unfiltered nanofat injections rejuvenate postburn scars of...

BURN SURGERY AND RESEARCH

Unfiltered Nanofat Injections Rejuvenate Postburn Scars of Face

Saadia Nosheen Jan FRCS Muhammad Mustehsan Bashir FCPS Farid Ahmad Khan FCPS

Zohaib Hidayat FCPS Hamid Hussain Ansari FCPS Muhammad Sohail FCPSAfzaal Bashir Bajwa FCPS Hussan Birkhez Shami MBBS Asif Hanif PhDdagger

Faiza Aziz MSDagger and Mahmood S Choudhery PhDDagger

Abstract The aim of this study was to compare the quality of postburn facialscars before and after injection of unfiltered nanofat The study was performedin the Plastic Surgery Department of Mayo Hospital Lahore Pakistan fromJanuary 2015 to December 2016 Forty-eight patients with postburn facial scarswere included age range was 4 to 32 years with Fitzpatrick skin types between3 and 4 Patients with hypertrophic scars contractures or keloids were excludedScars were assessed by a senior plastic surgeon and the patient on the POSAS(Patient Observer Scar Assessment Scale) Fat was harvested from the abdomenandor thighs with a 3-mm multiport liposuction cannula (containing severalsharp side holes of 1 mm) using Coleman technique The harvested fat was emul-sified and transferred into 1-mL Luer-Lock syringes for injection into the subder-mal or intradermal plane Final follow-up was scheduled at 6 months and scarwas rated by the patient and the same surgeon on the POSAS Preoperative andpostoperative scar scores were compared and P values were calculated Resultsindicated that after nanofat grafting there was a statistically significant improve-ment in scar quality The most significant improvements on the observer scalewere seen in pigmentation and pliability (P lt 00001) Thickness and relief werethe least improved variables (P = of 0785 and 099 respectively) ImageJ scan-ning also showed pigmentation change (P = 0076) A statistically significant im-provement was seen in all parameters of the patient section of the POSAS(P lt 00001) In conclusion unfiltered nanofat grafting seems to be a promisingand effective therapeutic approach in postburn facial scars showing significantimprovement in scar quality The trial was registered on wwwclinicaltrialsgovwith following ID NCT03352297

Key Words liposuction nanofat rejuvenation postburn scars

(Ann Plast Surg 201800 00ndash00)

F at grafting in its various forms could be considered as a hallmark inscar rejuvenation therapy in the 21st century With aesthetic appear-

ances increasingly proving to be a major factor for social survival it isonly logical that reconstructive surgery has become inextricable from itscosmetic counterpart Techniques described to improve the cosmetic ap-pearance of scars include scar revisions lasers steroid injections pressuregarments skin grafting tissue expansion chemical peels dermabrasiontopical creams and ointments

Fat grafting was conceptualized by Neuber1 in 1893 It furthergained impetus after Illouz2 introduced liposuction for harvesting fatin the 1980s A refinement of his technique proposed by Coleman34

has become the standard today A breakthrough in fat grafting occurredwhen multipotent stem cells were discovered in the stromal vascular

Received May 18 2018 and accepted for publication after revision August 2 2018From the King Edward Medical UniversityMayo Hospital daggerGulab Devi Hospital

and DaggerTissue Engineering and Regenerative Medicine Laboratory King EdwardMedical University Lahore Pakistan

Conflicts of interest and sources of funding None declaredReprintsMahmood S Choudhery PhD Tissue Engineering andRegenerativeMedicine

Laboratory Department of Biomedical Sciences King Edward Medical UniversityNelagumbad Anarkali Lahore 54000 Pakistan E-mail ms20031yahoocomdrmahmoodkemuedupk

Copyright copy 2018 Wolters Kluwer Health Inc All rights reservedISSN 0148-7043180000ndash0000DOI 101097SAP0000000000001631

Annals of Plastic Surgery bull Volume 00 Number 00 Month 2018

Copyright copy 2018 Wolters Kluwer Health Inc Unaut

fraction (SVF) of adipose tissue in 20015 The term ldquonanofat graftingrdquowas conceived by Tonnard et al6 in 2013 The ldquoelement of interestrdquo innanofat is the tissue stromal vascular fraction (t-SVF) which is essentiallya bioactive extracellular matrix adherent to a mixture of cells7 Amongthese the adipose-derived stem cells (ASCs) have a unique uncanny pro-clivity for differentiating into tissues in which they are injected Inevitablytherefore nanofat is of indispensable value in regenerative and rejuvenativetherapies8ndash10 including scar rejuvenation In addition the SVF of adiposetissue contains growth factors such as basic fibroblast growth factorinsulinlike growth factor 1 vascular endothelial factor and platelet-derived growth factor11 As such ASCs could also be potential key playersin scar rejuvenation12 Further processing of the t-SVF by enzymatic deg-radation of the matrix yields the cellular SVF which is a mixture of plurip-otent cells and growth factors without the connective tissue matrix

