242 Original Article
Autologous Fat Grafting for Scleroderma-Induced Digital Ulcers. An Effective Technique in Patients with Systemic Sclerosis Autologe Fettransplantation für Skleroderma verursachte Finger Ulzera. Eine effektive Technik für Patienten mit Systemische Sklerodermie M. Del Bene1, M. R. Pozzi2, L. Rovati1, I. Mazzola1, G. Erba2, S. Bonomi3
Authors
1
S. Gerardo Hospital, Department of Plastic, Hand Surgery and Reconstructive Microsurgery, Monza, Italy S. Gerardo Hospital, Clinica Medica – Università Milano Bicocca, Monza, Italy 3 Department of Plastic Reconstructive Surgery and Burn Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
Affiliations
Key words ▶ autologous fat grafting ● ▶ digital ulcers ● ▶ systemic sclerosis ● ▶ chronic ischemia ● ▶ adipose-derived stem cells ● Schlüsselwörter ▶ autologe Fettransplantation ● ▶ digitale Ulzera ● ▶ systemische Sklerodermie ● ▶ chronische Ischämie ● ▶ Adipose-derived stem cells ●
received accepted
20.10.2013 25.04.2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1376970 Handchir Mikrochir Plast Chir 2014; 46: 242–247 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Dr. Stefano Bonomi Department of Plasti Reconstructive Surgery and Burn Unit Niguarda Ca’ Granda Hospital P.zza Ospedale Maggiore, 3 Milano 20162 Italy [email protected]
Abstract
Zusammenfassung
Background: Digital ulcers (DUs) occur in up to 50 % of patients with Systemic Sclerosis (SSc). DUs are painful, recurring and lead to functional disability. Management of DUs includes pharmacologic and local therapy, the healing process is slow and the ulcer can become infected or evolve to gangrene. Autologous fat grafting (AFG) is a technique used to promote tissues repair. We used AFG to treat DUs refractory to conventional treatment to enhance healing process. Patients and Methods: We treated 9 SSc patients for a total of 15 ulcers. All 9 patients were treated with iv Iloprost. The purified fat tissue was injected at the border of larger ulcers or at the finger base of smaller DUs. The AFG was performed from 2 to 8 months since the ulcer onset. Results: Complete healing occured in 10 DUs and size reduction ≥ 50 % in 2, within 8–12 weeks. In all but 2 patients the pain improved allowing a reduction of analgesics. In the majority of the cases AFG was able to hasten ulcer healing and to reduce pain and the need of pharmacological therapy. The lack of efficacy on healing and pain reduction was observed when the ulcers were long-lasting, located on legs and with concurrent atherosclerotic macroangiopathy. Conclusions: Surgical resective treatment for finger ulcers in patients affected by SSc is fraught with morbidity and long prolonged recovery. This study introduces a novel minimally invasive approach. The procedure is safe and effective, with short recovery time and local deficient vascularization improvement.
Hintergrund: Digitale Ulzeras kommen in 50 % der Patienten mit systemische Sklerose (SSc) vor. Fingerulzera sind schmerzhaft, wieder auftretend und führen zu funktionelle Körperunfähigkeit. Die Behandlung besteht sowohl aus einer pharmakologischen als auch von einer lokalen Wundtherapie. Aufgrund einer verlangsamten Wundheilung, können sich leicht Infektionen und Gangräne entwickeln. Autologe Fettransplantation wird zur Regeneration von Gewebe benutzt. Wir haben diese Technik bei schwer heilende digitale Ulzeras angewendet welche keine positive Antwort zur konventionelle Therapie ergeben haben. Methoden: Wir haben 9 unter systemische Sklerodermie leidende Patienten behandelt, insgesamt 15 Ulzeras. Alle Patienten erhielten eine Therapie mit Iloprost. Das mittels der Coleman Technik purifizierte Fett wurde an der Basis der betroffenen Phalanx transplantiert. Die autologe Fettransplantation erfolgte zwischen 2 und 8 Monate nach Erscheinung der Ulzera. Ergebnisse: In einen Zeitraum von 8 bis 12 Wochen erfolgte eine komplette Wundheilung in 10 Ulzeras und eine Reduktion ≥ 50 % des Wunddurchmessers ergab sich in 2 Fällen. Alle Patienten außer 2 berichteten eine sofortige Schmerzenverminderung sodass eine Reduktion der Analgesie möglich war. Alle Ulzeras zeigten eine erschnellte Wundheilung und eine sofortige Verminderung der lokalen Schmerzen, welche eine Reduzierung der pharmakologischen Therapie ermöglichte. Ein Fehlen des Heilungsprozesses und der Schmerzreduktion zeigten sich nur in seit längerer Zeit bestehende Wunden welche sich an den unteren Extremitäten befanden. Schlussfolgerung: Eine chirurgische Resektion der digitalen Ulzeras bei durch Systemische Sklerodermie erkrankte Patienten, bedingt eine erhöhte Morbidität und ein verlängertes
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Original Article 243
Introduction
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Adipose tissue transfer has become a standard technique in plastic surgery. Since its introduction and the widespread adoption of the structural fat graft technique described by Coleman, its various applications have multiplied [1–5]. Adipose tissue currently represents the most common autologous filler used to treat volume and contour defects. The therapeutic effect of autologous fat grafts does not solely lie in its role as a filler material, but also in its wound healing and angiogenetic properties. The latter is attributed to the undifferentiated adipose-derived stem cells (ADSCs). Human adipose-derived stem cells are multipotent autologous mesenchymal stem cells. These multipotent cells are recognized as a potential regenerative tool that may be beneficial in a wide variety of medical therapies in reconstructive surgery and in a multitude of other medical disciplines [6]. This has many implications and has further enlarged its use in different conditions where a vascular pathogenesis is a
d
b
involved, such as in diabetic ulcers, radiodermitis and radionecrosis, and in systemic sclerosis (SSc) [7, 8]. SSc is a disease characterized by vasculopathy, immunological activation and fibrosis. The disease can involve a broad spectrum of organs, but the hallmark is the cutaneous involvement [9]. Vasospasm, structural digital vasculopathy, tissue fibrosis, and local trauma are risk factors for digital ulceration in SSc [10]. Digital ulcers (DUs) occur in up to 50 % of patients with limited or diffuse SSc. DUs are extremely painful, often multiple, with chronic course and they lead to functional disability and worsening of quality of life [11]. DUs located at distal aspects of digits are related to tissue ischemia due to vasospasm secondary to Raynaud’s phenomenon, intimal fibro-proliferation, and throm▶ Fig. 1). DUs located over bony promibosis of digital arteries (● nences are thought to be due to repetitive micro-trauma and difficult healing due to atrophic, avascular tissue overlying the joints [12]. Management of DUs includes non-pharmacological and pharmacological therapies, but the healing process is often c
e
Fig. 1 Appearance of digital ulcers on both hands in patient with systemic sclerosis (SSc) with severe necrosis a, b. Intra- and postoperative pictures show the result after autologous fat grafting and finger amputation c–e.
