Efficacy of Nano fat versus Non-Enzymatic Stromal Vascular Fraction in the Treatment of Androgenetic Alopecia.

            INTRODUCTION

   Androgenic alopecia is a kind of hair loss that affects both men and women. Androgenic alopecia is caused by a combination of genetic predisposition and hormonal imbalances. We now have a better grasp of the factors that incriminated in hair loss in androgenic alopecia due to recent discoveries in molecular biology and genetics. ¹

   The utilization of adipose tissue and ADSCs in regenerative medicine is becoming more common in all sectors of medicine. Hair loss and thickness of subcutaneous fat in the scalp have been linked as the decrease in  scalp thickness and loss of its fat was found to be  associated with hair loss. In addition, several researches on the effect of ADSCs in the growing of hair have shown connection between these two forms of cell treatments and the growing of hair. In consequence, the adipose tissue has been proven to be an important part of the natural hair cycle.²

ADRCs not only have the ability to differentiate into mesenchymal cells but also produce multiple growth factors that may have an effect in new vessel formation which is essential in management of many hair loss problems.³  Moreover, addition of fat in the subcutaneous layer of the scalp lead to increase of its thickness which is frequently thinner in androgenic alopecia.⁴

The area with support cells is called the stroma. Accordingly the stroma contains high amount of stem cells (ADSCs) in the area that surround blood vessels.  Yet  Nano fat is emulsified adipose tissue, it can be produced mechanically and easily pass from 27 gauge needle.⁵

Unique compartment present in the fat tissue that have regenerative properties and can differentiate to many types of cell which called SVF. In addition to,  adipose derived stem cells, SVF contains variant cell types; ASCs, mesenchymal, endothelial cells, pericytes, leukocytes.  Despite that the enzyme dependant technique is highly successful at SVF separation, it is a costly and consumes a lot of time, and also it requires an additional level of enzymatic purification. Also, it damaging the stem-cell niche; defined as the environment that present around the stem cell which allows connection between it and the neighbouring cells which enhances surviving, dividing and growth of cells.⁶ So using the simple mechanical method is now growing and even may replace the complicated expensive enzymatic method of SVF preparation. Non- enzymatic SVF is a mechanical process that get rid of almost all lipids and fluids from aspirated fat so stem cells and fragmented extracellular matrix are the only reminder.⁷

As regard stem cell therapy, one of these promising fields is Nanofat stem cells (NFSCs) which considered a subdivision of ADSCs.  A study of histological modifications in the skin that follow adipose tissue and ADSCs injection found that this therapy was successful in modification of the structures present in dermis in order to rejuvenate the skin. NFSCs have great role in tissue healing after being injured also major role in rejuvenating the skin, reformation of elastin, collagen, cellular matrix, and blood vessels. Which is essential for the reversal of skin aging signs.⁸ This work aim to evaluate the efficacy of Nanofat vs non-enzymatic SVF in treating androgenic alopecia.

PATIENTS AND METHODS

This study was done for 30 patients (8males and 22 females) suffering from androgenic alopecia from February to October 2021. patients were randomized into 2 equal groups; Group A injected with single session of autologous Nanofat and Group B injected with single session of stromal vascular fraction injection. All patients were recruited from the Dermatology outpatient clinic of Al-Azhar University Hospitals.

Evaluation was done by USB digital trichoscopy and canon digital camera (EOS 800EF-S 18-55mm F4-5.60 IS STM lens - 24.2MP DSLR) at baseline and after 6 months of treatment. two independent blinded dermatologists  were asked to compare digital and trichoscopic pictures at 6 months after treatment with baseline pictures regarding hair status as following; Great worsening get score -3, Moderate worsening get score -2, Slight worsening get score -1, Stabilized get score 0, Slight improvement get score 1, Moderate improvement get score 2 and  Great improvement get score 3. 

Also we ask patients to evaluate their satisfaction level by giving themselves a score from 0-3 points and the score was translated as follow; highly dissatisfied get score 0, dissatisfied get score 1, satisfied get score 2 and highly satisfied get score 3. An approval was obtained from the Ethical Research Board (ERB) of the Faculty of Medicine, Al-Azhar University in Cairo. Before the study proceeding, all patients assigned Informed consent after the obvious explanation of the possible adverse events.

          Fig.1: Emulsified Nanofat

Fig. 2: Nanofat injection syringes

As regard autologous Nanofat preparation we collected fat under tumescent anesthesia using the Coleman method. After that we performed liposuction using a 3 mm specific cannula with 3 holes, starting in deep fat tissue in the abdomen and moving up repeatedly with a fanning technique with back and forth movements.  After the harvesting is made, we washed the collected fat with ringer to discard all of the blood and adrenaline; they are both harmful to the fat particles and decrease their chance of survival in the recipient sit. The emulsification process starting by gentle thirty passages through the 2.4 mm adaptor with minimal pressure applied to generate force that is enough to emulsify and not to crush and destroy cells. Then we made another thirty passes through the 1.4 and 1.2 mm adaptors to produce an equal decrease in fat size.  A single pass of this micro fat through the Nanofat filter with 0.6mm pores was done to produce Nanofat. After processing was completed, patients had scalp injection of 0.1 ml/cm2 of emulsified Nano fat using 30 G syringes.

