Although neglected in the past, rejuvenation of the hand is increasingly requested because they are of a major cosmetic concern, the hand being the most constantly visible, unclothed part of the body besides the face, and it is believed to belie true age 1. Aging process involves changes that occur in all layers of the skin and subcutaneous tissue as well as underlying muscle and bone 2. Both intrinsic and extrinsic aging factors influence the appearance of the hands. Extrinsic aging affects the epidermal and dermal layers and is manifested in the form of actinic keratosis, solar lentigines, tactile roughness, punctate hypopigmentation, and telangiectasia 3. Intrinsic aging, however, affects the deeper soft tissue of the hand, thus decreasing skin elasticity, soft tissue volume, and dermal vascularity. These changes are manifested as dermal and fat atrophy, deep intermetacarpal spaces, prominent bones and tendons, and bulging reticular veins 4. The focus of most hand rejuvenation treatments is on extrinsic aging, whereas intrinsic signs of aging can be tackled with volume restoration 3,4.
Autologous fat transfer, known as fat grafting, fat injection, fat transplantation, and lipoinjection, referred to as soft tissue enhancement procedure involving the movement of subcutaneous fat from a donor site in the body to a recipient site in need of augmentation. It is a multistep procedure entailing harvesting, processing, and reinjection of the fat 5. Autologous fat is considered ideal for soft tissue augmentation because it is biocompatible, versatile, natural looking, nonimmunogenic, relatively inexpensive, and readily obtainable with low donor site morbidity. The major disadvantage is the unpredictable and often low graft survival, with resorption rates ranging from 25 to 80% after a period ranging from 4 to 6 months. The general requirement for multiple treatments to achieve optimal results is also another setback 6,7.
Some researchers believe that a major effect of fat tissue transfer is caused by the survival of adipose tissue-derived stem cells in the stromal fraction. Adipose tissue-derived stem cells are adult stem cells with high proliferation potential and angiogenic and antiapoptotic characteristics 8,9. They may be the only tissue to survive after fat transplantation, and the variability of these cells between individuals may be one of the reasons for the observed variability of longevity 10. Therefore, it seems logical to supplement the aspirated fat tissue with adipose tissue-derived stem cells to overcome the drawbacks of traditional autologous fat transfer, giving more predictable long-term results 11.
The aim of this study was to compare conventional lipofilling and adipose tissue-derived stem cell-enriched fat grafting for dorsal hand rejuvenation.
Patients and methods
This single-blinded nonrandomized comparative study included 20 right-handed women; their ages ranged between 45 and 55 years and were all menopausal for at least 2 years. They were recruited from the Outpatients’ Clinics of Ain Shams University hospitals over a period of 10 months from October 2014 to July 2015, after obtaining signed informed consent. The study was conducted according to the Declaration of Helsinki Principles and was approved by the medical ethical committee of Ain Shams University.
Patients showing visible signs of aging in the dorsum of hands seeking soft tissue augmentation were included. These signs were skin laxity, loss of subcutaneous fat, and prominence of veins and tendons. Smokers and patients who had received rejuvenation treatment for the hands within the last year were excluded from the study. Moreover, patients with systemic diseases such as diabetes mellitus, autoimmune diseases, hepatic, renal, and blood diseases, patients receiving systemic drugs, including hormonal replacement therapy, anticoagulants, and analgesics, and patients with local active skin disease were all excluded. In addition, obese women with BMI more than 30 kg/m2, or participants with significant weight changes during the study were excluded. All patients were subjected to detailed history taking, general and dermatological examination, and preoperative preparation including avoidance of aspirin and NSAIDs for 2 weeks before the procedure.
After sterilization of the abdomen (donor site) with povidone iodine 10%, local anesthesia was induced before making a 5 mm incision in the midline, 10 cm below the umbilicus. Through the incision, the standard Klein tumescent solution with 0.1% lidocaine was injected. After inducing anesthesia, a blunt-tipped cannula (Coleman microcannula; Mentor Medical Systems, Netherlands) was connected to a 10 ml Luer-Lok syringe (Medline industries, Inc.; firstname.lastname@example.org) with the plunger held back, creating light negative pressure container. The cannula was then moved back and forth in the subcutaneous tissue using fanning technique from midline to the right and left sides, collecting around 60 ml of fat that was gently drawn into the syringe. The syringe was capped to be airtight and kept upright for 10 min.
The lipoaspirate was divided into two portions. The first portion (used to extract adipose tissue-derived stem cells) was washed extensively with PBS, and then it was treated with 0.075% collagenase in PBS for 30 min at 37°C with gentle agitation using a water bath. Collagenase was then inactivated with an equal volume of fetal bovine serum, and the infranatant was centrifuged at 1500 rpm for 5 min. The remaining cellular pellet (stromal vascular fraction) was then resuspended in 10% PBS and filtered.