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Heilungsprozess. Die Vorliegende Arbeit gibt eine Übersicht über ein neues Behandlungskonzept bei Patienten mit systemische Sklerodermie und zeigt die minimale Invasivität der chirurgischen Vorgangsweise. Das Verfahren ist sicher und effektiv. Eine Beschleunigung der Wundheilung und eine Verbesserung der mangelhaften lokalen Vaskularisation werden somit erreicht.
244 Original Article
a
d
b
c
e
a
b
c
d
very slow and infection or gangrene can occur. Moreover, the rate of ulcer recurrence is quite high [13]. Despite advances in drug therapy and wound dressing techniques, there is still a critical need for new methods to enhance the healing process to achieve optimal outcomes. Although the use of autologous fat grafting (AFG) for the treatment of DUs in SSc patients was not previously reported, considering its beneficial effect in tissue regeneration and in situations where the vascularization is compromised, we decided to use AFG to treat patients affected by SSc with DUs unable to respond to conventional pharmacological and local treatment. This article presents our preliminary experience with the use of AFG as innovative potential treatment for difficult DUs in SSc.
Fig. 3 Changes in appearance of a digital ulcer in a patient with SSc before a and after fat transfer. Postoperative pictures were taken at one b, two c and three months, respectively. The ulcer completely has healed after 3 months d.
Patients and Methods
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We treated with AFG 9 patients affected by SSc for a total of 15 digital ulcers, refractory to pharmacological treatment and ▶ Fig. 2–4). SSc was diagnosed according to the wound care (● American College of Rheumatology Criteria (1980) [14] and classified as limited cutaneous SSc (lcSSC) and diffuse cutaneous SSc (dcSSc) according to Le Roy [15]. The clinical features are ▶ Table 1. reported in ● At the ulcer onset all patients were treated with Iloprost intravenously (0.5–2 ng/kg/min for 6 h/day) for 10 days, then for 3 days every 4 weeks until healing. All the patients, but one, were treated with calcium channel blockers. 4 patients were treated with Bosentan to prevent ulcer recurrence and in 2 patients
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Fig. 2 Changes in appearance of a digital ulcer in a patient with SSc before a, b and after fat grafting c–e.
Original Article 245
a
b
c
Fat tissue was harvested under local anesthesia. The surgical technique used for fat grafting was described by Coleman [16]. A 3-mm, smooth-ended cannula, attached to a 10-mL Luer Lock syringe was used for harvesting the fat tissue, which was centrifuged for 3 min at 3 000 rpm. The upper oily supernatant as well as blood and debris at the bottom were eliminated. Only the middle layer, containing purified fat tissue was transferred to 1-mL syringes and 2–3 mL of fat were injected into fingers with blunt cannulae, at the border of the larger ulcers with different ▶ Fig. depths, or at the finger base for the smaller digital ulcers (● 1, 2). All patients signed the informed consent for the procedure and Institutional Review Board (IRB) approval for the procedure was obtained. Patients were regularly interviewed about pain, analgesic use, functional impairment. Pictures were taken weekly until complete healing.
Table 1 Clinical features of treated patients. Clinical Features Patients Age (years) F/M lcSSc dcSSC ANA ACA Anti Scl70 Disease duration (years) Skin score Ulcer location (hand/foot/leg) Ulcer number Ischemic ulcer Traction ulcer Macroangiopathy (angiography) Diabetes mellitus Arterial hypertension Clinical Features Patients
9 63 (43–76) 8/1 5 4 9 4 2 11.25 (1–19) 9.4 (2–19) 10/3/2 15 14 1 3 1 1
Results
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9
Table 2 Pharmacological therapy for ulcer healing and recurrence prevention (*). Patients
Ilo
Bos (*)
CCB
PDE5-I
ASA
1 2 3 4 5 6 7 8 9
y y y y y y y y y
n n n y y n y y n
y y y y y n y y y
n n n n y n y n n
y y y y y y y y y
Sildenafil was also introduced. Low doses of aspirin were used in ▶ Table 2). 7 patients. Only one patient (no. 1) was a smoker (● The local ulcer treatment also included appropriate debridment, moist dressing with biocellulose hydrobalance, and antibiotic therapy when signs of local infection were present: the antibiotic was selected according to the antibiogram obtained on isolated bacteria from a local swab. For dry necrosis surgical resection was indicated.
The majority of the ulcers treated were ischemic and on the hand (digital): only one was a traction ulcer on the PIP joint ▶ Fig. 3). The ulcers on the legs were mostly digital and (● ischemic. AFG was done from 2 to 8 months since the ulcer onset because of lack of efficacy of all the conventional therapies used: the timeframe of 3 months was used to evaluate the outcomes. In patient no. 2 the two ulcers treated were very long-lasting, large, localizaed on legs and already treated unsuccessfully with autologous cutaneous skin grafts; after AFG amputation was done. In patient no. 3, the AFG outcome on a digital ischemic ulcer on the right foot was poor: the concomitant atherosclerotic stenosis on the anterior tibial artery was treated with percutaneous transluminal angioplasty (PTA) and after that transmetatarsal amputation was needed. In patient no. 5 the AFG was performed just after PTA; although healing was not achieved, the ulcer size decreased by 50 % and the pain improved allowing a reduction of analgesic therapy. In patient no. 9 the ischemic DU on the foot decreased by 50 % and analgesic theraphy was withdrawn. In 10 ulcers of the 15 treated, the AFG outcome was effective with ▶ Fig. 3, 4), complete healing obtained in 8 to 12 weeks (● ▶ Table 3). After a follow-up ranging from 6 months to 2 years (● we did not observe any ulcer recurrence in the same location.
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Fig. 4 Appearance of a skin ulcer in a patient with SSc before a and after fat grafting b. The ulcer completely healed after 3 months c.
