Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review

We read with great interest the article entitled “Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review.”1 We compliment the authors on their work and the valuable insights gained from this review on the clinical effectiveness of nanofat grafting. The authors showed the potential of nanofat grafting as an antiscarring treatment. However, the authors also firmly concluded that nanofat grafting alone is effective as a treatment for aged skin based on both clinical and histological data. However, the last conclusion should be interpreted with caution and needs to be addressed. In total, 4 studies (2 clinical studies and 2 experiment studies) regarding nanofat grafting for skin rejuvenation purposes were included. The 2 included studies treated a total of 15 patients and had a mean follow-up of 3 to 6 months. Preoperative photographs were compared with postoperative photographs; no other validated outcome measurements were used; and both studies lacked a proper study design (eg, nonblinded, nonrandomized, and no control group). Moreover, an improvement in skin quality after a sole treatment with nanofat grafting was stated without mention of any statistics. In addition, there was no mention of the heterogeneity across the studies in terms of fat harvesting and processing techniques (ie, enzymatic digestion of the lipoaspirates presents an even greater variety among the generated nanofat fractions). These 2 included clinical studies form the basis for the authors to conclude that nanofat grafting is effective in improving skin quality. The amount of evidence and the quality of the evidence to support this statement are weak and paper thin and should not be published in this way, in our opinion. In a previous systematic review by our group, we demonstrated that there is a lack of substantial evidence showing the skin rejuvenation effect of adipose tissue or therapeutic components of adipose tissue (eg, stromal vascular fraction or adipose tissue–derived stromal cells),2 at least when therapeutic components from adipose tissue are used as a sole treatment to improve skin quality. Our hypothesis is that skin-related changes throughout the years follow a certain normal physiological process in which some components of the dermal extracellular matrix (ie, elastin) gradually decrease because of hormonal changes, genetic factors, and environmental influences (ultraviolet radiation or smoking). In other aspects, such as epidermal regeneration, perfusion, and neurosensation, no remarkable changes occur due to aging. Thus, the reparative role of adipose-derived stromal cells in adipose tissue seems to be small in that case. In comparison, pathologic processes (eg, scars or wound healing) go along with an imbalance of extracellular factors, resulting in inflammation, excessive extracellular matrix deposition, and crosslinking, or a lack of angiogenesis. These factors trigger therapeutic components of adipose tissue to start “repairing” damaged tissue. Aging-related skin changes are not pathological and consequently will probably not result in clinically identifiable changes to the skin. Therapeutic components of adipose tissue might not be able to start “repairing” tissue. However, a trigger for repair can be added by combining nanofat grafting or fat grafting with a more invasive procedure, such as a face lift or chemical peel. The addition of a trigger for repair might increase the regenerative potential of nanofat grafting. There is no doubt that the development of nanofat grafting is of great importance to the field of regenerative medicine. There is evidence that nanofat grafting or other adipose tissue therapeutics might be an effective treatment to improve wound healing or to treat osteoarthritis. However, there is not enough evidence for nanofat grafting as a sole treatment for skin rejuvenation purposes yet. There is a definite need for more prospective randomized clinical trials to evaluate the effect of nanofat as a treatment for skin rejuvenation. DISCLOSURE The authors declare that they have no competing interest or received any kind of funding for this work.