Comprehensive Matrisome Profiling of Human Adipose Tissue for Soft Tissue Reconstruction.

For effective translation of research from tissue engineering and regenerative medicine domains, the cell-instructive extracellular matrix (ECM) of specific tissues must be accurately realized. As adipose tissue is gaining traction as a biomaterial for soft tissue reconstruction, with highly variable clinical outcomes obtained, a quantitative investigation of the adipose tissue matrisome is overdue. In this study, the human adipose tissue matrisome is profiled using quantitative sequential windowed acquisition of all theoretical fragment ion spectra - mass spectrometry (SWATH-MS) proteomics across a cohort of 13 fat-grafting patients, to provide characterization of ECM proteins within the tissue, and to understand human population variation. There are considerable differences in the expression of matrisome proteins across the patient cohort, with age and lipoaspirate collection technique contributing to the greatest variation across the core matrisome. A high abundance of basement membrane proteins (collagen IV and heparan sulfate proteoglycan) is detected, as well as fibrillar collagens I and II, reflecting the hierarchical structure of the tissue. This study provides a comprehensive proteomic evaluation of the adipose tissue matrisome and contributes to an enhanced understanding of the influence of the matrisome in adipose-related pathologies by providing a healthy reference cohort and details an experimental pipeline that can be further exploited for future biomaterial development.

Clinical Applicability of Visible Light-Mediated Cross-linking for Structural Soft Tissue Reconstruction.

Visible light-mediated cross-linking has utility for enhancing the structural capacity and shape fidelity of laboratory-based polymers. With increased light penetration and cross-linking speed, there is opportunity to extend future applications into clinical spheres. This study evaluated the utility of a ruthenium/sodium persulfate photocross-linking system for increasing structural control in heterogeneous living tissues as an example, focusing on unmodified patient-derived lipoaspirate for soft tissue reconstruction. Freshly-isolated tissue is photocross-linked, then the molar abundance of dityrosine bonds is measured using liquid chromatography tandem mass spectrometry and the resulting structural integrity assessed. The cell function and tissue survival of photocross-linked grafts is evaluated ex vivo and in vivo, with tissue integration and vascularization assessed using histology and microcomputed tomography. The photocross-linking strategy is tailorable, allowing progressive increases in the structural fidelity of lipoaspirate, as measured by a stepwise reduction in fiber diameter, increased graft porosity and reduced variation in graft resorption. There is an increase in dityrosine bond formation with increasing photoinitiator concentration, and tissue homeostasis is achieved ex vivo, with vascular cell infiltration and vessel formation in vivo. These data demonstrate the capability and applicability of photocrosslinking strategies for improving structural control in clinically-relevant settings, potentially achieving more desirable patient outcomes using minimal manipulation in surgical procedures.

Characterisation of the immune microenvironment of cutaneous squamous cell carcinoma in immunosuppression.

Cutaneous squamous cell carcinoma (cSCC) is a common cancer. Systemic immunosuppression with drugs such as Prednisone results in more aggressive disease. We hypothesise that more aggressive disease in immunosuppression is the result of immune changes in the tumor microenvironment. We characterised T cell, phagocytic and antigen presenting cell subsets in cSCC and determined if these infiltrates were altered by immunosuppressive therapy. We found a dominant "CD8 profile" in the centre of cSCC lesions, with CD8 cells correlating with Tbet, FoxP3, OX40 and "M2-like" macrophages, whereas a "Tbet and granulocyte profile" with associated inflammation predominated at the margin of the tumor. Individuals on systemic immunosuppressive therapy had lesions that were comparable in size, stage and number of vessels to immune competent individuals; however, the number of CD11c positive cells in the lesion centre was significantly reduced. We conclude that cSCC lesions are immunologically heterogeneous across the lesion and that systemically immunosuppressed individuals have reduced CD11c positive cells in the centre of the lesion. The role and detailed phenotype of CD11c positive cells in cSCC lesions warrant further investigation.

Overcoming functional challenges in autologous and engineered fat grafting trends.

Autologous fat grafting offers significant promise for the repair of soft tissue deformities; however, high resorption rates indicate that engineered solutions are required to improve adipose tissue (AT) survival. Advances in material development and biofabrication have laid the foundation for the generation of functional AT constructs; however, a balance needs to be struck between clinically feasible delivery and improved structural integrity of the grafts. A new approach combining the objectives from both the clinical and research communities will assist in developing morphologically and genetically mature AT constructs, with controlled spatial arrangement and increased potential for neovascularization. In a rapidly progressing field, this review addresses research in both the preclinical and bioengineering domains and assesses their ability to resolve functional challenges.

