Anti-Aging Therapeutics Volume XIV

Session.

Chapter 1

Pilot Study: The Effects of Stem Cells and Platelet Rich Plasma on Recovery from Laser Resurfacing

Robert Bowen M.D., FCCP, FASLMS

Clinical Associate Professor of Medicine, WVU-East;

Medical Director, The Center for Positive Aging, Martinsburg, WV

ABSTRACT

This paper presents the results of a pilot study into whether stem cells or cellular growth factors would improve the efficacy of fractional laser resurfacing of the skin and/or reduce recovery time.

Keywords: laser resurfacing, fractional laser, adipose derived stem cells, platelet rich plasma, platelet derived growth factors, facial aging, burn scars, acne scars

INTRODUCTION

The development of fractional laser resurfacing has allowed effective treatments with shorter recovery than after full-field resurfacing.¹,² This technique has been applied to the process of the aging face (wrinkles, texture irregularities, skin laxity, and sun damage), as well as treatment of surgical, acne, and burn scars.²-⁴ A variety of infrared wavelengths, each with a different absorption coefficient (affinity for water) has been used successfully (1319 nm, 1320 nm, 1440 nm, 1450 nm, 2750 nm, 2940 nm, 10,600 nm). The 2940 nm Er:YAG laser and the 10,600 nm CO2 laser have a high coefficient for absorption for water and are capable of complete ablation of tissue. These wavelengths have been effective for treating aging skin with reduced recovery times and approach but may not often achieve the results of full field resurfacing. The recent discovery of the regenerative properties of adult stem cells and platelet-derived growth factors (PDGFs) has raised questions as to whether stem cells or cellular growth factors would improve the efficacy or reduce the recovery time of these procedures.

PILOT STUDY

Stem Cells

Stem cells have the characteristics of both being able to replicate themselves and differentiate into a variety of other cells.⁵ Embryonic stem cells (ESCs) are truly pluripotent, meaning that they can become any type of human cell. Significant scientific and ethical issues still surround the use of ESCs, thus limiting their application. Fortunately, adult mesenchymal stem cells are multipotent and are plentiful in both bone marrow and adipose tissue.⁶ Adipose derived mesenchymal stem cells (ADSCs) can differentiate into vascular tissue, bone, cartilage, and adipoctyes among others. In addition to their cellular regenerative potential, these cells also exhibit chemotaxis and the ability to modulate inflammation via cytokines.⁶-⁸

Subcutaneous fat is a rich source of ADSCs, is available in sufficient quantities and can be harvested under local anesthesia.⁸ PDGFs can also be obtained by simple procedures of phlebotomy and centrifugation and also hold regenerative potential.

Materials and Methods

Three volunteers, skin type two and three, were tested in separate one-centimeter square areas with the ER:Yag laser (Sciton, Palo Alto, CA). Three 1 cm² squares were treated at 100 microns depth with a 100% coverage (full field) and three 1 cm² squares at 300 microns depth with 11% coverage (fractional) in each subject. Each treated area had topical application of; 1) gel vehicle only 2) gel and platelet rich plasma (PRP) 3) gel, PRP,and ADSCs. ADSCs were obtained from a mini-liposuction procedure using tumescent anesthesia and PRP was obtained from peripheral blood. The biologic agents were then topically applied to the wounds with a pipette and allowed to dry for 5 minutes. The treated skin was dressed with a gel to maintain the cells in an anaerobic environment. Sequential photographs were obtained and evaluated.

Results

Fractional wounds under all conditions healed rapidly. Epithelialization occurred within 24 hours or less in all 9 fractional wounds. 100 micron full field wounds healed more slowly. The surface area that had re-epithelialized was measured and compared to the total area of the wound and a percent healing was calculated. Mean time 50% epithelialization in the vehicle only group was 10 days, compared with 6 days in the PRP group, and 4 days in the PRP plus ADSCs group. Full re-epithelialization was achieved in a mean of 14 days with PRP and 7 days with PRP plus ADSCs. None of the areas treated with the gel vehicle alone were fully healed at the end of the 14 day observation period.