Table 3 Clinical outcome: ulcer healing and pain control. Patients
Healing
Ulcer reduction
Pain reduction
1 2 3 4 5 6 7 8 9
y n n y n y y y n
– n n – > 50 % – – – > 50 %
y n n y y y y y y
Discussion
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The digital ulcers represent a therapeutic challenge in systemic sclerosis. DUs cause local pain and functional impairment, are frequently recurrent and prone to infection. Despite the reduction in recurrence rates of DUs obtained with Bosentan [17], the efficacy of intravenous Iloprost in the healing of DUs, as stated by EULAR (European League Against Rheumatism) reccomendation [18] and of PDE5-inhibitors, like Sildenafil, as shown by non-controlled studies [19], the optimal strategy to heal a new ulcer has not yet been defined. The appropriate combination of vasodilator drugs, analgesia, wound dressing and infection control is mandatory, nevertheless, it is often insufficient [12], and the cure of DUs in SSc remains an unmet clinical need. For these reasons we decided to treat with AFG 9 consecutive patients affected by SSc with ulcers refractory to maximized pharmacological and local treatment. The AFG is used in reconstructive surgery and enables soft tissue repair: it is indicated for volume deficiency conditions due to aging, infection, trauma, Parry-Romberg syndrome, after cancer and reconstruction of the breast and scleroderma [20]. The fat graft injected fraction, obtained by centrifugation, contains adipocytes, but also a heterogeneous mesenchymal population of cells that includes also adipose-derived stem cells (ADSCs). ADSCs were identified as such by Zuck et al. in 2001. These authors defined the stem cell characteristics of ADSCs by their ability to differentiate into several mesenchymal lineages [21]. ADSC extraction from adipose tissue requires a multistep laboratory-based process. The majority of laboratories use collagenases that generate a cell pellet following centrifugation that has been named as the stromal vascular fraction (SVF). The SVF consists of multiple cell types, including circulating blood cells, fibroblasts, pericytes, endothelial cells, and adipose-derived stem cells [22]. ADSCs can be isolated from the SVF, and they can be identified by means of fluorescence-activated cell sorting, as they have several specific surface markers. ADSCs possess the ability to readily be expanded in vitro and the capacity to undergo adipogenic, osteogenic, chondrogenic, and myogenic (cardiomyocite and skeletal myocyte) differentiation [21]. Neurogenic differentiation potential has also been described in vitro [23], as has pancreatic endocrine phenotype expressing insulin [24], hepatic [25], and endothelial differentiation [26]. The metabolic properties of ADSCs (angiogenetic, antioxidative, immunotolerance) have been demonstrated in bench experiments and increasingly in preclinical models [27–29]. ADSCs secrete a favorable cytokine profile that is angiogenic, immunosuppressive, and antioxidative. The cytocine profile of
ADSCs contains vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF), and basic fibroblast growth factor (bFGF), which explains their impressive angiogenic capacity and their ability to induce tissue neovascularization [30]. Those functions are enhanced by hypoxia through an increased secretion of growth factors [27]. Furthermore, ADSCs have been shown to be immune-privileged because of a lack of human leukocyte antigen-DR expression and the suppression of the proliferation of activated lymphocytes [31]. ADSCs have also been shown to inhibit the production of inflammatory cytocines and to stimulate the production of antiinflammatory cytocines [32]. For all these reasons, cell therapy with ADSCs has emerged as a new approach to accelerate wound healing, but it is far to be available in clinical practice. Plastic surgery is a field where the clinical use of ADSCs is well developed, and the enrichment of fat grafts with ADSCs seems a promising approach for increasing the viability of the transplanted tissue. The cells are usually in the form of autologous stromal vascular fraction cells or noncultured adipose-derived stem cells, with one treatment given in a local immediate administration mainly in combination with fat grafts [20, 33–35]. Although there is no overlap between AFG and ADSCs therapy, we speculate that the beneficial effect in DUs healing could be due to ADSCs activities in fat graft: in fact, the chronic ischemia due to obstructive vasculopathy and the vasculogenesis impairment leading to tissue loss in sclerodermic DUs could potentially benefit from new vessels formation and cutaneous regeneration induced by ADSCs contained in the adipose tissue. We used the Coleman technique that is quite simple and minimally invasive: the fat graft is harvested by a light negative pressure to reduce cellular trauma, yielding a greater number of viable cells. The graft is distributed in small aliquots by injections through multiple access sites. We did not observe adverse reactions at the sites of injection and the pateint's discomfort was minimal. We observed in the majority of the treated ulcers an improvement in the healing process with the re-epithelization being obtained in 8–12 weeks. The improvement of pain was also attained in almost all patients/ulcers treated, reducing the use of pain medications. The lack of efficacy in healing and pain was observed only for long-lasting ulcers, located on legs and with concurrent atherosclerotic macroangiopathy. However, the AFG treatment was performed at the same time of vasodilator therapy and appropriate wound bed preparation: although we cannot distinguish the single contribution of each one of these procedures, the AFG was able to shorten the ulcer healing time and to reduce the need of pharmacological and local therapy in the majority of the cases. In this way, we have a potential synergism with which to obtain the healing. The main limitations of this study are based on the small number of ulcers/patients treated and the fact that AFG was used only on refractory ulcers (selection bias). The heterogeneity of digital ulcers in SSc patients makes difficult the judgment about the outcome of the treatment and the selection of an appropriate control group and for ethical reasons it not conceivable to avoid the pharmacological therapy.
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246 Original Article
Conclusion
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This preliminary study has shown the potential role of a simple method to exploit the regenerative potential of autologous fat in SSc ulcer repair. The use of AFG at ulcer onset concurrently with an appropriate pharmacological and local therapy and with a standardized measure of pain and functional disability will clarify the role of this procedure in sclerodermic ulcer treatment.
Stefano Bonomi was born in Milan, Italy (1977). He graduated from the Medical School of Università degli Studi di Milano in 2002. He then continued his training as a plastic surgeon obtaining his degree in 2007. After graduation he continued his plastic surgical training in Glasgow, Barcelona, Gent and Helsinki. He became interested in microsurgery and reconstructive surgery, attending training programmes in many international centers. He obtained the International Master’s degree in Reconstructive Microsurgery from the University of Barcelona. He is an active clinical researcher with over 20 indexed publications in prestigious journals. His interest in breast and microsurgical reconstruction is extensive, mainly with perforator flaps. He is a consultant plastic surgeon at Niguarda Ca’ Granda Hospital in Milan and coordinator of the Breast Unit.