A large number of facial postburn scars present in our outpatientdepartment every year Thus despite the fact that the face possesses anexcellent healing propensity a significant proportion of patients presentwith postburn facial stigmata Exacerbating this predicament are thedarker skin types prevalent in our race with a penchant for hyperpig-mentation that further aggravates the appearance of these scars Facebeing the most evident part of the body any imperfection has adverseand indelible psychosocial implications13 With studies expoundingthe beneficial effects of ASCs13 nanofat grafting for scar modulationseemed an exciting and encouraging proposition13 Given the signifi-cant number of postburn facial scars in our setup our study aimed to in-vestigate the efficacy of nanofat grafting for improvement of facialpostburn scars using a standard scar scoring scale

MATERIALS AND METHODSThis prospective study was held at the Department of Plastic and

Reconstructive Surgery Mayo Hospital Lahore from January 2015 toDecember 2016 Forty-eight patients were included in the study Facialscars of more than 1-year duration with Fitzpatrick skin types 3 or 4were selected for rejuvenation with nanofat therapy Patients who hadany previous treatment for their scars were excluded Patients with hy-pertrophic scarskeloids (defined for the purpose of this study as scarsraised gt5 mm above the skin when measured with a caliper) contrac-tures and comorbid conditions known to affect wound healing for ex-ample diabetes liver or connective tissue disease or a bodymass indexof 14 kgm2 or less (expected to yield insufficient fat) were also ex-cluded Patients taking blood thinners were advised to stop their medi-cation 2 weeks before surgery to minimize bruising and hematomaformation After informed consent photographs of the scars were takenwith a 10-megapixel camera Standard lighting and viewswere ensuredScars were assigned an initial score based on the Patient Observer ScarAssessment Scale (POSAS)14 Considering that only mature scars wereincluded in the study the vascularity of the scar on the observer scalewas not relevant and therefore not scored Similarly no change in sur-face area of the scar was expected thus this parameter was also deletedfrom the scale Apart from a subjective analysis of pigmentation on thePOSAS quantitative analysis of pigmentation levels before therapy wasassessed by ImageJ version 41 software (httpsimagejnihgovij)

wwwannalsplasticsurgerycom 1

horized reproduction of this article is prohibited

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ابداع روش svf و جداسازی سلول های بنیادی پرتوان از بافت چربی13
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TABLE 1 Pretherapy and Posttherapy Observer Values on thePOSAS

Variable Mean SD Median IQR P

Preprocedure pigmentation 758 123 800 100 lt00001Postprocedure pigmentation 642 151 600 200Pre procedure thickness 438 195 300 375 0785daggerPostprocedure thickness 425 178 300 300Preprocedure relief 425 207 300 300 0099daggerPostprocedure relief 358 165 300 300Preprocedure pliability 675 176 700 250 lt00001Postprocedure pliability 342 077 300 100Preprocedure overall scar score 750 077 800 100 lt00001Postprocedure overall scar score 433 048 40 10

Note that maximum benefit obtained was for improvement in pigmentationand pliability

Wilcoxon test was applied (comparison was made on median plusmn interquartilerange [IQR])

daggerPaired-sample t test was applied (comparison was made on mean plusmn SD)

Jan et al Annals of Plastic Surgery bull Volume 00 Number 00 Month 2018

Fat was mainly harvested from the abdomen the lateral thighandor the gluteal region Tumescent solution comprising of 09 saline1000 mL lidocaine 30 mL and 1 mL of 11000 epinephrine was infil-trated into the donor sites After making a stab incision at the site of har-vest fat was harvested using a 3-mm cannula with multiple sharp sideholes of 1 mm attached to a 20-mL syringe Negative pressure was cre-ated in the syringe by pulling the plunger back by 2 mL The fat wastransferred to a commercially available sterilized sieve It was rinsedwell with 09 saline to wash off all the blood and tumescent fluidsuctioned along with the fat This fat was then transferred to a 10-mLsyringe connected to another similar syringe with a female Luer-Lock Emulsification of this fat was achieved manually by 30 passesof this fat between two 10-mL syringes No local anesthesia was usedat the recipient site Pretunneling (subcision) was done in the intrader-mal or subdermal layer depending on the thickness of the dermis Fatwas injected in a fanwise pattern with an 18-gauge needle connectedto a 1-mL syringe until the skin blanched or displayed a yellowish dis-coloration6 Adhesive surgical strips (Steri-Strip) were applied over andaround the recipient area for 5 days to minimize edema and fat shiftStab incisions in the donor area were sutured or dressed with Steri-Strip and an elastic bandage was applied to contain edema and bruis-ing The patients were discharged the next day in the absence of anycomplications Sun protection was advised to all patients They werealso asked to take a soft diet and immobilize the area as much as possi-ble for the first 14 days to minimize shift and edema Gram-positivecoverage with cephradine was provided until 2 days postoperativelyFirst follow-up was at 10 days The grafted area was examined forany infection or edema The patients were asked to revisit after 6 monthsin case of no complaints in the interim period