Figure 1. 5 days post-treatment: 100 micron full field resurfacing (top), 300 micron 11% fractional resurfacing (bottom), vehicle dressing only (left), vehicle + PRP (center), vehicle+ PRP+ ADSCs (right)

Figure 2. 7 days post-treatment: 100 micron full field resurfacing (top), 300 micron 11% fractional resurfacing (bottom), vehicle dressing only (left), vehicle + PRP (center), vehicle+ PRP+ ADSCs (right)

Figure 3. 8 days post-treatment: 100 micron full field resurfacing (top), 300 micron 11% fractional resurfacing (bottom), vehicle dressing only (left), vehicle + PRP (center), vehicle+ PRP+ ADSCs (right)

CONCLUDING REMARKS

This pilot study showed faster healing times compared to a vehicle dressing only of laser wounds treated with PRP and PRP plus ADSCs. These results suggest the possibility of reduced recovery times from full field laser resurfacing treatment.

The PRP and PRP plus ADSCs were applied topically using a pipette to the forearm and abdominal skin of volunteers. Facial skin heals more quickly than abdominal and forearm skin and thus healing after treatment with PRP and ADSCs is likely to be more rapid than that observed in the forearm and abdominal skin treated in this study. Administration of the PRP and cells with a pipette, as was done in this study, is not likely to be practical when treating facial skin and further work is planned using a canula or a needle to implant these biological agents in the subcutaneous space and/or dermis of subjects just prior to treatment with the laser. A split face study using ADSCs and PRP applied in a thin coat with a brush following treatment or with subcutaneous/dermal injection prior to treatment is recommended.

REFERENCES

1. Manstein D, Heron GS, Sink RK, Tanner H. Fractional thermolysis: A new concept for cutaneous remodeling using microoscopic patterns of injury. Laser Surg Med. 2004;34:426-428.

2. Geronemus R. Fractional thermolysis: current and future applications. Laser Surg Med. 2006;38:169-176.

3. Bowen R. A novel approach to ablative fractional resurfacing of mature thermal burn scars. J Drugs Dermatol. 2010;9:389-393.

4. Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment of a third-degree burn. J Drugs Dermatol. 2009;8:294-297.

5. Plant-Bernard V, Silvertre JS, Cousin B, et al. Plasticity of human adipose lineage cells toward endothelial cells; physiological and therapeutic perspectives. Circulation 2004;109:656-663.

6. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell. 2002;13:4279-4294.

7. Moseley TA, Zhu M, Hedrick MH. Adipose derived stem and progenitor cells as fillers in plastic and reconstructive surgery. Plast Reconstr Surg. 2006;118 (3 suppl):121s-128s.

8. Strawford A, Autelo F, asured with 2 H2O. AmJ Physiol Endocrinol Metab. 2004;256:E577-E588.

9. Matsumoto D, Sato K, Gonda R, et al. Cell assisted lipotransfer: Supportive use of human adipose derived cells for soft tissue augmentation. Tissue Engineering. 2006;12:3375-3382.

ABOUT THE AUTHOR

Dr. Robert Bowen is an Internal Medicine and Pulmonary specialist, Board Certified in Cosmetic Laser Surgery by the American Board of Laser Surgery. He is a Fellow of the American Society of Laser Medicine and Surgery and has published research articles on laser medicine. Dr. Bowen is a Diplomate of the American Board of Anti-Aging Medicine and a graduate of the Aesthetic Medicine Fellowship.

Chapter 2

Cell-Assisted Facial Fat Transfer – The Natural Filler

Robert Bowen M.D., FCCP, FASLMS

Clinical Associate Professor of Medicine WVU-East;

Medical Director, The Center for Positive Aging, Martinsburg, WV

ABSTRACT

A key feature of facial aging is loss of volume, both of fat and bone. Attempts to create a more youthful looking face should address these components to be successful. Autologous fat holds appeal for this purpose

Keywords: Cell-assisted lipotransfer, adipose derived stem cells, stromal vascular fraction, platelet rich plasma, liposculpture, autologous fat transfer, platelet derived growth factors, fat grafting

INTRODUCTION

A key feature of facial aging is loss of volume, both of fat and bone. Attempts to create a more youthful looking face should address these components to be successful. Autologous fat holds appeal for this purpose due to the absence of tissue rejection and allergic reactions. Autologous fat is also readily available in many patients, and can be obtained from lipoaspiration performed under local anesthesia.