Conflict of interest: The authors have no financial interest in any of the products, devices, or drugs mentioned in this manuscript. The authors have no conflicts of interest to disclose. There was no outside funding for this study. References 1 Ellenbogen R. Autologous fat injection. Plast Reconstr Surg 1991; 88: 543–544 2 Coleman SR. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995; 19: 421–425 3 Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997; 24: 347–367 4 Mojallal A, Foyatier JL. Historical review of the use of adipose tissue transfer in plastic and reconstructive surgery. Ann Chir Plast Esthet 2004; 49: 419–425 5 Mojallal A, Foyatier JL. The effect of different factors on the survival of transplanted adipocytes. Ann Chir Plast Esthet 2004; 49: 426–436 6 Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells: Roles in adipose tissue remodelling and potential use for soft tissue augmentation. Regen Med 2009; 4: 265–273 7 Gir P, Oni G, Brown SA et al. Human adipose stem cells: Current clinical applications. Plast Reconstr Surg 2012; 129: 1277–1290 8 Rigotti G, Marchi A, Galiè M et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007; 119: 1409–1422 discussion 1423-1424 9 Guiducci S, Giacomelli R, Cerinic MM. Vascular complications of scleroderma. Autoimmun Rev 2007; 6: 520–523 10 Chung L, Fiorentino D. Digital ulcers in patients with systemic sclerosis. Autoimmun Rev 2006; 5: 125–128 11 Maeda M, Matubara K, Hirano H et al. Pitting scars in progressive systemic sclerosis. Dermatology 1993; 187: 104–108
12 Denton C, Korn J. Digital ulceration and critical digital ischemia in scleroderma. Scleroderma Care Res 2003; 1: 12–16 13 Herrick AL. Management of Raynaud’s phenomenon and digital ischemia. Curr Rheumatol Rep 2013; 15: 303 14 Subcommittee for Scleroderma Criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classification of systemic sclerosis (scleroderma). Arthritis Rheum 1980; 23: 581–590 15 LeRoy EC, Medsger TA Jr. Criteria for the classification of early systemic sclerosis. J Rheumatol 2001; 28: 1573–1576 16 Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001; 28: 111–119 17 Matucci-Cerinic M, Denton CP, Furst DE et al. Bosentan treatment of digital ulcers related to systemic sclerosis: results from the RAPIDS-2 randomized, double-blind, placebo-controlled trial. Ann Rheum Dis 2011; 70: 32–38 18 Kowal-Bielecka O, Landewe R, Avouac J et al. EULAR recommendations for the treatment of systemic sclerosis: a report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann Rheum Dis 2009; 68: 620–628 19 Brueckner CS, Becker MO, Kroencke T et al. Effect of sildenafi l on digital ulcers in systemic sclerosis: analysis from a single centre pilot study. Ann Rheum Dis 2010; 69: 1475–1478 20 Tabit CJ, Slack GC, Fan K et al. Fat grafting versus adipose-derived stem cell therapy: Distinguishing indications, techniques, and outcomes. Aesth Plast Surg 2012; 36: 704–713 21 Zuk PA, Zhu M, Mizuno H et al. Multilineage cells from human adipose tissue: Implications for cell-based therapies. Tissue Eng 2001; 7: 211–228 22 Brown SA, Levi B, Lequeux C et al. Basic science review on adipose tissue for clinicians. Plast Reconstr Surg 2010; 126: 1936–1946 23 Ashjian PH, Elbarbary AS, Edmonds B et al. In vitro differentiation of human processed lipoaspirate cells into early neural progenitors. Plast Reconstr Surg 2003; 111: 1922–1931 24 Timper K, Seboek D, Eberhardt M et al. Human adipose tissue-derived mesenchymal stem cells differentiate into insulin, somatostatin, and glucagon expressing cells. Biochem Biophys Res Commun 2006; 341: 1135–1140 25 Banas A, Teratani T, Yamamoto Y et al. Adipose tissue-derived mesenchymal stem cells as a source of human hepatocytes. Hepatology 2007; 46: 219–228 26 Planat-Benard V, Silvestre JS, Cousin B et al. Plasticity of human adipose lineage cells toward endothelial cells: Physiological and therapeutic perspectives. Circulation 2004; 109: 656–663 27 Rehman J, Traktuev D., Li J et al. Secretion of angiogenetic and antiapoptotic factors by human adipose stromal cells. Circulation 2004; 109: 1292–1298 28 Kim WS, Park BS, Kim HK et al. Evidence supporting antioxidant action of adipose-derived stem cells: Protection of human dermal fibroblasts from oxidative stress. J Dermatol Sci 2008; 49: 133–142 29 Kang JW, Kang KS, Koo HC et al. Soluble factors-mediated immunomodulatory effects of canine adipose tissue-derived mesenchymal stem cells. Stem Cells Dev 2008; 17: 681–693 30 Kim WS, Park BS, Sung JH et al. Wound healing effect of adipose-derived stem cells A critical role of secretory factors on human dermal fibroblasts. J Dermatol Sci 2007; 48: 15–24 31 Gronthos S, Franklin DM, Leddy HA et al. Surface protein characterization of human adipose tissue-derived stromal cells. J Cell Physiol 2001; 189: 54–63 32 Cui L, Yin S, Liu W et al. Expanded adipose-derived stem cells suppress mixed lymphocyte reaction by secretion of prostaglandin E2. Tissue Eng 2007; 13: 1185–1195 33 Karagianni M, Kraneburg U, Kluter H et al. Autologous fat grafts and supportive enrichment with adipose tissue stromal cells. Handchir Microkir Plast Chir 2013; 45: 93–98 34 Rennekampff HO, Reimers K, Gabka CJ et al. Current perspective and limitations of autologous fat transplantation – “Consensus Meeting” of German Society of Plastic, Reconstructive and Aesthetic Surgeons at Hannover; September 2009. Handchir Microkir Plast Chir 2010; 42: 137–142 35 Trojahn Kølle SF, Oliveri RS, Glovinski PV et al. Importance of mesenchymal stem cells in autologous fat grafting: A systematic review of existing studies. J Plast Surg Hand Surg 2012; 46: 59–68
Del Bene M et al. Autologous Fat Grafting for … Handchir Mikrochir Plast Chir 2014; 46: 242–247
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Original Article 247
Autologous Fat Grafting for Scleroderma-Induced Digital Ulcers. An Effective Technique in Patients with Systemic Sclerosis Autologe Fettransplantation für Skleroderma verursachte Finger Ulzera. Eine effektive Technik für Patienten mit Systemische Sklerodermie M. Del Bene1, M. R. Pozzi2, L. Rovati1, I. Mazzola1, G. Erba2, S. Bonomi3
Authors
1
S. Gerardo Hospital, Department of Plastic, Hand Surgery and Reconstructive Microsurgery, Monza, Italy S. Gerardo Hospital, Clinica Medica – Università Milano Bicocca, Monza, Italy 3 Department of Plastic Reconstructive Surgery and Burn Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
Affiliations