Stromal vascular fraction cells (containing adipose tissue-derived stem cells) (Fig. 1) obtained from the previous process were gently mixed with half of the second portion of lipoaspirate for 15 min to optimize cell adherence. The other half of the second portion of the lipoaspirate was centrifuged at 3000 rpm for 3 min. Both types of fat grafts (adipose tissue-derived stem cell-supplemented and conventional fat graft) were loaded in separate 10 ml syringes and were ready for reinjection. To validate the viability of adipose stem cells in the fat sample, it was cultured on basic cell culture media [Dulbecco’s modified Eagle’s medium composed of 13% fetal bovine serum, gentamycine (50 μg/ml), penicillin (100 U/ml), and streptomycin (0.1 mg/ml)]. Stem cells appeared as fibroblast-like mesenchymal stem cells stained with Giemsa stain under inverted microscopy (Fig. 1). This step was not needed before reinjection, but was carried out to confirm the viability of adipose stem cells in grafts.
After sterilization of both hands with povidone iodine 10%, ring anesthesia was used, and then a 5 mm incision was made into the dorsal wrist crease creating an entry point, through which the injection Coleman cannula was passed distally into the dorsal web spaces and fat was injected in a retrograde manner, dispersing small aliquots (0.3–0.5 ml per pass) as the cannula was withdrawn and filling the dorsal metacarpal spaces and sides of the hands adequately. Approximately 10 ml of fat was injected into each hand. The right hand received conventional fat, whereas the left hand received adipose tissue-derived stem cell-enriched fat. Both hands were massaged in a distal direction as the patient made a fist while blocking the injection site (to prevent escape of fat). Although overcorrection was not performed in this study, the hands did appear slightly full at the end of the procedure.
Patients were instructed on the following: to keep light compression bandage on both hands for 48 h after treatment to minimize possible subsequent edema; to elevate the hands for the first 24 h; and to avoid any strenuous manual activity for the first week. They were forewarned about marked edema and bruises that may last for 1–2 weeks. Pain killers were also prescribed for the first few days as well as cool compresses for mild pain. Patients were also advised to eat a healthy diet and use moisturizers on their hands.
Follow-up with clinical examination, digital photography, and progress evaluation was carried out during outpatient visits wherein both hands were compared before and after 1 and 3 months’ intervals by both physicians and patients. Clinical evaluation of hand photographs was carried out by two blinded physicians who were asked to grade photographs of both hands according to a given photograph of the Mertz scale 12 (Fig. 2), in which 0 score represented no loss of fatty tissue and 4 represented very severe loss of fatty tissue with marked prominence of veins and tendons with grooving of the metacarpal space. Patients’ satisfaction was measured using satisfaction score, in which 0 represented nonsatisfied and 10 represented excellent result, in addition to comparison with Mertz scale figures.
Statistical analysis of data was performed with IBM computer using statistical program for social science (SPSS Inc., Illinois, Chicago, USA). Quantitative variables were expressed as mean, SD, ranges, median, and interquartile range. Qualitative variables were expressed as number and percentage. The Mann–Whitney test was used to compare two independent groups with quantitative data and nonparametric distribution, and the Wilcoxon rank test was used to compare two paired groups with quantitative data and nonparametric distribution. Probability value was considered significant when P-value was less than 0.05.
The study included 20 menopausal right-handed nonsmoker women with signs of dorsal hand aging seeking soft tissue augmentation, with age ranging from 45 to 55 years (mean±SD 49.2±8.32 years) and BMI ranging from 20.55 to 29.68 kg/m2 (28.44±2.81 kg/m2).
There was a significant improvement in the studied parameters (Mertz scale 12) on comparison before treatment with that after 1 and 3 months’ values by both physicians and patients. The Mertz score for all patients was either 3 or 4 before the procedure and became 0 for all patients after the procedure (disappearance of visible veins, protruding tendons, and grooving of metacarpal spaces). However, physicians’ evaluation of photographs comparing the Mertz scale parameters after 1 month versus values after 3 months showed reduction score after 3 months (from 0 to 1 by Mertz). Nevertheless, the left hand showed no significant difference as regards prominence of veins and metacarpal space grooving, contrary to the right hand (conventional fat injection) that showed significant reduction in both parameters – that is right-sided partial loss of esthetic results obtained after 3 months (Table 1).
As regards the patients’ evaluation, there was an overall satisfaction with the results of both hands after 1 and 3 months with no statistically significant difference (Table 2).