Autologous fat transfer has been used surgically for a century and for a quarter of a century using lipoaspirate. More recently, techniques have focused on maintaining adipocyte viability by minimizing trauma, resulting in increased graph survival.¹-⁴ This paper introduces the concept of cell-assisted fat transfer, a complementary approach that augments gentle harvest and implantation techniques with adipose derived mesenchymal stem cells (ADSCs) and growth factors from platelet rich plasma (PRP).

Stem cells have the characteristics of both replicating themselves and differentiating into a variety of other cells. Embryonic stem cells are found in the blastocyst 5 to 6 days post fertilization and are truly pluripotent, meaning that they can differentiate into any type of mature cell. These cells require sterile culture, tissue expansion, and differentiation prior to any therapeutic use and the usage of embryonic stem cells remains controversial on a bioethical level. Conversely, adult mesenchymal stem cells are found in many tissues, including bone marrow and adipose tissue,⁵ and are multipotent, meaning that they can differentiate into many different cell types, including vascular tissue, bone, cartilage, and fat. In addition to their cellular regenerative potential, they also exhibit chemotaxis and the ability to modulate inflammation.⁶-⁸

Adipose tissue is a rich source of adult stem cells – as much as 500 times the concentration found in bone marrow. Subcutaneous fat is a source of both the adipocytes and ADSCs used in this procedure. ADSCs are available in large quantities and can be harvested in a simple procedure under local anesthesia.⁹,¹⁰ The growth factors: epithelial growth factor (EGF), platelet derived growth factor (PDGF), transforming growth factor beta (TGF-beta), vascular endothelial growth factor (VEGF), and fibroblast growth factor (FGF) are present in increased concentrations in the platelet rich fraction of plasma obtained from peripheral blood.

Among the changes of aging and environmental damage seen in the face are loss of volume of both fat and bone, decreased collagen with the impairment of light reflex (brightness), skin laxity, and surface irregularities. With the exception of laxity, all of these changes can be addressed with cell-assisted facial fat transfer.¹⁰,¹¹ Figures 1 and 2 illustrate the improvements achievable with cell-assisted facial fat transfer.

Figure 1. 59-Year-Old Male Before (left) and After (right) Undergoing Cell-Assisted Facial Fat Transfer

Figure 2. 47-Year-Old Female Before (left) and After (right) Undergoing Cell-Assisted Facial Fat Transfer

CELL-ASSISTED FACIAL FAT TRANSFER

Technique

Autologous fat transfer has been limited by the viability of the grafted adipocytes. Both graft and host issues contribute to this. Graft issues include both the harvesting technique and implantation technique. Host issues include the presence of systemic inflammatory disease and small vessel integrity, including the use of vasoconstrictors such as decongestants and nicotine.

Fat harvesting is performed by a mini lipo procedure designed to minimize trauma to the fragile adipocytes. First, a suitable area of subcutaneous fat is anesthetized using a tumescent technique with 0.05-0.10 lidocaine plus 1:1,000,000 epinephrine. The fat is extracted using: 1) gentle suction in the range of one half atmosphere (15-18 inches mercury or 350-370 mm mercury), 2) blunt cannula designed to minimize trauma, 3) decreased exposure to air, 4) low G-force (50 G) centrifugation or gravity density separation and 5) removal of free lipid. Each of these interventions has the aim of preserving the lobular architecture of adipocytes and optimizing graft survival. Equally important is preparing the host tissues by minimizing nicotine and other toxins and by optimizing nutrition.

The ADSCs are obtained by processing a portion (60-100 mL) of harvested adipocytes by incubating with an enzyme and then separating the stromal vascular fraction (SVF) with centrifugation. The SVF also contains pre-adipoctyes, endothelial cells, smooth muscle cells, fibroblasts, NK cells, endothelial progenitor cells, and growth factors.

The third component of the autologous mixture to be transplanted is the platelet rich portion of plasma. This is obtained by double centrifugation of a sample of the patient’s peripheral blood. PRP has increased quantities of multiple growth factors including EGF, PDGF, TGF-beta, VEGF, and FGF. The three components are then combined by gentle mixing prior to re-implantation.

