial role of Fps in stretching-induced skin regeneration.

Background: Tissue ischemia usually leads to necrosis and is a threatening condition associated with reconstructive surgery. Promoting the survival of ischemic tissue is critical for improving clinical outcomes. Although various solutions based on stem cells have been reported, there are still limitations to clinical translation. The aim of this study was to develop an effective method to promote the survival of ischemic tissue. Methods: Adipose-derived CD34+ and CD34- cells were obtained by magnetic bead sorting from the stromal vascular faction (SVF). Adipose-derived stem cell (ADSC) were collected by subculture. The angiogenic capacities of CD34+ cells, CD34- cells and ADSC were evaluated in vitro by comparing mRNA and protein expression. Random axial flaps in nude mice were used to evaluate the efficacy of these cells in protecting tissue from necrosis. The effect of these cells in preventing inflammation was also evaluated. Results: Our data suggest that CD34+ cells expressed higher levels of angiogenetic factors and lower levels of inflammatory factors than the other cell types. More vessel branches were formed when human umbilical vein endothelial cells (HUVECs) were treated with conditioned medium from CD34+ cells than conditioned medium from the other cell types. Compared to ADSC, CD34+ cells showed significantly higher efficacy in promoting tissue survival. More CD31+ cells and higher levels of angiogenic factors were observed in tissues from the CD34+ Group than from the other Groups. Lower levels of the proinflammatory factors TNF-α and IL-1b and higher levels of anti-inflammatory factors were found in the CD34+ Group than in the other Groups.Conclusion: Adipose-derived CD34+ cells showed better efficacy in improving ischemic tissue survival than ADSC by reducing tissue inflammation and promoting angiogenesis. CD34+ cells can be obtained easily and may be suitable for clinical applications.

Background: The regeneration response of skin to mechanical stretching in vivo has been explored in reconstructive surgery for repairing large-scale deformities. The ability of skin to regenerate limits the reconstructive outcome. Here, we propose an approach in which autologous adipose-derived stem cells and mechanical stretching are combined to overcome this limitation and promote skin regeneration.Methods: This randomized, blinded, placebo-controlled clinical trial screened 22 participants undergoing tissue expansion with a presence of exhausted regeneration. Twenty eligible participants received intradermal injections with stromal vascular fraction (SVF) or placebo treatments. Follow-ups were conducted at 4, 8, and 12-weeks to assess efficacy and for 2-years to assess safety. The primary endpoint was the expanded skin thickness at 12 weeks. The secondary endpoints included the skin thickness at 4 and 8 weeks, the expansion index (EI) and the skin texture score at all visits. Results: The skin thickness of the SVF group was significantly higher than that of the control group at both 8 weeks (mean difference 0.78 [95% CI -1.43 to -0.11]; p = 0.018) and 12 weeks(0.65 [95% CI -1.30 to -0.01]; p = 0.046). In the SVF group, the increment of skin thickness was significant at 4 weeks (0.49 [95% CI -0.80 to -0.06]; p = 0.010) to 8 weeks (0.45 [95% CI -0.92 to 0.02]; p = 0.026) and maintained after 12 weeks, whereas that in the control group was reduced after 8 weeks (0.42 [95% CI -0.07 to 0.91]; p = 0.037). The SVF group showed higher EI increments than the control group (0.50 [95% CI -0.00 to 0.99]; p = 0.047). The skin texture scores in the SVF group were higher than those in the control group at 12 weeks. Histologically, the SVF-treated expanded skin showed more proliferating cells and blood vessels, and the volume of extracellular matrix increased. No severe adverse events occurred.Conclusions: Transplantation of autologous adipose-derived stem cells can expedite the potency of mechanical stretch-induced skin regeneration and provide clinical reconstruction with plentiful tissue. Trial registration: This trial was registered with Chinese Clinical Trial, ChiCTR2000039317 (registered 23 Oct 2020 - retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=62738).

