Autologous fat transfer with in-situ mediation (AIM): a novel and compliant method of adult mesenchymal stem cell therapy
© Wu and Morrow; licensee BioMed Central Ltd. 2013
Received: 10 January 2013
Accepted: 20 May 2013
Published: 31 May 2013
In an attempt to engineer a regulatory compliant form of cell assisted lipotransfer in the U.S., the authors developed Autologous Fat Transfer with In-situ Mediation (AIM) for reconstruction of a refractory surgical scar.
This method incorporates use of accepted standard procedures like autologous fat grafting and intradermal injection of NB6 collagenase to release adipose stem cells from a naturally occurring high concentration stromal vascular fraction (SVF) fat graft. To prevent off-target effects of collagenase, a hyaluronic acid and serum deactivation barrier is placed circumferentially around the operative site.
This novel protocol was well tolerated by the patient and improved scar appearance, mobility and texture. Deepest scar contour defect correction was 80% and 77% at 4 and 12 weeks respectively.
AIM appears to be a practical and viable option for scar reconstruction requiring small to moderate volume correction.
Cell assisted lipotransfer (CAL), a process whereby free fat grafting is enriched with a supraphysiologic level of autologous stromal vascular fraction (SVF) cells (which include autologous adipose stem cells), has been utilized for nearly a decade in Japan for tissue augmentation and reconstruction . Thus far CAL, under appropriate conditions, appears to be clinically efficacious and safe . Within the United States, practitioners are confronted with regulatory issues of 21 CFR 1271 and concerns that a lengthy Investigational New Drug (IND) process is necessary for CAL use to be legal according to formal Requests for Determination now disclosed in the public domain. Further questions remain as to whether or not a key step in CAL (ex-vivo enzymatic separation of SVF and concentration by centrifugation) constitutes a greater than “minimal manipulation” procedure despite being done in the same surgical setting. The defining lower limits of what constitutes “minimal manipulation” have not been fully articulated directly by the Food and Drug Administration (FDA) at this juncture, and for this important reason plastic, cosmetic and reconstructive surgeons within the States struggle to find a practical and clearly compliant means of providing some form of CAL or adult mesenchymal stem cell therapy. Meanwhile the ever marching reality of refractory wounds, scar revisions, congenital abnormalities which have exhausted standard medical therapy continue to grow and remain untreated.
Historically, the procedures of: 1. autologous fat transplant (AFT), 2. in-vivo high quality current good manufacturing practice (cGMP) grade collagenase injection, 3. dermal chemical peeling and 4. dermal hyaluronic acid (HA) fillers are widely considered acceptable, safe and routine standards of medical care in the United States and abroad. We postulated on the outset of this case study that fat retaining pre-existing high concentrations of SVF/ADSC could be transferred under routine AFT methods, but further treated with collagenase subcutaneously to release or migrate ADSC off the collagen matrix into a wound bed or chemically peeled skin. A “ring” or moat of HA admixed with autologous serum surrounding the collagenase could also be placed as a deactivation barrier to prevent off-target or off-site effects of collagenase. This “under the skin” mediated approach using accepted standard of care techniques and materials avoids contentious ex-vivo manipulation, thereby allowing practitioners a potentially regulatory compliant form of regenerative surgery for soft tissue reconstruction. We have combined the stated standard of care procedures in a unique sequence to treat a patient that failed standard fat transfer for correction of a contracted and excavated scar sustained after previous lipoma excision.
Patient was selected for having failed previous standard AFT 2 years previously for correction of an adherent cicatrix scar sustained on the right lower back after lipoma excision. The procedure was performed in a fully accredited ambulatory surgery center staffed by a physician anesthesiologist. A comprehensive and thorough pre-operative consultation and specific consent for percutaneous aponeurotic lipofilling (PALF) with AFT in conjunction with collagenase and HA-serum was obtained.
Collagenase was prepared by serially diluting NB6 collagenase (GMP grade 17458 SERVA Electrophoresis, Nordmark GmBH, Crescent Chemical) with PBS (GMP grade D8662 Sigma) to a final concentration of 0.1 PZ-U/mL (Figures 2D and 3). A total of 10 cc of dilute NB6 was distributed with a 25 gauge needle within the dermis holding SVF rich graft. Wet application of T10 chemical peel, without deep scrubbing, was placed over the skin directly overlying the PALF wound bed, but not directly above the scar itself. After the skin was left to air dry a non-adherent (100540/960482, Kendall, Tyco Healthcare) occlusive dressing (1626, 3 M Corporation) was applied. Patient was placed on activity restriction to prevent direct compression of the nascent graft and received 3 days of post operative IV antibiotics (Cefotetan 2 gm q24 hours) followed by 7 days of oral antibiotics (Keflex 500 mg BID).
