Enhanced Fat Graft Viability and Remodeling Using a Helium-based Radiofrequency Device to Prepare the Recipient Site

Widespread adoption of autologous fat grafting has led to numerous reconstructive, esthetic, and regenerative applications [1‐3]. The benefits of autologous fat grafting include its inherent biocompatibility, low cost, accessibility, and low immunogenicity. Due to its myriad uses, surgeons from different medical specialties developed new techniques geared toward increasing fat retention. These developments in fat harvesting, fat processing, preparation for the donor site and the recipient site, and fat grafting techniques have improved patient outcomes. For soft tissue augmentation, these techniques enhance fat retention by increasing fat graft survival. However, there is no standardized method for autologous fat grafting leading to unpredictability and variable rates of fat retention.

Strategies to enhance autologous fat graft retention aim to increase angiogenesis into the graft and the proliferation of progenitor cells [4]. Grafted adipose tissue loses volume as mature adipocytes undergo apoptosis within the first 72 hours due to a lack of oxygen and nutrients [5]. Adipose-derived stem cells (ASCs) are more resistant to these hypoxic conditions and begin replacing the dead adipocytes after these older cells are removed by macrophages. The new blood vessels provide the cells, nutrients, and growth factors to support this remodeling of the fat graft. Adipose tissue that remains without oxygen for too long becomes necrotic leading to tissue fibrosis and cyst formation. Approaches to overcome poor retention for soft tissue augmentation increase tissue oxygen levels, the survival and number of progenitor cells, and growth factors in the recipient site. The main strategies include physical manipulation of the recipient site (e.g., BRAVA®, microneedling, biostimulation of tissue) [6, 7], or injection of either botulinum toxin for facial fat graft [8], growth factors [9‐11], or progenitor cells during the fat graft, i.e., cell-assisted lipotransfer (CAL) [12]. Supplementation of autologous fat grafts with ASCs [13], platelet-rich plasma (PRP) [14], stromal vascular fraction (SVF) [15], or exosomes [16] either alone or in combination have increased fat graft retention [17]. These techniques lead to increased vascularity within the graft and increased proliferation and number of ASCs.

An uncommon technique for soft tissue augmentation is the use of energy-based devices for recipient site preparation prior to grafting the fat. While ultrasound and laser devices are successfully used for removal of fat [18, 19], energy-based devices have rarely been investigated for their tissue stimulating properties regarding recipient site preparation. Tissue biostimulation using a subdermal fractional CO₂ laser was utilized by Jianu et al. to improve patient outcomes from facial fat grafting. The approach uses low-level laser therapy, hypothesized to induce ASCs to release proangiogenic and proliferative factors as observed in vitro [7]. The resulting photobioactivation changes the redox state of the ASCs and likely the surrounding tissue [20].

Renuvion (Apyx Medical Corporation, Clearwater, Florida), a helium-based radiofrequency device that combines radiofrequency (rf) energy and helium plasma, may be another approach to stimulate the tissue by combining their two effects: promotion of angiogenesis through heating the tissue, and the proliferation of ASCs and paracrine recruitment of immune cells in response to plasma treatment [21‐25]. Furthermore, plasma treatment in mouse wound models was shown to augment tissue oxygenation [26]. The combination of these effects may prove to be another strategy to promote fat graft retention.

For this study, we hypothesized that pretreatment of the recipient site with a helium-based radiofrequency device stimulates the tissue to enhance fat graft retention. To investigate this, the viability, vascularity, and the presence of macrophages and ASCs in the fat graft were stained in FFPE slides at 4 weeks in pretreated mice in comparison with the controls. Given the anecdotal evidence for plasma-enhanced recruitment of immune cells, enhanced proliferation of ASCs, increased tissue oxygenation, and promotion of angiogenesis, it was hypothesized that pretreatment of the recipient tissue would enhance fat grafting of bolus fat grafts. We observed more viable adipose tissue in the pretreated group in comparison with the control mice. Additionally, the overlapping location of ASCs with macrophages in the pretreated group suggested increased remodeling activity of the dead adipose tissue. The pretreatment did not show any evidence for enhanced angiogenesis or increased secretion of vascular endothelial growth factor (VEGF). Furthermore, increased fibrosis and damaged adipose tissue morphology were observed in the control group.

The study was conducted at the Comparative Medicine facility at the University of South Florida (USF) and approved by the USF’s Institutional Animal Care and Use Committee (IACUC). The paraffin embedding, sectioning and immunofluorescence staining were performed by the Molecular Pathology Core at the University of Florida. Whole slide imaging performed by the Analytic Microscopy Core Facility at H. Lee Moffitt Cancer Center.

The use of an energy-based device for stimulation of the recipient tissue was investigated for increased retention of fat grafts. Although new fat grafting techniques and animal models show increased retention using smaller fat grafts over a bolus fat graft model, the latter was used to assess if helium-based rf pretreatment could affect the remodeling of fat with large necrotic tissues in the center [31, 32]. This model allows for the assessment of the depth of effect, which in this study is shown to be improvement of at least a few hundred microns into the tissue at 4 weeks. The cranial fat graft model was selected and modified from Kato et al. because the fat was grafted in a site with minimal native fat and was easily accessible [27]. While typical animal retention studies assess fat grafts between 12 weeks and one year, the mechanisms of adipose tissue regeneration and the effects from energy-based pretreatment occur on shorter times scales. Four weeks were chosen because Kato et al. observed the highest concentration of ASCs at this time point [27]. The results discussed here will need to be proven in larger animal models and clinical studies to project any applicability of recipient site pretreatment using a helium-based rf pretreatment for large volume fat grafting. This results of this study and future animal studies will have limited direct applicability to humans; however, the results will build a foundation for potential mechanisms of action to pursue in clinical trials.