Transplantation

Candidates

Candidates for this procedure include patients who would benefit from restored volume, those who want a natural filler, and those who want a longer lasting effect than is available from hyaluronic acids. The patient with minimal laxity, who is a healthy non-smoker, will likely have the best results.

Pre-Op Consultation

During the pre-op consultation the physician should first understand what the patient expects. This can be facilitated by using pre/post operation photos of the physician’s previous patients and the patient’s own pictures from previous years. These can be compared to contemporary photos and can guide both the physician and patient towards seeing the desired end result. The patient should be prepared for a recovery of five to seven days social downtime and be aware that a final result will not be apparent for several months. Platelet inhibiting agents should be discontinued secondary to both the increase risk of both bleeding and bruising and also the potential decrease of platelet growth factors release.

Anesthesia

Autologous fat transfer is a minimally invasive procedure and requires adequate anesthesia for the patient’s comfort and cooperation. Regional nerve blocks in the supraorbital, infraorbital, and mental areas as well as limited local anesthesia plus or minus oral lorezapram and distracting conversation will accomplish this is in almost all patients. Both general anesthesia and the supine position distort normal anatomy and should be used sparingly.

Implantation

Newly transplanted adipocytes must establish a blood supply to engraft. This is facilitated by proper harvesting that retains lobular structure and by implantation in the form of micro-droplets (0.025-0.05 mL). These micro-droplets are deposited with retrograde technique, from several directions, to obtain a crisscrossing pattern, and should be injected into multiple tissue planes. The placement should be consistent with aesthetic principles and to achieve the closest approximation to the patient’s expectations.

Post-Op Care

The patient is instructed not to use anti-inflammatory agents for at least 48 hours. Pain can be managed with acetaminophen plus or minus hydrocodone. Cool packs and sleeping with the head elevated will minimize post operation edema.

Complications

Complications include infection, bleeding, introduction of a foreign body, and nerve injury. The most common complication, however, is under or over correction resulting in a less satisfied patient.

Legal

The FDA regulates drug, supplements, and devices but does not directly regulate practitioners. This oversight is provided by the state boards of medicine. FDA CFR Title 21 part 1271 concerns the regulation of human cells and cellular products. It states the physician is in compliance if the cell products are removed and re-implanted into the same patient during the same procedure. These cells must also be minimally manipulated. This has been interpreted to mean that centrifugation and cell selection is permissible but cell expansion and tissue culture is not. It should be recognized that regulations are likely to change in areas such as these where technology is evolving quickly.

CONCLUDING REMARKS

Autologous fat transplantation has great appeal for facial rejuvenation and soft tissue augmentation because it avoids complications of foreign material and requires no surgical scars. However, the technique has been limited by the unpredictability of graft survival.¹-³

The above method of cell-assisted facial fat transfer combines optimal harvesting and implantation of adipocytes with the addition of growth factors from PRP and a cell population derived from the enzymatic digestion and centrifugation of adipose tissue SVF. This SVF contains ADSCs, pre-adipocytes, endothelial cells, fibroblasts, macrophages, NK cells, and others. The ADSCs offer proliferative potential and the ability to differentiate into mature adipocytes and endothelial structures, as well as, secrete cytokines and growth factors.⁵-⁸

In the cell augmented lipotransfer (CAL) strategy, ADSCs are used to increase angiogenesis, improve graft survival, and reduce postoperative atrophy. These cells (found in SVF) are added to intact adipocytes, which provide volume and act as a living scaffold.¹²

A potential improvement in the efficacy of growth factor and cell assisted lipotransfer is likely due to ADSCs differentiating into mature adipocytes as cell turnover progresses, as well as other ADSCs differentiating into vascular endothelial cells contributing to neo-angiogenesis during the healing process. This results in increased microvasculature, decreased central necrosis, and prolonged survival of the transplanted adipocytes.⁶,⁸-¹⁰,¹²

REFERENCES

1. Coleman SR. Structural fat grafts: The ideal filler. Clin Plast Surg. 2001;28:111-119.

2. Shiffman MA, Mirafati S. Fat transfer techniques: The effects of harvest and transfer methods on adipocytes viability and review of the literature. Dermatol Surg. 2001;27:819-826.