Post operative photography and ultrasounds (Acuson 7 mHz flat probe) were obtained days 1–5 and 1, 2, 4, 8 and 12 weeks following surgery.
PALF and AFT were able to immediately resolve adherence of the scar directly against the muscle without need or use of complete scar subcision. Manual palpation post-operative days 1 through 5 and weeks 2 through 4 did not reveal any subcutaneous fremitus or hypermobility of scar.
Ultrasound revealed correction of 77% of the original excavated defect at the maximal depth. The lateral aspect of the scar showed 100% correction at 3 months out from the original procedure (Figure 5).
The authors emphasize that based on current literature CAL appears to be a safe and efficacious procedure [6–8]. Although CAL may be performed under an IRB or IND based clinical study in the U.S., the reality of not being able to perform procedures unapproved by the FDA, either from a liability insurance or institutional policy standpoint, precludes many a North American practitioner from providing the service. Trichloroacetic acid (TCA) chemical peeling of the skin has been widely used through out dermatology and plastic aesthetic surgery for skin resurfacing and remodeling [9, 10]. Collagenase has been utilized in-vivo extensively in reconstructive surgery to facilitate anesthesia and dissection of skin flaps, fibrotic tissue and correction of misplaced dermal fillers [11–13]. It has also been commonly used as a debriding topical agent for wound care . FDA approved hyaluronic acid based dermal fillers have also been safely employed for reconstructive reasons [15–17]. However, of all the procedures mentioned, autologous fat grafting has the longest track record of use well prior to the advent of modern medicine . These safe and FDA allowable procedures when combined using the protocol presented, should provide some practitioners a means of practicing a form of regenerative surgery without legal regulatory repercussion. However, the use of an FDA approved material for a new indication is considered “off-label” use, and while not illegal, it is not without clinical risk if sound medical judgment is ignored. The authors also emphasize the important distinction that although the independent incremental procedures used are standard of care, many accepted standard surgical procedures performed in the United States are never granted “approval” by the FDA, as the jurisdiction of purely surgical procedures is in large part the domain of State medical boards and professional organizations. (The authors in no way state or imply that the AIM procedure is endorsed or approved by the FDA.)
Unique to this procedure is the isolation of native high SVF fat. This can be achieved by visual inspection and volumetric location alone . However, with small volume fat extraction, use of non-invasive spectroscopy to measure surrogate markers of pericyte loci provides maximum harvest of this essential graft, which visual inspection can under calculate . It is also important to emphasize that well characterized high grade cGMP collagenase near absent of endotoxin is critical for direct in-vivo use and may be prove critical for creating a directional migration of ADSC when employing this technique. Our choice of NB6 was prompted by historical data and full disclosure readily provided by the manufacturer regarding cGMP and endotoxin status (<< 11 I.U./mg). Custom compounded collagenase commercially available within the United States does not always carry as copious of manufacturing documentation, and with recent concerns of sterility and safety of compounded preparations, use of high quality cGMP material is strongly recommended for this unique application .
Although it was not the intent of this pilot study to elucidate the theoretical underpinnings for why the novel procedure works, further confirmatory studies using animal models will need to be performed. (However, cursory results of nude-mice studies, simultaneously being pursued by our group appear promising.) The authors fully acknowledge this is a single case study with remarkable results the reproducibility of which will need to be verified with further study. In light of this, three other patients have been treated using the same protocol in other regions of the body with no adverse or safety events. At this juncture, precaution is advised in extrapolating this procedure to large volume augmentations used in full breast or buttock augmentation. Use of the procedure on smaller lesions such as chronic lower extremity wounds, which allow adequate circumscribing with an HA-serum deactivation zone, is ideal and will be the focus of pending clinical investigations at our institution.
In-vivo use of NB6 collagenase subdermally is well tolerated and well suited for the AIM technique. The AIM procedure itself also appears safe and capable of providing contour correction and soft-tissue reconstruction and augmentation where standard AFT might fail.
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