After 6 months photographs of the scar were taken again usingthe same views and lighting as used preoperatively and reanalyzed withImageJ version 41 software1516 A final POSAS score was ascribed tothe scar Data were analyzed using SPSS version 22 and tabulated forinterpretation In order to apply paired-sample t test we checked thenormality of data using 1-sample Kolmogorov-Smirnov test If the nor-mality assumptions were not fulfilled the Wilcoxon test was applied

RESULTSThe mean age of patients was 2225 plusmn 579 years with an age

range between 4 and 32 years There were 20 (417) male and 28(583) female cases The mean scar size was 2420 plusmn 1639 cm2The mean volume of fat injected was 1234 plusmn 1007 mL The observer(Tables 1 and 2) and patient (Tables 3 and 4) results were tabulatedThe scores were also presented on a bar graph for a quick overview ofthe overall improvement after nanofat therapy (Tables 1 and 3 lowerpanels) The most significant improvements were found in pliability andpigmentation on the observer scale (Table 1 and Fig 1) Improvementin thickness and relief (the extent to which surface irregularitiesare present preferably compared with adjacent normal skin) werehowever unremarkable Decrease in scar pigmentation ldquoposttherapyrdquo was also recorded on ImageJ scanning (Fig 2) but wasnot statistically significant with a P = 0076 Statistically significantimprovement (P lt 00001) was observed on all parameters of thepatient section of the POSAS (Table 3 and Fig 2) Figure 1 shows avisible improvement in the relief and overall appearance of thescar postoperatively There was mild edema in 25 patients (625)that settled per se within 2 weeks in all cases No bruising was notedin any patient No fat cysts or granulomas were observed in any patient

DISCUSSIONNanofat in our study proved to be an effective and viable entrant

within thewide domain of scar therapies Scar appearancewas statisticallybetter on almost all parameters following a single session of nanofat

2 wwwannalsplasticsurgerycom


injection using a simple technique requiring no special equipmentWe excluded hypertrophic scars and keloids from our study as the pa-thology in these scars requires their regression rather than rejuvenationAccordingly the study recorded least improvement in scar thicknessand relief Scars of less than 1-year duration were also excluded as theyare amenable to improvement with standard postburn scar therapy atthis stage However we regard not recording the age of individual scarsa limitation of our study

Microfat grafting has been used successfully in treating radiother-apy ulcers and scars17 filling of rhytides18 facial scar improvement19

and breast augmentation2021 among others However its progeny thenanofat is still a relatively new concept as such literature pertaining toit is scanty limiting our comparisonswith other studiesMicrofat graftingon the contrary has been around for a longer period and is therefore moreresearched established and prevalent

Tonnard et al6 in his seminal article described emulsifying andfiltering microfat through a nylon gauze with 05-mm perforations toproduce nanofat The resultant effluent was fluid enough to be injectedeasily through a 27-gauge needle Ten milliliters of lipoaspirate typicallyyields about 1mL of nanofat with this method6 In our study nanofat wascreated by simple emulsification of microfat without further filtrationEmulsification of fat harvested with multiperforated cannulas is suffi-cient to generate tiny nanofat particles per se while filtration would facil-itate injection with small 27-gauge needles Significant improvement inscar appearance occurred with emulsified fat alone A predecessor ofTonnard and colleagues6 filtered nanofat it would logically contain allelements as its filtered offspring Moreover the deceased adipocytesretained in the unfiltered specimen are indefatigable even in their deathserving to release cytokines and attract growth factorndashreleasing macro-phages to the injected areas22 These factors further incite stem cell pro-liferation and tissue regeneration2223