  Fig.3: SVF preparation, upper oil, Middle fat and SVF pellet in the bottom

Fig.4: Nanofat      injection technique

Fig.5: SVF injection

On the other hand, SVF preparation is quite different in which  After  we harvesting a 60 ml of fat, the process of condensation started by centrifugation of lipoaspirate at 500g for 2 minutes and this was enough to isolate the tumescent fluid and the blood elements in the lowest layer were  they then discarded.  After centrifugation, fat was passed 30 times between two Luer lock 20-ml syringes connected to each other by connectors 2.4mm, 1.4mm, and 1.2mm arranged from higher diameter to lower diameter with minimal pressure force in order to achieve successful mechanical micronization of fat. The micronized fat was the undergoing another centrifugation (1200 g for 3 minutes) to eliminate the oil.  When oil was eliminated, the emulsified fat was filtered by passing through a Nano filter with a 0.6mm pore size to produce residual tissue of emulsified fat and filtrated fluid of emulsified fat. For the last time the product was centrifuged at 1200g for 6 minutes, as a result of this process, 3 layers are obtained depending on the density with the SVF pellet in the bottom. After isolation of SVF in one -ml syringes, the scalp is injected with 0.1 ml/cm2 of SVF intra-dermal with small 30 G needle.

RESULTS

The present study showed great improvement in 1 participants (6.7%) in group A and 4 participants (26.7%) in group B. moderate improvement present in 2 participants (13.3%) in group A and 7 participants (46.7%) in group B. slight improvement occurred in 8 participants (53.3%) in group A and 2participants (13.3%) in group B. after 6 months of treatment No response occurred in 4 participants (26.7%) in group A and 2 participants (13.3%) in group B. As regard hair count/cm2 , it was 129.9 ± 13.7 /cm2 before treatment and it was 139.5 ± 18.1 /cm2  after treatment in group A. While it was 129.5 ± 10.8 /cm2 before treatment and it was 158.1 ± 21.02 /cm2 after treatment, all nonresponsive participants had higher grades of AGA.

Fig.6: Female patient 27 years old complaining of hair loss of 1 year  duration before (left)  treated with single session SVF  injection showing improvement after (right) 6 months of single session of SVF injection.

Fig.7:  Female patient 23 years old complaining of hair loss of 6 months duration before (left) treated with single session Nanofat injection showing improvement after (right) 6 months of single session of Nanofat injection.

Fig.8: Male patient 21  years old complaining of hair loss of 11 months duration before (left)  treated with single session SVF injection showing improvement after (right) 6 months of single session of SVF injection.

Fig.9: Male patient 25 years old complaining of hair loss of 2 years  duration before (left) treated with single session Nanofat injection showing improvement after (right) 6 months of single session of  Nanofat injection.

Fig. 10: USB digital trichoscopy is used to assess hair density and thickness before  (A, B) and after (C, D),  showing decrease hair density and hair thinning before  treatment (A,B)  and increase hair density and thicknes after single session of SVF injection.(C,D).

Fig. 11: USB digital trichoscopy is used to assess  hair density and thickness before  (A, B) and after (C, D),  showing decrease hair density and hair thinning before  treatment (A,B)  and increase hair density and thicknes after single session of Nanofat  injection.(C,D).

Table 1: Comparison between studied groups as regard digital and trichoscopic photography

This table shows statistically significant difference (p-value < 0.05) between studied groups as regard digital and Trichoscopic photography.

Fig. 11: Comparison between studied groups as regard digital and trichoscopic Photography, showing that group B is improved more than group A as regard digital and  trichoscopic photos.

Table 2: Comparison between studied groups as regard hair count.

This table shows no statistical significant difference (p-value > 0.05) between studied groups as regard hair count/cm2 before treatment. It was 129.9 ± 13.7 /cm2 in group A versus 129.5 ± 10.8 /cm2 in group B.  Statistically significant difference (p-value < 0.05) between studied groups as regard hair count/cm2 after treatment. It was 139.5 ± 18.1 /cm2 in group A versus 158.1 ± 21.02 /cm2 in group B.

No statistical significant difference (p-value > 0.05) of hair count/cm2 (before & after treatment) in group A. Before treatment, it was 129.9 ± 13.7 /cm2 while after treatment; it was 139.5 ± 18.1 /cm2.  Highly statistical significant difference (p-value < 0.001) of hair count/cm2 (before & after treatment) in group B. Before treatment, it was 129.5 ± 10.8 /cm2 while after treatment; it was 158.1 ± 21.02 /cm2.

Fig. 12: Comparison between studied groups as regard hair count/cm2 , showing that group B is improved more than group A as regard hair count/cm2

               Table 3: comparison between studied groups as regard patient’s satisfaction.

This table shows statistically significant difference (p-value < 0.05) between studied groups as regard patient’s satisfaction

Fig. 13:  Comparison between studied groups as regard patient’s satisfaction   showing that, satisfaction level is higher in group B than group A.