The results suggest that helium-based rf pretreatment leads to an increased viability of the fat grafts through higher concentrations of viable ASCs present in the tissue. These smaller, strongly perilipin positive cells localized near macrophages indicate that the ASCs are migrating to the locations where dead adipocytes and lipids are removed. The apparent increase in viable ASCs may be due to enhanced proliferation or paracrine recruitment of these cells in response to tissue pretreatment.

As shown by several groups, helium plasma treatment of ASCs in vitro resulted in increased proliferation of ASCs [23, 33]. Furthermore, helium plasma treatment stimulated ASCs by upregulating genes for stem cell proliferation while downregulating intrinsic apoptotic pathways and by activating ERK1/2, Akt and NF-kB through nitric oxide production [23, 34]. These activated signaling pathways in response to helium plasma are similar to pathways in ASCs stimulated by PRP [11]. The helium plasma produced by the helium-based rf device has similarities to other helium plasma devices described as cold atmospheric plasma (CAP), namely the production of reactive oxygen and nitrogen species (RONS), ultraviolet light, and electric field gradients [35]. The plasma discharge is created when rf energy delivered to the electrode is transferred to the helium gas, which creates an electrically conductive plasma. As this discharge interacts with medical solutions, such as saline or Ringer’s, the charged molecules in the plasma dissociate the liquid molecules and some recombine into bioactive RONS. Therefore, the enhanced recruitment or proliferation of ASCs in the grafted adipose tissue may be due to the RONS produced by the helium-based rf plasma and may result in similar stimulatory properties to PRP. Future studies are needed to tie these potential mechanisms of action to pretreatment of the recipient site and increased presence of ASCs in pretreated grafts.

The response in the recipient tissue to pretreatment may exhibit enhanced immune cell function as observed by cold plasma treatment [36, 37]; however, the pretreatment does not show any evidence for influencing angiogenesis into the tissue. In comparison with the study by Kato et al., the remodeling zone of the control groups looks similar at 4 weeks, and however, the helium-based rf pretreated groups resemble remodeling at 8 weeks [27]. Furthermore, there was less fibrotic tissue observed in the pretreated grafts in comparison with the control grafts. These observations suggest that either the biological effects of this pretreatment result in a hastened remodeling of the tissue, or that there are more immune cells recruited to the tissue that may contribute to the observed healthier tissue. However, immune cell function was not measured, and more studies are needed to prove recruitment of immune cells or enhancement of function contributed to the healthier adipose tissue in pretreated grafts. CD44 has a role in both pro- and anti-inflammatory environments for regulating immune cell migration and recruitment [30, 38, 39] and its higher signal in the pretreated fat grafts may influence the rate of adipose tissue remodeling. Unlike other reports suggesting increased angiogenesis due to rf energy or CAP treatment [22, 40, 41], the helium-based rf pretreatment of the tissue did not stimulate angiogenesis into the fat graft. This may be due to the difference in heat delivery to the tissue (rf energy), RONS generation and delivery to the tissue (plasma), or the differences in CAP devices. This also suggests that treatment using a helium-based rf device may stimulate the tissue differently than other energy-based devices, specifically low-level laser therapy (CO₂ fractional lasers) where increased angiogenesis was observed post-treatment in vitro [7].

The mechanism of action behind the increased viability of the fat grafts with pretreated recipient sites will need more detailed investigations to show the role of recipient cells and donor graft cells. An extension of this model using native and green fluorescent protein expressing mice was utilized by Doi et al. to show that mature adipocytes mostly derived from the donor tissue ASCs after 12 weeks of remodeling [42]. For vascularity, the mural cells and nearly half of the vascular endothelial cells originated from the donor and recipient bone marrow, respectively. The recipient immune cells were shown to infiltrate into the areas of necrotic adipose tissue. These results serve as a suitable model to further investigate if the helium-based rf pretreatment affects the immune cell recruitment and ASC replacement into the tissue. The time points to investigate would also need to change from the current study (4 weeks) to measure promotion of angiogenesis and recruitment of immune cells (1-2 weeks) the long-term fat retention and formation of necrotic cysts (12 weeks).

This work is the first step in understanding the impact of helium-based radiofrequency pretreatment on tissue in anticipation of grafting fat, confirming what has been observed clinically. The stimulated tissue and cellular responses are consistent with other enhanced graft survival optimization techniques. The pretreatment increased the viability of the adipose tissue four weeks after the fat graft procedure. The results suggest the increase in viability is due to the higher concentration of ASCs in the tissue. The mechanism may be through either proliferation or recruitment by paracrine signaling. Future work needs to consider the complete impact of helium-based radiofrequency pretreatment for fat graft retention by investigating final retention volume after remodeling is completed, the mechanisms behind proliferation and migration of ASCs, and how this treatment would interact with native adipose tissue in the recipient site.