Who operated on me? What patients understand about surgical trainees.

AIMS: To evaluate whether information delivered to patients about the level of training of the person operating on them is understandable and meaningful. To establish whether post-operative patients can identify when a doctor, undergoing training in surgery, has performed their surgery. To identify terms that are clear to patients, which can be used to improve understanding. METHOD: A 15-question survey was developed to evaluate the expectations, understanding and knowledge post-operative patients had about their recent surgery. Patients were questioned about the level of training of their surgeon, the current designations used and their knowledge about surgical training. RESULTS: Over a one-month period, 161 patients were requested to fill in surveys. Sixty-one percent of patients agreed that it is very important to know the level of training of their surgeon, but only 39% of patients could correctly identify this. Of the 62 patients who thought that a consultant had performed their procedure, 40% were correct. The terms we use to denote level of training are confusing to the majority of patients. CONCLUSION: The majority of patients are unable to recognise the level of training of the person who operated on them. There is a common public misconception that the consultant surgeon will be the operator in the majority procedures, however in teaching hospitals, a significant number of procedures are performed by doctors working under the supervision of the consultant surgeon. Many patients are not being adequately educated prior to surgery about the level of training of the person doing their procedure.

A Comparative Outcome Study of Hamstring Versus Tibialis Anterior and Synthetic Grafts for Deltoid to Triceps Transfers.

PURPOSE: To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts. METHODS: A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014. RESULTS: Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms. CONCLUSIONS: Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Cutaneous squamous cell carcinomas with markers of increased metastatic risk are associated with elevated numbers of neutrophils and/or granulocytic myeloid derived suppressor cells.

BACKGROUND: A subset of presenting cutaneous squamous cell carcinomas (CSCC) is high risk with respect to their high rates of recurrence, metastasis and patient death. The identification of such high risk CSCC is problematic. Neutrophil and granulocytic myeloid derived suppressor cell (G-MDSC) numbers are elevated in a number of cancers, but their association with current markers of high risk tumors in the setting of CSCC is unknown. OBJECTIVES: To assess circulating and tumor-localised neutrophil and G-MDSC populations for associations with high-risk tumor characteristics and overall survival (OS) in CSCC patients. METHODS: A retrospective clinical audit was performed of patients who had hospital operations for primary CSCC and did not have other malignancies or HIV. Therapeutically immuno-suppressed individuals (TII, n=129) and non-TII (n=29) were analysed separately with respect to the presence of high-risk tumor features and OS. In addition, 47 patients with prospectively collected blood and primary CSCC tumor samples were analysed to determine frequencies of circulating G-MDSC and tumor localised CD66b+ and CD8+ leukocytes. RESULTS: In the clinical audit of non-TII, high circulating neutrophil counts were associated with tumor thickness≥5mm, Clark level V and high T-stage. Univariate analysis showed elevated neutrophil count was a significant marker of poor OS, whilst tumor thickness remained the only independent histological predictor of OS after adjusting for age and immuno-suppression. The prospective study demonstrated that tumors≥5mm thick had significantly increased total and peri-tumorally localised CD66b+ leukocytes (comprising neutrophils and/or G-MDSC) and that elevated circulating G-MDSC numbers were associated with high T-stage tumors. CONCLUSIONS: This study demonstrates that the presence of high risk CSCC is associated with increased numbers of both circulating and tumor resident populations of neutrophils and/or G-MDSC. These cell types therefore merit further investigation with respect to their functional and prognostic significance in CSCC.

Tendon Transfer Surgery for People With Tetraplegia: An Overview.

After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

OBJECTIVE: Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. DESIGN: BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. SETTING: Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. PARTICIPANTS: Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. RESULTS: Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. CONCLUSIONS: Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Keratin-based products for effective wound care management in superficial and partial thickness burns injuries.

This n=40 cohort study on superficial and partial thickness burns compares novel keratin-based products with the standard products used at our facility. The keratin products are found to facilitate healing with minimal scarring, be well tolerated with minimal pain and itch, be easy to use for the health professional and be cost effective for the health care provider. For these reasons they are being adopted into use at our facility.

A regional programme to improve skin cancer management.