Background Adipose-derived stem cells (ADSCs) promote tissue regeneration and repair. Cryoprotective agents (CPAs) protect cells from cryodamage during cryopreservation. Safe and efficient cryopreservation of ADSCs is critical for cell-based therapy in clinical applications. However, most CPAs are used at toxic concentrations, limiting their clinical application. Objective The aim of this study is to develop a non-toxic xeno-free novel CPA aiming at achieving high-efficiency and low-risk ADSC cryopreservation. Methods We explored different concentrations of trehalose (0.3 M, 0.6 M, 1.0 M, and 1.25 M) and glycerol (10%, 20%, and 30% v/v) for optimization and evaluated and compared the outcomes of ADSCs cryopreservation between a combination of trehalose and glycerol and the commonly used CPA DMSO (10%) + FBS (90%). All samples were slowly frozen and stored in liquid nitrogen for 30 days. The effectiveness was evaluated by the viability, proliferation, migration, and multi-potential differentiation of the ADSCs after thawing. Results Compared with the groups treated with individual reagents, the 1.0 M trehalose (Tre) + 20% glycerol (Gly) group showed significantly higher efficiency in preserving ADSC activities after thawing, with better outcomes in both cell viability and proliferation capacity. Compared with the 10% DMSO + 90% FBS treatment, the ADSCs preserved in 1.0 M Tre + 20% Gly showed similar cell viability, surface markers, and multi-potential differentiation but a significantly higher migration capability. The results indicated that cell function preservation can be improved by 1.0 M Tre + 20% Gly. Conclusions The 1.0 M Tre + 20% Gly treatment preserved ADSCs with a higher migration capability than 10% DMSO + 90% FBS and with viability higher than that with trehalose or glycerol alone but similar to that with 10% DMSO + 90% FBS and fresh cells. Moreover, the new CPA achieves stemness and multi-potential differentiation similar to those in fresh cells. Our results demonstrate that 1.0 M Tre + 20% Gly can more efficiently cryopreserve ADSCs and is a non-toxic CPA that may be suitable for clinical applications.

Background: Adipose-derived stem cells (ADSCs) promote tissue regeneration and repair. Cryoprotective agents (CPA) protect cells from cryodamage in the process of cryopreservation. Safe and efficient cryopreservation of ADSCs is critical in the clinical application of cell-based therapy. However, most CPAs contain toxic concentrations limiting the possibility of their clinical application. Objective: The aim of this study is to develop a non-toxic xeno-free CPA for ADSCs to achieve high-efficiency and low-risk cryopreservation. Methods: We explored the most efficient concentrations in different concentrations of trehalose (0.3M, 0.6M, 1.0M, and 1.25M) and glycerol (10%, 20%, 30% v/v); then evaluated the outcome of the combination of trehalose and glycerol in ADSC cryopreservation, compared to the commonly used CPA, DMSO (10%) + FBS (90%). All samples were slowly freezed and stored in liquid nitrox for 30 days. The effectiveness was evaluated by the cell viability, proliferation, migration and multi-potential differentiation of ADSCs after thawing. Results: Compared to the CPAs with single reagent, 1.0M Tre + 20%Gly group showed significantly higher efficiency in preserving ADSCs activities after thawing, with better outcome in both cell viability and proliferating capacity. Compared to 10%DMSO+90%FBS, ADSCs preserved in 1.0M Tre + 20%Gly group showed similar cell viability, surface markers and multi-potential differentiation but significantly higher migration capability, indicating that better cell function preservation can be achieved by 1.0M Tre + 20%Gly. Conclusions: 1.0M Tre + 20%Gly can preserve ADSCs with high migration capability and cell viability compared to 10%DMSO+90%FBS and maintain similar stemness and multi-potential differentiation as fresh cells. Our results demonstrate that 1.0M Tre + 20%Gly can achieve highly efficient cryopreservation of ADSCs and is suitable for clinical applications.