Lo Furno et al22 compared the number of ASCs in samples ofmicrofat nanofat and unfiltered-emulsified fat that was given the ap-pellation ldquonanofat 20rdquo A greater number of ASCs were recorded inthe nanofat 20 as compared with the conventional nanofat sample fil-tration being culpable for the destruction of the stem cell population Incontrast to Tonnard and colleagues6 findings the number of CD34+ he-mopoietic stem cells was low by the 20th day in all 3 samples whereasthe population of CD90 CD44 andCD105 positive mesenchymal stemcells (MSCs) increased Lipoaspirate derivedCD34 stem cells area tran-sient species compared with their more tenacious peers in hemopoietic

copy 2018 Wolters Kluwer Health Inc All rights reserved


TABLE 2 Mean Preoperative and Postoperative Observer POSASShown

TABLE 4 Mean Preoperative and Postoperative Patient POSASShown

Annals of Plastic Surgery bull Volume 00 Number 00 Month 2018 Rejuvenation of Burn Scars With Nanofat

tissue Tonnard and colleagues6 CD34+ cell count was performed at10 days whereas Lo Furno et al22 extended the count time to 20 days

Unfiltered emulsified nanofat was also used by Goisis et al24 totreat tear trough deformities Filtration was omitted because medical-grade nylon gauzewas not available Instead 15-mm cannulas were usedto suction smaller fat particles that would not plug fine-bore needles Inour study the thicker nanofat had to be injectedwith large-gauge needlesFortunately no conspicuous scars remained at the puncture sites

One of the earliest manifestations of nanofat therapy is improvedpliability Although long-term improvement in scar pliability is a func-tion of stem cellndashinduced collagen and elastin synthesis and remodel-ing early improvement in scar pliability stems from the separation ofthe scarred skin from underlying tissues and the placement of soft fluidfat in between whereas assessment of pliability in our study was limited

TABLE 3 Prendash and Postndash6Months of Therapy Patient Scoring onthe POSAS


Preprocedure pain 329 219 200 275 lt00001Postprocedure pain 233 063 200 100Preprocedure itching 371 270 200 500 lt00001Postprocedure itching 204 046 200 000Preprocedure color 825 067 800 100 lt00001Postprocedure color 725 118 800 100Preprocedure stiffness 783 129 800 075 lt00001Postprocedure stiffness 329 062 300 100Preprocedure thickness 754 162 800 175 lt00001Postprocedure thickness 288 073 300 100Preprocedure irregularity 750 170 800 075 lt00001Postprocedure irregularity 288 079 300 175Preprocedure overall score 800 105 800 100 lt00001

Patients recorded significantly better scores on all parameters after nanofatgrafting




to a mere subjective assessment by a feel of the skin on pinch due tononavailability of objective tools such as a cutometer or a durometerJaspers et al25 objectively measured and recorded improvement in pli-ability of scars after microfat grafting using a cutometer Jaspers et al25

recorded statistically significant improvements in pliability and anoverall POSAS score over a 3-month follow-up period We reckonthe short follow-up period is too early to preempt the very veritable ef-fect of persisting erythema on scar pigmentation However in ourstudy too pigmentation changes on POSAS over a 1-year follow-upwere insignificant

Tonnard et al6 postulate the use of nanofat to treat dark circlesunder the eyes Similarly in another study nanofat was successfullyused for treatment of dark circles under the eyes26 Nanofat forms alayer between the thin almost translucent eyelid skin and the underly-ing vasculature that imparts the dark shadows Although the skin ofpostburn scars selected for our study group was mostly thin similarto eyelid skin hyperpigmentation was largely the result of persistentpostinflammatory melanocytic hyperactivity in our darker skin typesrather than a show of the underlying vasculature Even so we surmisethat in our study the interposition of pearly white nanofat between thethinned-out dermal layers and the deeper tissues contributed to the im-provement in pigmentation Moreover enhanced contours may bemisperceived as paler areas due to increased reflection of light fromthem Thus the significantly improved pigmentation recorded on thesubjective POSAS could partly be the result of a visual perceptioncontradicted by the more objective ImageJ scan However we wouldplace greater emphasis on subjective scar scores because in such as-sessments patient satisfaction carries more weight than nonchalantmathematical values

Mailey et al27 claim to be the first to report improvement in skinpigmentation after autologous fat grafting This was attributed to the anti-oxidant and wound healing properties of the constituents of the SVF2728

In vitro SVF is reported to cause whitening by suppressing melanin syn-thesis and tyrosinase activity28 Only Fitzpatrick types 3 and 4 were se-lected for this study to minimize bias as different Fitzpatrick skin typesrespond differently to the various stimuli that effect pigmentation ImageJsoftware can be used to detect the density of color A lower density corre-sponds to a darker color and vice versa with white possessing the highestdensity Using the ImageJ to identify a numerical shift in color density wasa distinctive feature of our study29 Gu et al30 also used ImageJ to highlightimprovement in pigmentation improvement after condensed (unfilteredtwice centrifuged nanofat to remove the oleaginous components) nanofattherapy As described previously nanofat in this study refers to the milkyfluid produced after emulsification of microfat Very few adipocytesresponsible for approximately 70 of the filling effect survive the