BACKGROUND AND CONTEXT: In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives. ASSESSMENT OF PROBLEM: There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care. RESULTS: The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians. STRATEGIES FOR IMPROVEMENT: The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors. LESSONS: Skin cancer management can be improved by a coordinated approach between primary and secondary care.

Keratin gel improves poor scarring following median sternotomy.

BACKGROUND: Linear hypertrophic scarring is a common surgical problem that can be difficult to manage. This article evaluates median sternotomy wounds that have often been reported to scar poorly resulting in hypertrophic scar formation. METHODS: This study is a single-blinded, open-labelled pilot study of 20 patients using keratin gel as the intervention and aqueous cream as the control, which are each applied to a different half of the wound daily over 6 months. We use the Patient and Observer Scar Assessment Scale (POSAS) and the Manchester Scar Score (MSS) to assess the scarring. RESULTS: At the 6-month assessment the MSS, patient-POSAS and observer-POSAS were 12.00, 16.70 and 15.00 in the treatment half and 12.58, 17.85 and 16.55 in the control half respectively. Overall, we found that there was a decrease in all score scales after 6 months (P = 0.005). Furthermore, in the subset of patients with poor scarring, decreases in the MSS, patient-POSAS and observer-POSAS were statistically significant (P = 0.025, <0.01 and 0.01) with scores of 12.22, 17.33 and 15.33 in the treatment half and 14.22, 23.67 and 22.33 in the control half respectively. CONCLUSION: In patients who scar more poorly than average, there were significant improvements in scarring. This demonstrates a simple, well-tolerated intervention that reduces problematic scarring following surgery.

Skin closure after laparotomy with staples or sutures: a study of the mature scar.

BACKGROUND: Surgeons are divided in their method of choice for skin closure following laparotomy. We suggest that the most important determinant should be the resulting scar. This study aims to compare both patients' and independent observers' assessment of mature laparotomy scars that had been closed with either subcuticular sutures or external staples. METHODS: Consecutive patients were enrolled at least 1 year following colorectal surgery. Scars were assessed with the validated Patient and Observer Scar Assessment Scoring (POSAS) tool. Photographs were assessed by a blinded independent panel. RESULTS: Overall, 232 patients were enrolled (90 suture, 143 staples). The two groups were well matched by factors affecting wound healing. Patients' overall opinion of their scar was significantly better for the Suture group than the Staples group (P = 0.028) despite there being no difference in their self-assessment of the components of their scar score (pain, itch, colour, stiffness, thickness, irregularity). The panel recorded similar overall scores for the Suture and Staples groups (P = 0.059). There was a significant lower (better) score recorded for the scar area component for the Suture group than the Staples group (P = 0.008) but no differences for the other components (vascularity, pigmentation or thickness). DISCUSSION: This study has shown that independent of skin closure method, patients who have undergone major abdominal surgery have a positive opinion of their mature scars. The patients' overall impression of the wound favours a sutured closure due to a smaller scar area (no staple marks). In all other respects, skin closure with staples would appear acceptable.

A randomized steady-state bioavailability study of synthetic versus natural (kiwifruit-derived) vitamin C.

Whether vitamin C from wholefoods has equivalent bioavailability to a purified supplement remains unclear. We have previously showed that kiwifruit provided significantly higher serum and tissue ascorbate levels than synthetic vitamin C in a genetically vitamin C-deficient mouse model, suggesting a synergistic activity of the whole fruit. To determine if these results are translatable to humans, we carried out a randomized human study comparing the bioavailability of vitamin C from kiwifruit with that of a vitamin C tablet of equivalent dosage. Thirty-six young non-smoking adult males were randomized to receive either half a gold kiwifruit (Actinidia Chinensis var. Hort 16A) per day or a comparable vitamin C dose (50 mg) in a chewable tablet for six weeks. Ascorbate was monitored weekly in fasting venous blood and in urine, semen, leukocytes, and skeletal muscle (vastus lateralis) pre- and post-intervention. Dietary intake of vitamin C was monitored using seven day food and beverage records. Participant ascorbate levels increased in plasma (P < 0.001), urine (P < 0.05), mononuclear cells (P < 0.01), neutrophils (P < 0.01) and muscle tissue (P < 0.001) post intervention. There were no significant differences in vitamin C bioavailability between the two intervention groups in any of the fluid, cell or tissue samples tested. Overall, our study showed comparable bioavailability of synthetic and kiwifruit-derived vitamin C.