3. Kurita M, Matsumoto D, Shigeruro T. Influences of centrifugation on cells and tissues in liposuction aspirate. Optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg. 2008;7: 211-228.

4. Carpenda CA, Ribiero MT. Percentage of grafts vs. injected volume in adipose autotransplants. Aesthetic Plastic Surg. 1994;18:17-19.

5. Zuk PA, Zhu M, Mizuno H, Huang J. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell. 2005;13:4279-4294.

6. Moseley TA, Zhu M, Hedrick MH. Adipose derived stem and progenitor cells as fillers in plastic and reconstructive surgery. Plast Reconstr Surg. 2006;118 (3 supplement):1215-1285.

7. Planat-Bernard V, Silvestre JS, Cousin B. Plasticity of human adipose lineage cells toward endothelial cells: physiological and therapeutic perspective. Circulation 2004;109:656-663.

8. Strawford A, Autelo F, Christianseu M. Adipose triglyceride turnover, cell proliferation in humans measured with 2 H2O. AmJ Physiol Endocrinol Metab . 2004;256:E 577-588.

9. Yoshimura K, Sato K, Aoi N, Cell assisted lipotransfer for cosmetic breast augmentation – supportive use of adipose derived stem-stromal cells. Aesthetic Plast Surg . 2008;32:48-55.

10. Yoshimura K, Sato K, Aoi N, Masakazu K. Cell assisted lipotransfer for facial lipoatrophy: efficacy of clinical use of adipose derived stem cells. Dermatol Surg . 2006;34:1178-1185.

11. Mojallal N. Improvement in skin quality after fat grafting: clinical observations and an animal study. Plast reconstruct Surg . 2009;124:765-774.

12. Matsumoto D, Sato K, Gonda R, Takakai Y. Cell assisted lipotransfer: Supportive use of human adipose derived cells for soft tissue augmentation. Tissue Engineering . 2006;3375-3382.

ABOUT THE AUTHOR

Dr. Robert Bowen is an Internal Medicine and Pulmonary specialist, Board Certified in Cosmetic Laser Surgery by the American Board of Laser Surgery. He is a Fellow of the American Society of Laser Medicine and Surgery and has published research articles on laser medicine. Dr. Bowen is a Diplomate of the American Board of Anti-Aging Medicine and a graduate of the Aesthetic Medicine Fellowship.

Chapter 3

Innovations in the Treatment of Chronic Wounds

Robert E. Bowen, M.D., FCCP, FSLMS

Clinical Associate Professor, WVU-East

Medical Director, The Center for Positive Aging, Martinsburg, WV

ABSTRACT

Healing of wounds is a complex process that most often proceeds in an orchestrated fashion resulting in repair of the injured area. When this orchestration proceeds in a disordered fashion then the healing process may result in an over-expression of fibroblasts (resulting in a hypertrophic scar or keloid) or inability to form new tissue (chronic wound). Hypertrophic scars are commonly seen as sequelae of thermal injuries (burns) and chronic wounds are often seen in patients with arterial and venous insufficiency and diabetes.

Previous approaches to these problems have resulted only in marginal improvement in care. Newly developed innovations in wound care are discussed as are future directions for research.

INTRODUCTION

Thermal Injuries

Advances in the treatment of serious burns have been achieved by centralizing treatment in burn units where multiple specialties including surgery, infectious disease, and critical care medicine have contributed to improvement in survival. This has been achieved by more effective management of the hypermetabolic state, infection control and nutrition. As a result of increased survival from serious burns, more patients are left with the sequelae of the resultant cutaneous and psychological scars.

The fibroblastic reaction to a thermal injury includes increased levels of inflammatory cytokines including interleukin-4 (IL-4), which increases several weeks after injury and continues for several months. In this stage of disordered healing there is increased collagen formation and decreased collagenolysis resulting in the formation of a hypertrophic scar.