Key words ▶ autologous fat grafting ● ▶ digital ulcers ● ▶ systemic sclerosis ● ▶ chronic ischemia ● ▶ adipose-derived stem cells ● Schlüsselwörter ▶ autologe Fettransplantation ● ▶ digitale Ulzera ● ▶ systemische Sklerodermie ● ▶ chronische Ischämie ● ▶ Adipose-derived stem cells ●
received accepted
20.10.2013 25.04.2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1376970 Handchir Mikrochir Plast Chir 2014; 46: 242–247 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Dr. Stefano Bonomi Department of Plasti Reconstructive Surgery and Burn Unit Niguarda Ca’ Granda Hospital P.zza Ospedale Maggiore, 3 Milano 20162 Italy [email protected]
Abstract
Zusammenfassung
Background: Digital ulcers (DUs) occur in up to 50 % of patients with Systemic Sclerosis (SSc). DUs are painful, recurring and lead to functional disability. Management of DUs includes pharmacologic and local therapy, the healing process is slow and the ulcer can become infected or evolve to gangrene. Autologous fat grafting (AFG) is a technique used to promote tissues repair. We used AFG to treat DUs refractory to conventional treatment to enhance healing process. Patients and Methods: We treated 9 SSc patients for a total of 15 ulcers. All 9 patients were treated with iv Iloprost. The purified fat tissue was injected at the border of larger ulcers or at the finger base of smaller DUs. The AFG was performed from 2 to 8 months since the ulcer onset. Results: Complete healing occured in 10 DUs and size reduction ≥ 50 % in 2, within 8–12 weeks. In all but 2 patients the pain improved allowing a reduction of analgesics. In the majority of the cases AFG was able to hasten ulcer healing and to reduce pain and the need of pharmacological therapy. The lack of efficacy on healing and pain reduction was observed when the ulcers were long-lasting, located on legs and with concurrent atherosclerotic macroangiopathy. Conclusions: Surgical resective treatment for finger ulcers in patients affected by SSc is fraught with morbidity and long prolonged recovery. This study introduces a novel minimally invasive approach. The procedure is safe and effective, with short recovery time and local deficient vascularization improvement.
Hintergrund: Digitale Ulzeras kommen in 50 % der Patienten mit systemische Sklerose (SSc) vor. Fingerulzera sind schmerzhaft, wieder auftretend und führen zu funktionelle Körperunfähigkeit. Die Behandlung besteht sowohl aus einer pharmakologischen als auch von einer lokalen Wundtherapie. Aufgrund einer verlangsamten Wundheilung, können sich leicht Infektionen und Gangräne entwickeln. Autologe Fettransplantation wird zur Regeneration von Gewebe benutzt. Wir haben diese Technik bei schwer heilende digitale Ulzeras angewendet welche keine positive Antwort zur konventionelle Therapie ergeben haben. Methoden: Wir haben 9 unter systemische Sklerodermie leidende Patienten behandelt, insgesamt 15 Ulzeras. Alle Patienten erhielten eine Therapie mit Iloprost. Das mittels der Coleman Technik purifizierte Fett wurde an der Basis der betroffenen Phalanx transplantiert. Die autologe Fettransplantation erfolgte zwischen 2 und 8 Monate nach Erscheinung der Ulzera. Ergebnisse: In einen Zeitraum von 8 bis 12 Wochen erfolgte eine komplette Wundheilung in 10 Ulzeras und eine Reduktion ≥ 50 % des Wunddurchmessers ergab sich in 2 Fällen. Alle Patienten außer 2 berichteten eine sofortige Schmerzenverminderung sodass eine Reduktion der Analgesie möglich war. Alle Ulzeras zeigten eine erschnellte Wundheilung und eine sofortige Verminderung der lokalen Schmerzen, welche eine Reduzierung der pharmakologischen Therapie ermöglichte. Ein Fehlen des Heilungsprozesses und der Schmerzreduktion zeigten sich nur in seit längerer Zeit bestehende Wunden welche sich an den unteren Extremitäten befanden. Schlussfolgerung: Eine chirurgische Resektion der digitalen Ulzeras bei durch Systemische Sklerodermie erkrankte Patienten, bedingt eine erhöhte Morbidität und ein verlängertes
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Del Bene M et al. Autologous Fat Grafting for … Handchir Mikrochir Plast Chir 2014; 46: 242–247
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Downloaded by: University of Pittsburgh. Copyrighted material.
2
Original Article 243
Introduction
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Adipose tissue transfer has become a standard technique in plastic surgery. Since its introduction and the widespread adoption of the structural fat graft technique described by Coleman, its various applications have multiplied [1–5]. Adipose tissue currently represents the most common autologous filler used to treat volume and contour defects. The therapeutic effect of autologous fat grafts does not solely lie in its role as a filler material, but also in its wound healing and angiogenetic properties. The latter is attributed to the undifferentiated adipose-derived stem cells (ADSCs). Human adipose-derived stem cells are multipotent autologous mesenchymal stem cells. These multipotent cells are recognized as a potential regenerative tool that may be beneficial in a wide variety of medical therapies in reconstructive surgery and in a multitude of other medical disciplines [6]. This has many implications and has further enlarged its use in different conditions where a vascular pathogenesis is a
d
b
involved, such as in diabetic ulcers, radiodermitis and radionecrosis, and in systemic sclerosis (SSc) [7, 8]. SSc is a disease characterized by vasculopathy, immunological activation and fibrosis. The disease can involve a broad spectrum of organs, but the hallmark is the cutaneous involvement [9]. Vasospasm, structural digital vasculopathy, tissue fibrosis, and local trauma are risk factors for digital ulceration in SSc [10]. Digital ulcers (DUs) occur in up to 50 % of patients with limited or diffuse SSc. DUs are extremely painful, often multiple, with chronic course and they lead to functional disability and worsening of quality of life [11]. DUs located at distal aspects of digits are related to tissue ischemia due to vasospasm secondary to Raynaud’s phenomenon, intimal fibro-proliferation, and throm▶ Fig. 1). DUs located over bony promibosis of digital arteries (● nences are thought to be due to repetitive micro-trauma and difficult healing due to atrophic, avascular tissue overlying the joints [12]. Management of DUs includes non-pharmacological and pharmacological therapies, but the healing process is often c
e
Fig. 1 Appearance of digital ulcers on both hands in patient with systemic sclerosis (SSc) with severe necrosis a, b. Intra- and postoperative pictures show the result after autologous fat grafting and finger amputation c–e.
