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Dobke et al. Plast Aesthet Res 2020;7:1 I http://dx.doi.org/10.20517/2347-9264.2019.65 Page 5 of 8

Figure 3. How far are we willing to go to alter, edit, or prevent decay of the skin and/or body genome? Are we able to slow down aging (lower
arrow) or reverse skin decay that has already taken place (upper arrow)?

and that they stimulate the regenerative ability of skin by maintaining stem cells that are present in the
skin or by assuming the role of native cells upon injection/deposition. Signaling pathways for cellular
interactions within the skin and their “controls” appear to be at the core for the maintenance of youthful
facial and neck tissues or for the reversal of the loss of a smooth skin surface, dermal cohesion, and/or
[2,8]
firmness . One of the already existing and commercially available systems (SkinMedica TNS Recovery
Complex®, SkinMedica®, An Allergan Company, Anaheim, CA), capable of upregulation of extracellular
matrix regeneration controlling genes, exemplifies the feasibility and effectiveness of skin rejuvenation
[17]
interventions at a molecular level .
Technical refinements of tissue replacement by fat grafting are based on at least level III evidence, and they
include such factors as the physical form of transferred fat, ratios between the vascularized recipient site
[18]
and surface/volume of the adipose tissue graft, and the proportion between the stroma and adipocytes .
Adipose-based tissue graft volumization in combination with customized laser-based skin resurfacing
may lead to marked improvements in facial rejuvenation outcomes, as it appears that both modalities
[7]
may augment specific individual effects . Potentiation of the viability, and ultimately the retention rate of
the adipose cell grafts by the stromal vascular fraction (including enhancements by the addition of stem
cells obtained by culturing), may require more than one operative step. For example, obtaining extra stem
cell tissue cultures for 2-3 weeks may be required prior to the addition of stem cells to newly procured
adipose tissue. Increased ratio between stem cells (or stroma) and the adipose cells may enhance composite
autograft potential, but the entire procedure requires two steps (harvest of adipose tissue to obtain stroma
[19]
and produce stem cells and procurement of fat to be enriched with cultured stem cells prior to usage) .
Therefore, from the standpoint of practicality in cosmetic surgery, tissue regeneration and/or enhancing
products which can be stored and “taken off the shelf” - just as many synthetic tissue fillers are - is of
particular interest [8,20,21] . For example, the mVASC (Microvascular Tissues, Inc., San Diego, CA) product,
which consists of aseptically-processed and freeze-dried allogeneic microvascular tissue derived from
donated tissue, requires less than one minute to prepare for use. This is in contrast to procedures
involving commercially available closed systems for isolating platelet rich plasma, which typically
[10]
require approximately 30 min to obtain . The proprietary mVASC manufacturing process eliminates
the proliferative ability of cells within the graft as well as its immunogenicity. The resultant injectable
tissue graft (which can also be applicable as a topical agent, e.g., to senescent wounds) is stable at room
[20]
temperature for four years [Figure 4]. Ongoing trials indicate enormous angiogenic potential of mVASC
through upregulation of signaling cascades resulting in tissue remodeling, regeneration, rejuvenation of