Dermal substitutes require sufficient tissue integration and vascularization to be successfully covered with split-thickness skin grafts. To rapidly achieve this, we provide the proof of principle for a novel vascularization strategy with high translational potential. Nanofat was generated from subcutaneous adipose tissue of green fluorescence protein (GFP)⁺ C57BL/6J donor mice and seeded onto small samples (4 mm in diameter) of the clinically approved dermal substitute Integra^®. These samples and non-seeded controls were then implanted into full-thickness skin defects in the dorsal skinfold chamber of C57BL/6J wild-type mice and analyzed by intravital fluorescence microscopy, histology and immunohistochemistry over a 14-day period. Nanofat-seeded dermal substitutes exhibited an accelerated vascularization, as indicated by a significantly higher functional microvessel density on days 10 and 14 when compared to controls. This was primarily caused by the reassembly of GFP⁺ microvascular fragments inside the nanofat into microvascular networks. The improved vascularization promoted integration of the implants into the surrounding host tissue, which finally exhibited an increased formation of a collagen-rich granulation tissue. There were no marked differences in the inflammatory host tissue reaction to nanofat-seeded and control implants. These findings demonstrate that nanofat significantly improves the in vivo performance of dermal substitutes without affecting their biocompatibility.

Autologous fat grafting is the main surgical technique for soft tissue reconstruction. However, its clinical use with more extended volumes is limited by repeated procedures due to the little possibility of banking tissue, donor-site morbidity and unpredictable graft resorption rates. To overcome these problems, adipose tissue engineering has focused on developing injectable scaffolds. Most of them are hydrogels that closely mimic the biological, structural and mechanical characteristics of native adipose tissue. This review provides an overview of current injectable scaffolds designed to restore soft tissue volume defects, emphasizing their translational potential and future directions. Natural injectable scaffolds exhibit excellent biocompatibility but degrade rapidly and lack mechanical strength. Synthetic injectable scaffolds provide tunable elasticity and degradation rates but require biofunctionalization to support cell adhesion and tissue integration. Adipose extracellular matrix-derived injectable scaffolds are fabricated by decellularization of adipose tissue. Accordingly, they combine bio-mimetic structure with intrinsic biological cues that stimulate host-driven adipogenesis and angiogenesis, thus representing a translatable “off-the-shelf” alternative to autologous fat grafting. However, despite this broad spectrum of available injectable scaffolds, the establishment of clinically reliable soft tissue substitutes capable of supporting large-volume and long-lasting soft tissue reconstruction still remains an open challenge.

The exposure of endothelial cells to high glucose concentrations promotes angiogenesis. The present study investigated whether this pro-angiogenic effect of glucose is suitable to improve the capability of nanofat to vascularize implanted dermal substitutes. Nanofat was processed from white adipose tissue originating from green fluorescent protein (GFP)⁺ C57BL/6J donor mice and incubated for 1 h in Hank’s Balanced Salt Solution with or without (control) a high level of glucose (30 mM). The pretreated nanofat was seeded onto dermal substitutes, which were analyzed by intravital fluorescence microscopy, histology and immunohistochemistry in dorsal skinfold chambers of GFP⁻ C57BL/6J mice to assess their vivo performance over a period of 14 days. A high level of glucose-pretreated nanofat did not induce a stronger immune response when compared to the control. However, it improved the vascularization of the implants, as shown by a significantly higher density of blood-perfused microvessels in the border zones (~3.6-fold increase) and more CD31⁺/GFP⁺ microvessels (~3-fold increase) inside the implants. Accordingly, high glucose-pretreated nanofat levels also enhanced the tissue integration of the dermal substitutes, as indicated by the deposition of more type I collagen (~2.9-fold increase). These findings suggest that the short-term exposure of nanofat to a high level of glucose represents a promising and clinically feasible strategy to enhance its regenerative properties when seeded onto dermal substitutes.

Heat preconditioning has been shown to promote nutritive perfusion and tissue survival in autologous fat grafting as well as in flap and breast surgery. However, its impact on the vascularization properties of nanofat has not been investigated so far. Therefore, we exposed nanofat from donor mice to a temperature of 43 °C for 1 h and assessed the effects of this heat stress on cell viability and the expression of heat shock proteins (HSPs) and angiogenesis-related factors. Moreover, dermal substitutes seeded with heat-preconditioned and non-preconditioned control nanofat were implanted into dorsal skinfold chambers of recipient mice to study their vascularization and tissue integration in vivo by means of repeated intravital fluorescence microscopy, histology and immunohistochemistry. Heat preconditioning upregulated the expression of HSPs in nanofat without affecting cell viability. Moreover, it resulted in the downregulation of many pro-angiogenic factors and the increased expression of anti-angiogenic factors, indicating a shift towards an anti-angiogenic phenotype. Accordingly, implanted dermal substitutes seeded with heat-preconditioned nanofat exhibited a reduced vascularization and were not better integrated into the host tissue when compared to controls. These findings indicate that heat preconditioning cannot be recommended for enhancing the vascularization capacity of nanofat.

Background: Autologous fat grafting is increasingly used in daily clinical practice across various surgical fields, including the treatment of chronic wounds, scars, burns, and non-healing perianal fistulas. Recently, some studies have shown that non-enteric cutaneous fistulas can also benefit from adipose tissue injections, but the efficacy remains unclear. This study aims to systematically review the literature on fat grafting in the context of non-enteric cutaneous fistulas and to assess treatment outcomes. Methods: A comprehensive search of the PubMed/Medline database was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to January 2024 without restrictions on the time period or the language of publication. Results: Seven studies meeting the inclusion criteria were analyzed, encompassing 13 patients with non-healing cutaneous fistulas treated with injections of autologous fat. The mean age of the patients was 58 ± 3 years, of which 85% had comorbidities. Fat grafting resulted in complete healing in 92% of the cases, with a mean fistula persistence of 158 days before treatment. Treatment protocols varied among patients, including preparation of the fistulous tract, fat processing techniques, and suturing of the fistulous orifice. Conclusions: The results highlight the potential of autologous fat grafting in promoting tissue regeneration and healing of non-enteric cutaneous fistulas. Standardized protocols are essential to confirm and optimize treatment efficacy and, eventually, improve patient outcomes. Further research with a larger sample size and standardization is needed to confirm fat graft efficacy.

Capsular contracture (CC) is the most common complication following implant-based breast surgery. It results from a dysregulated foreign body response characterized by inflammation and fibrosis. Effective strategies in the management of CC remain limited. Autologous fat grafting (AFG) is a promising alternative to current approaches due to its regenerative and immunomodulatory properties. This review provides an overview of the current understanding of CC pathophysiology and consolidates preclinical and clinical evidence on the influence of AFG on this pathogenic condition. Preclinical studies use both conventional AFG and isolated adipose-derived stem cells to prevent CC. They consistently demonstrate attenuated capsule formation and reduced inflammatory response. Clinical evidence suggests that AFG reduces both the incidence and recurrence of CC. This is also the case in the high-risk setting of previously irradiated breasts. Therefore, AFG may act as more than a purely volumetric reconstructive technique by modulating the foreign body response and improving capsule characteristics. Emerging strategies in implant-based breast surgery include the improvement of fat graft viability as well as immunomodulatory and bioengineering-based approaches. Overall, AFG appears to be feasible and effective in the management of CC. However, standardized protocols and additional long-term outcomes are required to ensure safe implementation in clinical practice.