IMPORTANCE: Previous anatomical and clinical studies have suggested that targeted restoration of the volume and distribution of fat compartments using appropriate cannula entry sites and injection planes is an excellent fat-grafting technique for facial contouring and hand rejuvenation. OBJECTIVE: To perform subjective and objective evaluations of the safe and effective profile of the targeted fat-grafting technique for temporal hollowing augmentation. DESIGN, SETTING, AND PARTICIPATIONS: In a retrospective cohort study, a total of 96 consecutive patients with temporal hollowing were treated at the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, China, with the targeted fat-grafting technique from January 1, 2009, to January 1, 2017. MAIN OUTCOMES AND MEASURES: The safety and efficacy profile of this technique was evaluated by the following methods: (1) a quantitative measurement of fat-graft survival and temporal augmentation rates by using 3-dimensional laser scanning, (2) a subjective assessment using a satisfaction survey and the Hollowness Severity Rating Scale (grades range from 0-3, with higher grades representing more hollowness), and (3) the complication rate. RESULTS: Of the 96 study patients, 94 (97.9%) were women and the mean (SD) age was 34.4 (7.4) years. Of the 142 autologous fat-grafting procedures performed, the mean (SD) total follow-up time was 16.3 (3.2) months, with a mean (SD) of 1.5 (0.7) procedures performed. The mean (SD) baseline volume requirement per temple for each patient was 12.8 (4.8) mL, and the total volume of the fat graft per temple was 17.8 (7.5) mL. Quantitative analysis revealed that the mean (SD) total augmentation volume per temple was 11.7 (3.0) mL, the total survival rate of the fat grafts was 65.7% (12.6%), and total augmentation rate of hollowness was 91.4% (23.4%). Subjective analysis revealed that all patients showed an improved appearance after fat grafting, and 142 temples (74.0%) exhibited clinical improvement by more than 2 grades. In all, 88 patients (91.7%) were satisfied with the outcomes, with a low complication rate reported. CONCLUSIONS AND RELEVANCE: The targeted fat-grafting technique allows the transplant of fat tissue into 4 separate fat compartments in a double-plane manner through a unique cannula entry site that avoids severe neurovascular injury. The long-term results demonstrate that this technique is an effective, reproducible, and safe approach for temporal hollowing augmentation. LEVEL OF EVIDENCE: 4.

Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.Pragmatic multicenter stepped-wedge cluster randomized controlled trial.Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians.Multidisciplinary medication review-directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.

Introduction An ageing population has become an urgent concern for Asia in recent times. In nursing homes, polypharmacy has also become a compounding issue. Deprescribing practice is an evidence-based strategy to provide a better outcome in this group of patients; however, its implementation in nursing homes is often challenging, and prospective outcome data on deprescribing practice in the elderly is lacking. Our study assesses the implementation of team-care deprescribing to understand the benefits of this practice in geriatric setting and to explore the factors affecting deprescribing practice. Methods and analysis This multicentre prospective study consists of a prestudy interview questionnaire, and a preintervention and postintervention study to be conducted in the nursing home setting on residents at least 65 years old and on five or more medications. We will employ a cluster randomised stepped-wedge interventional design, based on a five-step (reviewing, checking, discussion, communication and documentation) team-care deprescribing practice coupled with the use of a deprescribing guide (consisting of Beers and STOPP criteria, as well as drug interaction checking), to assess the health and pharmacoeconomic outcome in nursing homes’ practice. Primary outcome measures of the intervention will consist of fall risks using a fall risk assessment tool. Other outcomes assessed include fall rates, pill burden including number of pills per day, number of doses per day and number of medications prescribed. Cost-related measures will include the use of cost–benefit analysis, which is calculated from the medication cost savings from deprescribing. For the prestudy interview questionnaire, findings will be analysed qualitatively using thematic analysis. Ethics and dissemination This study is approved by the Domain Specific Review Board of National Healthcare Group, Singapore (2016/00422) and Monash University Human Research Ethics Committee (2016-1430-7791). The study findings shall be disseminated in international conferences and peer-reviewed publications. The study is registered with ClinicalTrials.gov (NCT02863341), Pre-results