FIGURE 1 Visible improvement in scar appearance 6 months after a single session of nanofat grafting Representative photographs of3 patients are shown

FIGURE 2 ImageJ scanning showing increase in optical density corresponding to a decrease in pigmentation after nanofat graftingImageJ values are shown before (A) and after (B) nanofat injections


4 wwwannalsplasticsurgerycom copy 2018 Wolters Kluwer Health Inc All rights reserved

Copyright copy 2018 Wolters Kluwer Health Inc Unauthorized reproduction of this article is prohibited


mechanical stress induced by emulsification of fat631 Hence unlikemicrofat grafting filling is not a primary component of nanofat graftingAny augmentation in volume is only a consequent of proliferation incitedby growth factors provided by the nanofat and therefore not evident before3 weeks6 Microfat or macrofat is conclusively the material of choicewhen provision of volume is the prime reason for fat grafting Converselynanofat is more suited for aesthetic enhancement The small size of thenanofat particles facilitates injection in and under scars the stem cellscontained in the nanofat make it ideal for skin rejuvenation Unlike macrofat and microfat nanofat is not known to be associated with infectiongranulomas or fat cysts3233

As cited previously the most relevant component of nanofat isthe adipose-derived tissue stromal vascular fraction that survives theemulsification process and is responsible for the rejuvenative proliferativeand subsequent filling effects of nanofat The heterogeneous multipotentstem cell population in the adipose-derived t-SVF has the ability to trans-form into the host cell lineage such as adipogenic chondrogenic cardio-genic or even neurogenic34ndash36 Apart from these stem cells the SVFcontains other cell populations such as preadipocytes endothelial cellsand cells of hemopoietic lineage as well as fibroblasts Growth factorsare secreted in a paracrine fashion by the SVF triggered by inflammationduring pretunneling and hypoxia during suctioning103738 In additiont-SVF acts as a bioactive matrix to provide a scaffold for the attachmentof proliferating stem cells Stem cells can also be harvested from the bonemarrow but the procedure is more invasive and painful Enzymatic diges-tion of the stromal element in this bioactive t-SVF results in the creation ofadipose tissuendashderived cellular stromal vascular fraction that is an evenmore refined source of stem cells It is clear that the nanofat functions ata cellular level Keeping this in view Tonnard et al6 are skeptical if itshould in fact be classified as a fat graft or an in vivo tissue engineeringprocess6 The highest concentration of MSCs is clustered around thepericytes of the adipose tissue vasculature Based on this knowledgeLipogem technology39ndash40 (Lipogems Lipogems International SpAMilan Italy) was developed in 2013 that enabled isolation of nanofatwith an intact perivascular structure Lipogems are being used in manyfields of medicines today for their regenerative properties41ndash44 Relyingon a closed low-pressure system to inflict minimal trauma to the stromalvasculature and hence to theMSCs it is very similar to the emulsificationsans filtration method practiced in this study

Similar to Lo Furno22 skipping the filtration step in our studywas driven by necessity rather than a moment of eureka as we toolacked the relevant filtration capabilities As noted previously the sur-vival of ASCs depends on the treatment meted to them22 Filtrationhas been cited to damage the ASCs2239 Its only benefit seems to beeasy infiltration that can be overruled by other methods or even skippedaltogether as observed in our study without impacting on the resultsGiven our own success with unfiltered nanofat and that of other studiescited it is food for thought that it might in fact be beneficial to precludethe step of filtration from nanofat processing Having procured filtrationequipment studies are now underway to compare the results of filteredwith unfiltered nanofat in scar rejuvenation

CONCLUSIONSInjection of nanofat sourced from unfiltered emulsified fat in

nonhypertrophic postburn scars caused statistically significant im-provements in scar appearance

ACKNOWLEDGMENTSThe authors thank the colleagues for critically reviewing

the manuscript

REFERENCES

1 Neuber F Fat transplantaion Chir Kongr Verhandl Dsch Gesellch Chir 18932066



2 Illouz YG Body contouring by lipolysis a 5-year experience with over 3000cases Plast Reconstr Surg 198372591ndash597

3 Coleman SR Long-term survival of fat transplants controlled demonstrationsAesthetic Plast Surg 199519421ndash425

4 Coleman SR Structural fat grafts the ideal filler Clin Plast Surg 200128111ndash119

5 Zuk PA Zhu M Mizuno H et al Multilineage cells from human adipose tissueimplications for cell-based therapies Tissue Eng 20017211ndash228

