Lipotransfer Effectively Reverses Skin Fibrosis In Scleroderma In The Long Term Mediated Through MEK-Erk Signalling Pathways
Michelle Griffin, Aurora Almadori, MBChB MSc, Faith Jeon, MBChB MSc, Peter Butler, MD FRCS(Plast).
University College London, London, United Kingdom.
PURPOSE: Oro-facial fibrosis in systemic sclerosis (SSc) causes significant impairment in mouth function and patientís quality of life. Lipotransfer is a reconstructive technique that may be used to treat facial fibrosis. This study aimed to prospectively assess the use of lipotransfer to reverse orofacial fibrosis and restore facial volume in patients with SSc. Adipose derived stem cells (ADSCs) within the lipotransfer may mediate the anti-fibrotic effect of the surgical treatment but the precise mechanism by which ADSCs reverse fibrosis is unknown. To understand the mechanism by which lipotransfer acts, an in vitro co-culture model of ADSCs with human dermal fibroblasts derived from patients with SSc was performed. METHODS: Prospective analysis of patients undergoing lipotransfer for oro-facial scleroderma was performed between 2011-2018. Eighty-eight female patients were included (average age 58 years) in the study with diffuse and limited SSc. Improvement in aesthetic and functional outcome was assessed at a minimum of 12 months (range 12-84 months) following surgery by the patient and surgeon. Clinical evaluation included assessment of mouth function using the validated Mouth Handicap in Systemic Sclerosis Scale (MHISS) and pre and postoperative volumetric assessment using 3D-surface imaging systems. The effect of lipotransfer on the psychological health of the patients was assessed using the Derriford Appearance Scale (DAS24), Short Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Scale (VAS). Following isolation of adipose stem cells (SSc-ADSCs) and dermal fibroblasts (SSc-HDFs) from 6 female patients within the cohort, in vitro co-culture assays were performed for 14 days. The SSc-HDF proliferation using DNA content and toxicity with LDH assay was analysed. Furthermore, invasion and migration using wound scratch assays of SSc-HDF co-cultured with SSc-ADSCs were analysed over 14 days. At 7 and 14 days a fibrosis pathway specific qPCR array was performed of SSc-HDFs gene expression in monoculture and co-culture. Furthermore, the SSc-HDF secretion of fibrotic proteinís TGF-β1 and CTGF at day 7 and 14 was assessed using enzyme-linked immunosorbent assay (ELISA). RESULTS: All patients reported aesthetic and functional improvement in their orofacial fibrosis following lipotransfer without any complications. The patient demonstrated significant improvement in postoperative MHISS scores compared to preoperative scores, demonstrating enhanced mouth function (p < 0.05). All post-operative psychological health questionnaires scores were significantly improved following lipotransfer compared to pre-operative scores (p < 0.05). Volume analysis of the orofacial region confirmed the long-term lipotransfer restoration at 12-months for all patients, with significant retention in the cheek regions compared to all other facial regions (p < 0.05). Proliferation, migration and invasive capacity of SSc-HDFs was significantly enhanced in co-culture with SSc-ADSCs than monocultures (p < 0.05). A down regulation of fibrotic genes (PDGF, MMP8, SMAD3, Raf, MEK, Erk) and secretion of CTGF and TGF-β1 proteins by SSc-HDFs was observed over 14 days in co-culture with SSc-ADSCs (p < 0.05). CONCLUSIONS: Lipotransfer effectively reverses orofacial fibrosis in SSc and may mediate this through MEK-Erk pathways. Further understanding into the mechanism by which lipotransfer reverses fibrosis will improve the efficacy of such treatment for SSc skin fibrosis.
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