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Heilungsprozess. Die Vorliegende Arbeit gibt eine Übersicht über ein neues Behandlungskonzept bei Patienten mit systemische Sklerodermie und zeigt die minimale Invasivität der chirurgischen Vorgangsweise. Das Verfahren ist sicher und effektiv. Eine Beschleunigung der Wundheilung und eine Verbesserung der mangelhaften lokalen Vaskularisation werden somit erreicht.
244 Original Article
a
d
b
c
e
a
b
c
d
very slow and infection or gangrene can occur. Moreover, the rate of ulcer recurrence is quite high [13]. Despite advances in drug therapy and wound dressing techniques, there is still a critical need for new methods to enhance the healing process to achieve optimal outcomes. Although the use of autologous fat grafting (AFG) for the treatment of DUs in SSc patients was not previously reported, considering its beneficial effect in tissue regeneration and in situations where the vascularization is compromised, we decided to use AFG to treat patients affected by SSc with DUs unable to respond to conventional pharmacological and local treatment. This article presents our preliminary experience with the use of AFG as innovative potential treatment for difficult DUs in SSc.
Fig. 3 Changes in appearance of a digital ulcer in a patient with SSc before a and after fat transfer. Postoperative pictures were taken at one b, two c and three months, respectively. The ulcer completely has healed after 3 months d.
Patients and Methods
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We treated with AFG 9 patients affected by SSc for a total of 15 digital ulcers, refractory to pharmacological treatment and ▶ Fig. 2–4). SSc was diagnosed according to the wound care (● American College of Rheumatology Criteria (1980) [14] and classified as limited cutaneous SSc (lcSSC) and diffuse cutaneous SSc (dcSSc) according to Le Roy [15]. The clinical features are ▶ Table 1. reported in ● At the ulcer onset all patients were treated with Iloprost intravenously (0.5–2 ng/kg/min for 6 h/day) for 10 days, then for 3 days every 4 weeks until healing. All the patients, but one, were treated with calcium channel blockers. 4 patients were treated with Bosentan to prevent ulcer recurrence and in 2 patients
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Fig. 2 Changes in appearance of a digital ulcer in a patient with SSc before a, b and after fat grafting c–e.
Original Article 245
a
b
c
Fat tissue was harvested under local anesthesia. The surgical technique used for fat grafting was described by Coleman [16]. A 3-mm, smooth-ended cannula, attached to a 10-mL Luer Lock syringe was used for harvesting the fat tissue, which was centrifuged for 3 min at 3 000 rpm. The upper oily supernatant as well as blood and debris at the bottom were eliminated. Only the middle layer, containing purified fat tissue was transferred to 1-mL syringes and 2–3 mL of fat were injected into fingers with blunt cannulae, at the border of the larger ulcers with different ▶ Fig. depths, or at the finger base for the smaller digital ulcers (● 1, 2). All patients signed the informed consent for the procedure and Institutional Review Board (IRB) approval for the procedure was obtained. Patients were regularly interviewed about pain, analgesic use, functional impairment. Pictures were taken weekly until complete healing.
Table 1 Clinical features of treated patients. Clinical Features Patients Age (years) F/M lcSSc dcSSC ANA ACA Anti Scl70 Disease duration (years) Skin score Ulcer location (hand/foot/leg) Ulcer number Ischemic ulcer Traction ulcer Macroangiopathy (angiography) Diabetes mellitus Arterial hypertension Clinical Features Patients
9 63 (43–76) 8/1 5 4 9 4 2 11.25 (1–19) 9.4 (2–19) 10/3/2 15 14 1 3 1 1
Results
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9
Table 2 Pharmacological therapy for ulcer healing and recurrence prevention (*). Patients
Ilo
Bos (*)
CCB
PDE5-I
ASA
1 2 3 4 5 6 7 8 9
y y y y y y y y y
n n n y y n y y n
y y y y y n y y y
n n n n y n y n n
y y y y y y y y y
Sildenafil was also introduced. Low doses of aspirin were used in ▶ Table 2). 7 patients. Only one patient (no. 1) was a smoker (● The local ulcer treatment also included appropriate debridment, moist dressing with biocellulose hydrobalance, and antibiotic therapy when signs of local infection were present: the antibiotic was selected according to the antibiogram obtained on isolated bacteria from a local swab. For dry necrosis surgical resection was indicated.
The majority of the ulcers treated were ischemic and on the hand (digital): only one was a traction ulcer on the PIP joint ▶ Fig. 3). The ulcers on the legs were mostly digital and (● ischemic. AFG was done from 2 to 8 months since the ulcer onset because of lack of efficacy of all the conventional therapies used: the timeframe of 3 months was used to evaluate the outcomes. In patient no. 2 the two ulcers treated were very long-lasting, large, localizaed on legs and already treated unsuccessfully with autologous cutaneous skin grafts; after AFG amputation was done. In patient no. 3, the AFG outcome on a digital ischemic ulcer on the right foot was poor: the concomitant atherosclerotic stenosis on the anterior tibial artery was treated with percutaneous transluminal angioplasty (PTA) and after that transmetatarsal amputation was needed. In patient no. 5 the AFG was performed just after PTA; although healing was not achieved, the ulcer size decreased by 50 % and the pain improved allowing a reduction of analgesic therapy. In patient no. 9 the ischemic DU on the foot decreased by 50 % and analgesic theraphy was withdrawn. In 10 ulcers of the 15 treated, the AFG outcome was effective with ▶ Fig. 3, 4), complete healing obtained in 8 to 12 weeks (● ▶ Table 3). After a follow-up ranging from 6 months to 2 years (● we did not observe any ulcer recurrence in the same location.