6 Tonnard P Verpaele A Peeters G et al Nanofat grafting basic research and clin-ical applications Plast Reconstr Surg 20131321017ndash1026

7 Alexander RW Biocellular regenerative medicine use of adipose-derived stemstromal cells and its native bioactive matrix Phys Med Rehabil Clin N Am201627871ndash891

8 Oh JS Park IS Kim KN et al Transplantation of an adipose stem cell cluster in aspinal cord injury Neuroreport 201223277ndash282

9 Zhou B Yuan J Zhou Y et al Administering human adipose-derived mesenchy-mal stem cells to prevent and treat experimental arthritisClin Immunol 2011141328ndash337

10 Kapur SK Katz AJ Review of the adipose derived stem cell secretomeBiochimie 2013952222ndash2228

11 Pallua N Pulsfort AK Suschek C et al Content of the growth factors bFGF IGF-1 VEGF and PDGF-BB in freshly harvested lipoaspirate after centrifugation andincubation Plast Reconstr Surg 2009123826ndash833

12 BlantonMWHadad I Johnstone BH et al Adipose stromal cells and platelet-richplasma therapies synergistically increase revascularization during wound healingPlast Reconstr Surg 2009123(suppl 2)56Sndash64S

13 Hoogewerf CJ vanBaarMEMiddelkoop E et al Impact of facial burns relation-ship between depressive symptoms self-esteem and scar severity Gen Hosp Psy-chiatry 201436271ndash276

14 Draaijers LJ Tempelman FR Botman YA et al The patient and observer scar as-sessment scale a reliable and feasible tool for scar evaluation Plast ReconstrSurg 20041131960ndash1965

15 Yamamoto T Takiwaki H Arase S et al Derivation and clinical application ofspecial imaging by means of digital cameras and Image J freeware for quantifica-tion of erythema and pigmentation Skin Res Technol 20081426ndash34

16 Schneider CA Rasband WS Eliceiri KW NIH Image to ImageJ 25 years of im-age analysis Nat Methods 20129671ndash675

17 Rigotti G Marchi A Galiegrave M et al Clinical treatment of radiotherapy tissue dam-age by lipoaspirate transplant a healing process mediated by adipose-derivedadult stem cells Plast Reconstr Surg 20071191409ndash1422

18 Clauser LC Tieghi R Galiegrave M et al Structural fat grafting facial volumetricrestoration in complex reconstructive surgery J Craniofac Surg 2011221695ndash1701

19 Pallua N Baroncini A Alharbi Z et al Improvement of facial scar appearance andmicrocirculation by autologous lipofilling J Plast Reconstr Aesthet Surg 2014671033ndash1037

20 Rosing JH Wong G Wong MS et al Autologous fat grafting for primary breastaugmentation a systematic review Aesthetic Plast Surg 201135882ndash890

21 Yoshimura K Sato K Aoi N et al Cell-assisted lipotransfer for cosmetic breastaugmentation supportive use of adipose-derived stemstromal cells AestheticPlast Surg 20083248ndash55

22 Lo FurnoDL Tamburino SManninoG et al Nanofat 20 experimental evidencefor a fat grafting rich in mesenchymal stem cells Physiol Res 201766663ndash671

23 Mahdavian Delavary B van der Veer WM van EgmondM et al Macrophages inskin injury and repair Immunobiology 2011216753ndash762

24 Goisis M Stella E Di Petrillo A et al Nanofat grafting compared to hyaluronicacid and prp treatment of the lower lid and tear trough clinical outcomeJSM Ophthalmol 201531027

25 Jaspers ME Brouwer KM van Trier AJ et al Effectiveness of autologous fatgrafting in adherent scars results obtained by a comprehensive scar evaluationprotocol Plast Reconstr Surg 2017139212ndash219

26 Oh DS Kim DH Roh TS et al Correction of dark coloration of the lower eyelidskin with nanofat grafting Arch Aesthet Plast Surg 20142092ndash96

27 Mailey B Saba S Baker J et al A comparison of cell-enriched fat transfer to con-ventional fat grafting after aesthetic procedures using a patient satisfaction surveyAnn Plast Surg 201370410ndash415

28 Kim JH Jung M Kim HS et al Adipose-derived stem cells as a new therapeuticmodality for ageing skin Exp Dermatol 201120383ndash387

29 Rasband W ImageJ US National Institutes of Health Bethesda MD USAAvailable at httpimagejnih govij 1997ndash2016

30 Gu Z Li Y Li H Use of condensed nanofat combined with fat grafts to treat atro-phic scars JAMA Facial Plast Surg 201820128ndash135