Lasers have been used in the treatment of these hypertrophic scars with varying degrees of success. The SOFT™ method was developed to address the issue of the heterogeneity of the thickness of such scars. With this approach each region of a scar is treated with a fractional ablative laser at a depth sufficient to penetrate the scar.¹ This both reduces the volume of the scar tissue and creates channels that may allow resident and circulating stem cells to gain access to the scar and help normalize the structure of the tissue. Early case studies have established the credibility of this concept and further improvement of efficacy can be achieved by defining the optimal:

• Density of treatment to the area (pitch);

• Quantity of thermal effect (in addition to the ablative effect);

• Timing of the treatment in relation to the burn. ²

Other areas of potential research include optimizing nutrition, low-level light therapy (LLT), and the use of growth factors (including platelet rich plasma) and adult mesenchymal stem cells to modify abnormal tissue generation.

Chronic Wounds

In 2007, 5.7 million patients were treated for chronic wounds at a direct cost of $20 billion.³ Failure of wounds to heal can result in aesthetic issues, pain, decreased mobility, amputation, and decreased quality of life.

Wound healing in diabetic patients is especially problematic. This is secondary to:

• Large and small vessel vascular disease resulting in decreased profusion;

• Neuropathy – diabetic patients are more likely to become injured (and re-injured);

• Dysfunction of white blood cells;

• Glycation – resulting in increased susceptibility to free radical injury.

The microbiology of chronic wounds is also problematic. These wounds are often populated by multiple organisms living in a biofilm. Bacteria coexisting in a biofilm are organized in a 3-dimensional structure, are able to react to the environment, to communicate, and to act in concert to overcome the limitations of nutrients, low oxygen tension, and host defenses.⁴,⁵

TREATMENT OF CHRONIC WOUNDS

Conventional Treatment

Conventional treatment of chronic wounds includes:

• Treating the underlying condition (revascularization, improving insulin receptor sensitivity);

• Avoiding re-injury (therapeutic footwear);

• Debridement (scalpel, curette, biological);

• Dressings impregnated with iodine or silver;

• Antibiotics

• Hyperbaric oxygen (HBO 2 ).

The conventional wisdom regarding HBO2 is that it improves the physiologic state of hypoxic hypoperfused tissue. Recently, it has been proposed that the therapeutic effect is based on oxidative stress that activates intracellular reactive oxygen species (ROS) and reactive nitrogen species (RNS). ROS and RNS are signaling molecules that stimulate the production of cytokines and growth factors which lead to increased angiogenesis.⁶,⁷

The treatment outlined above, often delivered in the setting of a specialized multidisciplinary wound care center, has resulted in improvement in the care of patients with chronic wounds although challenges remain.8

Innovative Treatments

Vacuum Assisted Closure (VAC)

Negative pressure wound therapy has been employed successfully to treat non-healing wounds and is thought to remove exudates, harmful cytokines, and bacteria, thus disrupting the adaptive mechanisms of the biofilm.⁹

Growth Factors

Platelet derived growth factor (PDGF) is believed to stimulate angiogenesis via a paracrine mechanism. A recombinant PDGF has been synthesized and incorporated into a topical product (becaplermin) that has shown a 14% improvement in wound healing of diabetic ulcers at 20 weeks. Enhancement of this effect may be achieved by incorporating growth factor into nanofibrous scaffolds or by a gene delivery system. For gene delivery, human PDGF-B gene is inserted into an adenovirus vector and the virus is applied to the wound. Fibroblasts, endothelial cells, and inflammatory cells that migrate into the wound from surrounding tissue become transfected and then manufacture PDGF.¹⁰,¹¹

Mesenchymal Stem Cells

Adult mesenchymal stem cells can differentiate into fibroblasts and keratinocytes. They also modulate immune response and stimulate angiogenesis by paracrine signaling (release of growth factors such as PDGF, epidermal growth factor, transforming growth factor-β, vascular endothelial growth factor, keratinocyte growth factor, and fibroblast growth factor-2).¹² This approach can potentially overcome barriers preventing healing in a chronic wound. These barriers include both a loss of resident stem cells and growth factors and prevention of the influx of remote stem cells which are limited by fibrin cuffs surrounding the wound and poor local perfusion.

Adult mesenchymal stem cells can be harvested from autologous adipose tissue (ADSC) and are used in several applications in orthopedic, cosmetic, and regenerative medicine. This approach has been used in the treatment of traumatic lower extremity ulcers improving healing in 10 weeks from 87.4% +/- 4.4% to 97.8% +/- 1.5% over hyalauronic acid alone.¹³ Studies are now ongoing for the treatment of critical limb ischemia with encouraging preliminary results.