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Fig. 4 Appearance of a skin ulcer in a patient with SSc before a and after fat grafting b. The ulcer completely healed after 3 months c.
Table 3 Clinical outcome: ulcer healing and pain control. Patients
Healing
Ulcer reduction
Pain reduction
1 2 3 4 5 6 7 8 9
y n n y n y y y n
– n n – > 50 % – – – > 50 %
y n n y y y y y y
Discussion
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The digital ulcers represent a therapeutic challenge in systemic sclerosis. DUs cause local pain and functional impairment, are frequently recurrent and prone to infection. Despite the reduction in recurrence rates of DUs obtained with Bosentan [17], the efficacy of intravenous Iloprost in the healing of DUs, as stated by EULAR (European League Against Rheumatism) reccomendation [18] and of PDE5-inhibitors, like Sildenafil, as shown by non-controlled studies [19], the optimal strategy to heal a new ulcer has not yet been defined. The appropriate combination of vasodilator drugs, analgesia, wound dressing and infection control is mandatory, nevertheless, it is often insufficient [12], and the cure of DUs in SSc remains an unmet clinical need. For these reasons we decided to treat with AFG 9 consecutive patients affected by SSc with ulcers refractory to maximized pharmacological and local treatment. The AFG is used in reconstructive surgery and enables soft tissue repair: it is indicated for volume deficiency conditions due to aging, infection, trauma, Parry-Romberg syndrome, after cancer and reconstruction of the breast and scleroderma [20]. The fat graft injected fraction, obtained by centrifugation, contains adipocytes, but also a heterogeneous mesenchymal population of cells that includes also adipose-derived stem cells (ADSCs). ADSCs were identified as such by Zuck et al. in 2001. These authors defined the stem cell characteristics of ADSCs by their ability to differentiate into several mesenchymal lineages [21]. ADSC extraction from adipose tissue requires a multistep laboratory-based process. The majority of laboratories use collagenases that generate a cell pellet following centrifugation that has been named as the stromal vascular fraction (SVF). The SVF consists of multiple cell types, including circulating blood cells, fibroblasts, pericytes, endothelial cells, and adipose-derived stem cells [22]. ADSCs can be isolated from the SVF, and they can be identified by means of fluorescence-activated cell sorting, as they have several specific surface markers. ADSCs possess the ability to readily be expanded in vitro and the capacity to undergo adipogenic, osteogenic, chondrogenic, and myogenic (cardiomyocite and skeletal myocyte) differentiation [21]. Neurogenic differentiation potential has also been described in vitro [23], as has pancreatic endocrine phenotype expressing insulin [24], hepatic [25], and endothelial differentiation [26]. The metabolic properties of ADSCs (angiogenetic, antioxidative, immunotolerance) have been demonstrated in bench experiments and increasingly in preclinical models [27–29]. ADSCs secrete a favorable cytokine profile that is angiogenic, immunosuppressive, and antioxidative. The cytocine profile of
ADSCs contains vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF), and basic fibroblast growth factor (bFGF), which explains their impressive angiogenic capacity and their ability to induce tissue neovascularization [30]. Those functions are enhanced by hypoxia through an increased secretion of growth factors [27]. Furthermore, ADSCs have been shown to be immune-privileged because of a lack of human leukocyte antigen-DR expression and the suppression of the proliferation of activated lymphocytes [31]. ADSCs have also been shown to inhibit the production of inflammatory cytocines and to stimulate the production of antiinflammatory cytocines [32]. For all these reasons, cell therapy with ADSCs has emerged as a new approach to accelerate wound healing, but it is far to be available in clinical practice. Plastic surgery is a field where the clinical use of ADSCs is well developed, and the enrichment of fat grafts with ADSCs seems a promising approach for increasing the viability of the transplanted tissue. The cells are usually in the form of autologous stromal vascular fraction cells or noncultured adipose-derived stem cells, with one treatment given in a local immediate administration mainly in combination with fat grafts [20, 33–35]. Although there is no overlap between AFG and ADSCs therapy, we speculate that the beneficial effect in DUs healing could be due to ADSCs activities in fat graft: in fact, the chronic ischemia due to obstructive vasculopathy and the vasculogenesis impairment leading to tissue loss in sclerodermic DUs could potentially benefit from new vessels formation and cutaneous regeneration induced by ADSCs contained in the adipose tissue. We used the Coleman technique that is quite simple and minimally invasive: the fat graft is harvested by a light negative pressure to reduce cellular trauma, yielding a greater number of viable cells. The graft is distributed in small aliquots by injections through multiple access sites. We did not observe adverse reactions at the sites of injection and the pateint's discomfort was minimal. We observed in the majority of the treated ulcers an improvement in the healing process with the re-epithelization being obtained in 8–12 weeks. The improvement of pain was also attained in almost all patients/ulcers treated, reducing the use of pain medications. The lack of efficacy in healing and pain was observed only for long-lasting ulcers, located on legs and with concurrent atherosclerotic macroangiopathy. However, the AFG treatment was performed at the same time of vasodilator therapy and appropriate wound bed preparation: although we cannot distinguish the single contribution of each one of these procedures, the AFG was able to shorten the ulcer healing time and to reduce the need of pharmacological and local therapy in the majority of the cases. In this way, we have a potential synergism with which to obtain the healing. The main limitations of this study are based on the small number of ulcers/patients treated and the fact that AFG was used only on refractory ulcers (selection bias). The heterogeneity of digital ulcers in SSc patients makes difficult the judgment about the outcome of the treatment and the selection of an appropriate control group and for ethical reasons it not conceivable to avoid the pharmacological therapy.
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246 Original Article
Conclusion
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This preliminary study has shown the potential role of a simple method to exploit the regenerative potential of autologous fat in SSc ulcer repair. The use of AFG at ulcer onset concurrently with an appropriate pharmacological and local therapy and with a standardized measure of pain and functional disability will clarify the role of this procedure in sclerodermic ulcer treatment.
Stefano Bonomi was born in Milan, Italy (1977). He graduated from the Medical School of Università degli Studi di Milano in 2002. He then continued his training as a plastic surgeon obtaining his degree in 2007. After graduation he continued his plastic surgical training in Glasgow, Barcelona, Gent and Helsinki. He became interested in microsurgery and reconstructive surgery, attending training programmes in many international centers. He obtained the International Master’s degree in Reconstructive Microsurgery from the University of Barcelona. He is an active clinical researcher with over 20 indexed publications in prestigious journals. His interest in breast and microsurgical reconstruction is extensive, mainly with perforator flaps. He is a consultant plastic surgeon at Niguarda Ca’ Granda Hospital in Milan and coordinator of the Breast Unit.