User 2
Highlight
اثر مثبت تزریق نانوفت برای ترمیم زخم های بعد از سوختگی13


31 Mashiko T Wu SH Feng J et al Mechanical micronization of lipoaspiratessqueeze and emulsification techniques Plast Reconstr Surg 201713979ndash90

32 Yoshimura K Coleman SR Complications of fat grafting how they occur andhow to find avoid and treat them Clin Plast Surg 201542383ndash388

33 Park HE Kim HT Lee CH et al Delayed lipogranuloma of the cheek followingautologous fat injection report of 2 cases Int J Clin Exp Pathol 201476391ndash6394

34 Coradeghini R Guida C Scanarotti C et al A comparative study of proliferationand hepatic differentiation of human adipose-derived stem cells Cells TissuesOrgans 2010191466ndash477

35 Aluigi MG Coradeghini R Guida C et al Pre-adipocytes commitment toneurogenesis 1 preliminary localisation of cholinergic molecules Cell Biol Int200933594ndash601

36 Scanarotti C Bassi AM Catalano M et al Neurogenic-committed humanpre-adipocytes express CYP1A isoforms Chem Biol Interact 2010184474ndash483

37 Forsythe JA Jiang BH Iyer NE et al Activation of vascular endothelial growthfactor gene transcription by hypoxia-inducible factor 1 Mol Cell Biol 1996164604ndash4613



38 Caruana G Bertozzi N Boschi E et al Role of adipose-derived stem cells inchronic cutaneous wound healing Ann Ital Chir 2015861ndash4

39 Tremolada C Ricordi C Caplan AI et al Mesenchymal stem cells in lipogems areverse story from clinical practice to basic science Methods Mol Biol 20161416109ndash122

40 Tremolada C Colombo V Ventura C Adipose tissue and mesenchymal stemcells state of the art and Lipogemsreg technology development Curr Stem CellRep 20162304ndash312

41 Raffaini M Tremolada C Micro fractured and purified adipose tissue graft(Lipogemsreg) can improve the orthognathic surgery outcomes both aestheticallyand in postoperative healing CellR4 20142e1118

42 Tassinari R Canaider S Pasquinelli G et al Lipogems a new modality of fattissue handling to enhance tissue repair in chronic hind limb ischemiaCellR4 20142e1289

43 Giori A Tremolada C Vailati R et al Recovery of function in anal incontinenceafter micro-fragmented fat graft (Lipogemsreg) injection twoyears follow up of thefirst 5 cases CellR4 20153e1544

44 Randelli P Menon A Ragone V et al Lipogems product treatment increases theproliferation rate of human tendon stem cells without affecting their stemnessand differentiation capability Stem Cells Int 201620164373410



TABLE 1 Pretherapy and Posttherapy Observer Values on thePOSAS


Preprocedure pigmentation 758 123 800 100 lt00001Postprocedure pigmentation 642 151 600 200Pre procedure thickness 438 195 300 375 0785daggerPostprocedure thickness 425 178 300 300Preprocedure relief 425 207 300 300 0099daggerPostprocedure relief 358 165 300 300Preprocedure pliability 675 176 700 250 lt00001Postprocedure pliability 342 077 300 100Preprocedure overall scar score 750 077 800 100 lt00001Postprocedure overall scar score 433 048 40 10

Note that maximum benefit obtained was for improvement in pigmentationand pliability


daggerPaired-sample t test was applied (comparison was made on mean plusmn SD)


Fat was mainly harvested from the abdomen the lateral thighandor the gluteal region Tumescent solution comprising of 09 saline1000 mL lidocaine 30 mL and 1 mL of 11000 epinephrine was infil-trated into the donor sites After making a stab incision at the site of har-vest fat was harvested using a 3-mm cannula with multiple sharp sideholes of 1 mm attached to a 20-mL syringe Negative pressure was cre-ated in the syringe by pulling the plunger back by 2 mL The fat wastransferred to a commercially available sterilized sieve It was rinsedwell with 09 saline to wash off all the blood and tumescent fluidsuctioned along with the fat This fat was then transferred to a 10-mLsyringe connected to another similar syringe with a female Luer-Lock Emulsification of this fat was achieved manually by 30 passesof this fat between two 10-mL syringes No local anesthesia was usedat the recipient site Pretunneling (subcision) was done in the intrader-mal or subdermal layer depending on the thickness of the dermis Fatwas injected in a fanwise pattern with an 18-gauge needle connectedto a 1-mL syringe until the skin blanched or displayed a yellowish dis-coloration6 Adhesive surgical strips (Steri-Strip) were applied over andaround the recipient area for 5 days to minimize edema and fat shiftStab incisions in the donor area were sutured or dressed with Steri-Strip and an elastic bandage was applied to contain edema and bruis-ing The patients were discharged the next day in the absence of anycomplications Sun protection was advised to all patients They werealso asked to take a soft diet and immobilize the area as much as possi-ble for the first 14 days to minimize shift and edema Gram-positivecoverage with cephradine was provided until 2 days postoperativelyFirst follow-up was at 10 days The grafted area was examined forany infection or edema The patients were asked to revisit after 6 monthsin case of no complaints in the interim period