FUTURE PROSPECTS

Improvements in tissue harvesting and laboratory processing are ongoing and currently able to produce approximately 3-4 times as many platelets (and growth factors) and 20 times the number of stromal vascular fraction (SVF) cells (including ADSCs) as were reported in Cervelli’s study above.¹³ Studies to evaluate the hypothesis that increased growth factors and ADSCs would result in improved healing are planned.

REFERENCES

1. Bowen R. An objective approach to ablative fractional treatment of scars (SOFT). Lasers Surg Med. 2009; supplement 21:91.

2. Bowen R. A novel approach to ablative fractional treatment of mature thermal burn scars. J Drugs Dermatol. 2010;9:389-92.

3. Branski LK,Gauglitz GG, Hendon DN, Jeschke MG. A review of gene and stem cell therapy in cutaneous wound healing. Burns. 2009;35:171-180.

4. Parsek MR, Greenberg EP. Sociomicrobiology: the connections between quorum sensing and biofilms. Trends Microbiol. 2005;13:27-33.

5. deBeer D, Stoodley P, Roe F, Lewandowski Z. Effects of biofilm structures on oxygen distribution and mass transport. Biotechnol Bioeng. 2004;43:1131-1138.

6. Maulik N. Redox signaling of angiogenesis. Antioxid Redox Signal. 2002;4:805-815.

7. Ushio-Fukai M, Alexander R. Reactive oxygen species as mediators of angiogenesis signaling: role of NAD(P)H oxidase. Mol Cell Biochem . 2004;264:85-97.

8. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2004;2:CD004123.

9. Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet. 2005;366:1704-1710.

10. Tyrone JW, Mogford JE, Chandler LA, et al. Collagen-embedded platelet-derived growth factor DNA plasmid promotes wound healing in a dermal ulcer model. J Surg Res . 2000;93:230-236.

11. Wei G, Jin Q, Giannobile WV, Ma PX. Nano-fibrous scaffold for controlled delivery of recombinant human PDGF-BB. J Control Release. 2006;112:103-110.

12. Phinney DG, Prockop DJ. Concise review: mesenchymal stem/multipotent stromal cells: the state of transdifferentiation and modes of tissue repair--current views. Stem Cells. 2007;25:2896-2902.

13. Cervelli V, Gentile P, De Angelis B, et al. Application of enhanced stromal vascular fraction and fat grafting mixed with PRP in post-traumatic lower extremity ulcers. Stem Cell Res. 2011;6:103-111.

ABOUT THE AUTHOR

Dr. Robert Bowen is an Internal Medicine and Pulmonary specialist, Board Certified in Cosmetic Laser Surgery by the American Board of Laser Surgery. He is a Fellow of the American Society of Laser Medicine and Surgery and has published research articles on laser medicine. Dr. Bowen is a Diplomate of the American Board of Anti-Aging Medicine and a graduate of the Aesthetic Medicine Fellowship.

Chapter 4

Nitric Oxide: The Overlooked Molecule in Patient Care

Nathan S. Bryan, Ph.D.

Texas Therapeutics Institute, The University of Texas

Health Science Center at Houston

ABSTRACT

Although often overlooked, nitric oxide (NO) is one of the most important signaling molecules in the body. It is involved in virtually every organ system, and is responsible for modulating an astonishing variety of effects. Thus, it is no surprise to learn that a host of diseases or conditions may be caused or affected by the body’s dysregulation of NO production/signaling. Maintaining NO homeostasis is critical for optimal health and disease prevention, and developing diagnostics and therapeutics to accomplish this will have a profound effect on public health. The aim of this paper is to introduce the reader to the importance of NO, and the age-dependent decline in NO production and its consequences, NO diagnostics and therapeutic strategies for maintaining NO homeostasis will also be considered.

INTRODUCTION

Chronic diseases including heart disease, diabetes, Alzheimer’s, and cancer account for 61% of deaths worldwide. Almost 45 % of these deaths occur prematurely before the age of 70. Fortunately though, most of these deaths are preventable by diet and lifestyle modification. The common factor