Comparison between the right and the left hand
The left hand appeared to have superior results when compared with the right hand after 3 months as per the physicians’ scores but not by the patients’ overall satisfaction score (P>0.05) (Tables 1 and 2).
Comparison of results’ assessment by the blinded physicians and patients
The two blinded physicians’ and patients’ assessments for both hands were compared before and after 1 month as well as at 3 months, with no significant difference (P<0.05) (Table 3). Although all patients gave a score of 10/10 for both hands after 3 months, 90% preferred the esthetic appearance of the left hand as did the blinded physician in 85% of patients. Figure 3 shows the results immediately after the procedure, after 1 month and after 3 months in one of the patients.
Autologous fat is considered ideal for soft tissue augmentation because of its biocompatibility, versatility, and nonimmunogenic nature. It is also readily obtainable with low donor site morbidity 6. Compared with other fillers used for soft tissue augmentation, the procedure is relatively less expensive, with long-lasting results and potentially no serious side effects (due to the blunt needle used for the injection of fat, thus lowering the risk for injury to the underlying vessels and nerves). Furthermore, autologous fat transfer has not been proven to cause lumps or subcutaneous nodules and granulomas as with poly-L-lactic acid, or cause any type of hypersensitivity as those caused by collagen 3.
In this study, fat transfer for hand augmentation, either alone or enhanced with stem cells, gave satisfactory esthetic results. Nevertheless, stem cell-enriched fat grafts maintained longer impressive results due to better fat graft retention. These results can be explained by the angiogenic and antiapoptotic potential of adipose tissue-derived stem cells, inducing neovascularization and adipogenesis and helping the newly grafted adipocytes to merge with the surrounding tissue and live longer 9. Previously, Yoshimura et al.13,14 used adipose tissue-derived stem cell-enriched fat for breast augmentation and/or correction of breast implant complications. They reported doubling in breast circumference and delay in fat resorption in the site injected with adipose tissue-derived stem cell-enriched fat compared with conventional lipofilling.
In patients with facial lipoatrophy, Yoshimura et al.15 found that all patients obtained improvement in facial contour, with better clinical improvement score in the group that received adipose tissue-derived stem cell-enriched fat injections compared with the group that received conventional lipofilling. This is in agreement with the findings of Sterodimas et al.16, who compared autologous fat transplantation with adipose tissue-derived stem cell-enriched lipograft in 20 patients with congenital or acquired facial defects. They concluded that adipose tissue-derived stem cell-enriched fat grafts produced more esthetically acceptable results for longer durations without the need for repeated treatment sessions, which were necessary with autologous fat transplantation.
Trojahn Kølle et al.6 compared injecting expanded adipose tissue-derived stem cell-enriched fat graft with traditional lipofilling. They injected each type of fat graft as a bolus into the back of either arm. A biopsy was taken after 121 days and examined histologically with cell surface markers of mesenchymal stem cell (anti-CD73, CD90, and CD105) and hematopoietic surface markers (anti-CD14, CD20, CD34, and CD45) to study neolipogenesis and neovascularization. They found that the enriched fat significantly had higher volume of newly formed connective tissue, higher amounts of adipose tissue, and a lower amount of necrosis, but without significant difference in vessel density compared with control graft. The enriched fat graft also gave significantly higher residual volume (more than 80% after 4 months) and improved graft survival as was displayed on MRI. Attempts aim to expand adipose tissue-derived stem cells to improve results achieved quantitatively as well as qualitatively, reflected as better survival of grafts and improved tissue quality based on histological variables rendering lipofilling a reliable alternative to other methods of tissue augmentation 17–19. Finally, it is worth mentioning that, although our participants were right handed, there was no significant difference in esthetic preference between the two hands up to 3 months with patients’ satisfaction score and the Mertz scale. However, physicians’ evaluation after 3 months showed a significant difference between the right and the left hand as regards the same parameters. These considerably more favorable results of the left hand could be partially interpreted by more muscle movement in the dominant hand, but further comparative studies are needed to validate whether or not the average daily activities of the dominant hand influences the longevity of the graft.
Fat transfer for hand augmentation either alone or enhanced with adipose tissue-derived stem cells gives satisfactory esthetic results. The enrichment of fat graft with adipose tissue-derived stem cells converts progenitor-poor fat into progenitor-rich fat graft, rendering lipofilling a predictable and attractive alternative for soft tissue augmentation for hand rejuvenation. Further studies that involve control groups are recommended to compare results objectively in larger cohorts for longer periods of follow-up, to confirm the favorable long-term results seen in this preliminary study. Furthermore, comparative studies are needed to study whether or not the average daily activities of the dominant hand could influence the longevity of the graft.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2017 Egyptian Women's Dermatologic Society
adipose tissue stem cell; fat transfer; hand rejuvenation