After 6 months photographs of the scar were taken again usingthe same views and lighting as used preoperatively and reanalyzed withImageJ version 41 software1516 A final POSAS score was ascribed tothe scar Data were analyzed using SPSS version 22 and tabulated forinterpretation In order to apply paired-sample t test we checked thenormality of data using 1-sample Kolmogorov-Smirnov test If the nor-mality assumptions were not fulfilled the Wilcoxon test was applied

RESULTSThe mean age of patients was 2225 plusmn 579 years with an age

range between 4 and 32 years There were 20 (417) male and 28(583) female cases The mean scar size was 2420 plusmn 1639 cm2The mean volume of fat injected was 1234 plusmn 1007 mL The observer(Tables 1 and 2) and patient (Tables 3 and 4) results were tabulatedThe scores were also presented on a bar graph for a quick overview ofthe overall improvement after nanofat therapy (Tables 1 and 3 lowerpanels) The most significant improvements were found in pliability andpigmentation on the observer scale (Table 1 and Fig 1) Improvementin thickness and relief (the extent to which surface irregularitiesare present preferably compared with adjacent normal skin) werehowever unremarkable Decrease in scar pigmentation ldquoposttherapyrdquo was also recorded on ImageJ scanning (Fig 2) but wasnot statistically significant with a P = 0076 Statistically significantimprovement (P lt 00001) was observed on all parameters of thepatient section of the POSAS (Table 3 and Fig 2) Figure 1 shows avisible improvement in the relief and overall appearance of thescar postoperatively There was mild edema in 25 patients (625)that settled per se within 2 weeks in all cases No bruising was notedin any patient No fat cysts or granulomas were observed in any patient

DISCUSSIONNanofat in our study proved to be an effective and viable entrant

within thewide domain of scar therapies Scar appearancewas statisticallybetter on almost all parameters following a single session of nanofat



injection using a simple technique requiring no special equipmentWe excluded hypertrophic scars and keloids from our study as the pa-thology in these scars requires their regression rather than rejuvenationAccordingly the study recorded least improvement in scar thicknessand relief Scars of less than 1-year duration were also excluded as theyare amenable to improvement with standard postburn scar therapy atthis stage However we regard not recording the age of individual scarsa limitation of our study

Microfat grafting has been used successfully in treating radiother-apy ulcers and scars17 filling of rhytides18 facial scar improvement19

and breast augmentation2021 among others However its progeny thenanofat is still a relatively new concept as such literature pertaining toit is scanty limiting our comparisonswith other studiesMicrofat graftingon the contrary has been around for a longer period and is therefore moreresearched established and prevalent

Tonnard et al6 in his seminal article described emulsifying andfiltering microfat through a nylon gauze with 05-mm perforations toproduce nanofat The resultant effluent was fluid enough to be injectedeasily through a 27-gauge needle Ten milliliters of lipoaspirate typicallyyields about 1mL of nanofat with this method6 In our study nanofat wascreated by simple emulsification of microfat without further filtrationEmulsification of fat harvested with multiperforated cannulas is suffi-cient to generate tiny nanofat particles per se while filtration would facil-itate injection with small 27-gauge needles Significant improvement inscar appearance occurred with emulsified fat alone A predecessor ofTonnard and colleagues6 filtered nanofat it would logically contain allelements as its filtered offspring Moreover the deceased adipocytesretained in the unfiltered specimen are indefatigable even in their deathserving to release cytokines and attract growth factorndashreleasing macro-phages to the injected areas22 These factors further incite stem cell pro-liferation and tissue regeneration2223

Lo Furno et al22 compared the number of ASCs in samples ofmicrofat nanofat and unfiltered-emulsified fat that was given the ap-pellation ldquonanofat 20rdquo A greater number of ASCs were recorded inthe nanofat 20 as compared with the conventional nanofat sample fil-tration being culpable for the destruction of the stem cell population Incontrast to Tonnard and colleagues6 findings the number of CD34+ he-mopoietic stem cells was low by the 20th day in all 3 samples whereasthe population of CD90 CD44 andCD105 positive mesenchymal stemcells (MSCs) increased Lipoaspirate derivedCD34 stem cells area tran-sient species compared with their more tenacious peers in hemopoietic



































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unfiltered nanofat injections rejuvenate postburn scars of...

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