Conflict of interest: The authors have no financial interest in any of the products, devices, or drugs mentioned in this manuscript. The authors have no conflicts of interest to disclose. There was no outside funding for this study. References 1 Ellenbogen R. Autologous fat injection. Plast Reconstr Surg 1991; 88: 543–544 2 Coleman SR. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995; 19: 421–425 3 Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997; 24: 347–367 4 Mojallal A, Foyatier JL. Historical review of the use of adipose tissue transfer in plastic and reconstructive surgery. Ann Chir Plast Esthet 2004; 49: 419–425 5 Mojallal A, Foyatier JL. The effect of different factors on the survival of transplanted adipocytes. Ann Chir Plast Esthet 2004; 49: 426–436 6 Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells: Roles in adipose tissue remodelling and potential use for soft tissue augmentation. Regen Med 2009; 4: 265–273 7 Gir P, Oni G, Brown SA et al. Human adipose stem cells: Current clinical applications. Plast Reconstr Surg 2012; 129: 1277–1290 8 Rigotti G, Marchi A, Galiè M et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007; 119: 1409–1422 discussion 1423-1424 9 Guiducci S, Giacomelli R, Cerinic MM. Vascular complications of scleroderma. Autoimmun Rev 2007; 6: 520–523 10 Chung L, Fiorentino D. Digital ulcers in patients with systemic sclerosis. Autoimmun Rev 2006; 5: 125–128 11 Maeda M, Matubara K, Hirano H et al. Pitting scars in progressive systemic sclerosis. Dermatology 1993; 187: 104–108
12 Denton C, Korn J. Digital ulceration and critical digital ischemia in scleroderma. Scleroderma Care Res 2003; 1: 12–16 13 Herrick AL. Management of Raynaud’s phenomenon and digital ischemia. Curr Rheumatol Rep 2013; 15: 303 14 Subcommittee for Scleroderma Criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classification of systemic sclerosis (scleroderma). Arthritis Rheum 1980; 23: 581–590 15 LeRoy EC, Medsger TA Jr. Criteria for the classification of early systemic sclerosis. J Rheumatol 2001; 28: 1573–1576 16 Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001; 28: 111–119 17 Matucci-Cerinic M, Denton CP, Furst DE et al. Bosentan treatment of digital ulcers related to systemic sclerosis: results from the RAPIDS-2 randomized, double-blind, placebo-controlled trial. Ann Rheum Dis 2011; 70: 32–38 18 Kowal-Bielecka O, Landewe R, Avouac J et al. EULAR recommendations for the treatment of systemic sclerosis: a report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann Rheum Dis 2009; 68: 620–628 19 Brueckner CS, Becker MO, Kroencke T et al. Effect of sildenafi l on digital ulcers in systemic sclerosis: analysis from a single centre pilot study. Ann Rheum Dis 2010; 69: 1475–1478 20 Tabit CJ, Slack GC, Fan K et al. Fat grafting versus adipose-derived stem cell therapy: Distinguishing indications, techniques, and outcomes. Aesth Plast Surg 2012; 36: 704–713 21 Zuk PA, Zhu M, Mizuno H et al. Multilineage cells from human adipose tissue: Implications for cell-based therapies. Tissue Eng 2001; 7: 211–228 22 Brown SA, Levi B, Lequeux C et al. Basic science review on adipose tissue for clinicians. Plast Reconstr Surg 2010; 126: 1936–1946 23 Ashjian PH, Elbarbary AS, Edmonds B et al. In vitro differentiation of human processed lipoaspirate cells into early neural progenitors. Plast Reconstr Surg 2003; 111: 1922–1931 24 Timper K, Seboek D, Eberhardt M et al. Human adipose tissue-derived mesenchymal stem cells differentiate into insulin, somatostatin, and glucagon expressing cells. Biochem Biophys Res Commun 2006; 341: 1135–1140 25 Banas A, Teratani T, Yamamoto Y et al. Adipose tissue-derived mesenchymal stem cells as a source of human hepatocytes. Hepatology 2007; 46: 219–228 26 Planat-Benard V, Silvestre JS, Cousin B et al. Plasticity of human adipose lineage cells toward endothelial cells: Physiological and therapeutic perspectives. Circulation 2004; 109: 656–663 27 Rehman J, Traktuev D., Li J et al. Secretion of angiogenetic and antiapoptotic factors by human adipose stromal cells. Circulation 2004; 109: 1292–1298 28 Kim WS, Park BS, Kim HK et al. Evidence supporting antioxidant action of adipose-derived stem cells: Protection of human dermal fibroblasts from oxidative stress. J Dermatol Sci 2008; 49: 133–142 29 Kang JW, Kang KS, Koo HC et al. Soluble factors-mediated immunomodulatory effects of canine adipose tissue-derived mesenchymal stem cells. Stem Cells Dev 2008; 17: 681–693 30 Kim WS, Park BS, Sung JH et al. Wound healing effect of adipose-derived stem cells A critical role of secretory factors on human dermal fibroblasts. J Dermatol Sci 2007; 48: 15–24 31 Gronthos S, Franklin DM, Leddy HA et al. Surface protein characterization of human adipose tissue-derived stromal cells. J Cell Physiol 2001; 189: 54–63 32 Cui L, Yin S, Liu W et al. Expanded adipose-derived stem cells suppress mixed lymphocyte reaction by secretion of prostaglandin E2. Tissue Eng 2007; 13: 1185–1195 33 Karagianni M, Kraneburg U, Kluter H et al. Autologous fat grafts and supportive enrichment with adipose tissue stromal cells. Handchir Microkir Plast Chir 2013; 45: 93–98 34 Rennekampff HO, Reimers K, Gabka CJ et al. Current perspective and limitations of autologous fat transplantation – “Consensus Meeting” of German Society of Plastic, Reconstructive and Aesthetic Surgeons at Hannover; September 2009. Handchir Microkir Plast Chir 2010; 42: 137–142 35 Trojahn Kølle SF, Oliveri RS, Glovinski PV et al. Importance of mesenchymal stem cells in autologous fat grafting: A systematic review of existing studies. J Plast Surg Hand Surg 2012; 46: 59–68
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