Do functional keratin dressings accelerate epithelialization in human partial thickness wounds? A randomized controlled trial on skin graft donor sites.

OBJECTIVE: To determine if the experimental (keratin-based) dressing accelerates epithelialization rates during healing of partial-thickness wounds, relative to a Standard Care dressing. METHOD: A randomized control trial was conducted using a Standard Care dressing side by side with the experimental dressing on a sample (n=26) of partial-thickness donor site wounds. The proximal/distal placement of the control and treatment was randomized. Percentage epithelialization after approximately 7 days was estimated from which time to fully epithelialize can be inferred. Patients were grouped into "young" (≤50 y/o) and "old" (>50 y/o). RESULTS: For the "old" patients (n=15), the median epithelialization percentage at 7 days is 5% and was significantly (P=.023) greater for the experimental dressing. For the "young" patients (n=11), the median epithelialization percentage at 7 days was 80% and there is no significant difference between the experimental and Standard Care control dressings. CONCLUSIONS: The experimental dressing significantly increases the rate of epithelialization of acute, traumatic partial-thickness wounds in older patients. We suggest that the dressing may be clinically useful in similar situations where epithelialization may be delayed because of patient or wound characteristics.

Reduction mammaplasty and resource allocation--are patients being treated fairly? An examination of the current New Zealand situation, and looking towards the future.

AIM: To review the access to publically-funded reduction mammaplasty for New Zealand (NZ) women. Additionally, to evaluate quality of life gains from reduction mammaplasty and other surgical treatments of chronic conditions. Ultimately to determine whether access to surgical treatment for this condition is equitable. METHOD: Four tertiary referral centres for Plastic Surgery in NZ completed a survey to characterise patient access. A literature search was done to investigate the global situation and obtain quality of life information following breast reduction and other operations for chronic conditions. RESULTS: The survey showed there was significant inequity in allocation and access to breast reduction surgery in NZ over time and geographical location. There were hopes that the Ministry of Health Prioritisation Tool would ensure more equitable access to plastic surgical procedures nationally in the future. A similar situation exists in Europe in regards to allocation, and insurance companies dictate access in the US. There was overwhelming evidence to support quality of life gains with reduction mammaplasty, which are equal to if not greater than more accessible operations. CONCLUSION: In NZ there is inequitable access to surgery for patients who would be treated by breast reduction surgery, with substantial variation across geography and time. A new Prioritisation Tool may address this discrepancy. Much evidence exists that quality of life gains for reduction mammaplasty are equivalent to other surgical procedures, which are more readily available. The challenge is to improve equity of access across all surgical conditions.

Human skeletal muscle ascorbate is highly responsive to changes in vitamin C intake and plasma concentrations.

BACKGROUND: Vitamin C (ascorbate) is likely to be essential for skeletal muscle structure and function via its role as an enzyme cofactor for collagen and carnitine biosynthesis. Vitamin C may also protect these metabolically active cells from oxidative stress. OBJECTIVE: We investigated the bioavailability of vitamin C to human skeletal muscle in relation to dietary intake and plasma concentrations and compared this relation with ascorbate uptake by leukocytes. DESIGN: Thirty-six nonsmoking men were randomly assigned to receive 6 wk of 0.5 or 2 kiwifruit/d, an outstanding dietary source of vitamin C. Fasting blood samples were drawn weekly, and 24-h urine and leukocyte samples were collected before intervention, after intervention, and after washout. Needle biopsies of skeletal muscle (vastus lateralis) were carried out before and after intervention. RESULTS: Baseline vastus lateralis ascorbate concentrations were ~16 nmol/g tissue. After intervention with 0.5 or 2 kiwifruit/d, these concentrations increased ~3.5-fold to 53 and 61 nmol/g, respectively. There was no significant difference between the responses of the 2 groups. Mononuclear cell and neutrophil ascorbate concentrations increased only ~1.5- and ~2-fold, respectively. Muscle ascorbate concentrations were highly correlated (P < 0.001) with dietary intake (R = 0.61) and plasma concentrations (R = 0.75) in the range from 5 to 80 µmol/L. CONCLUSIONS: Human skeletal muscle is highly responsive to vitamin C intake and plasma concentrations and exhibits a greater relative uptake of ascorbate than leukocytes. Thus, muscle appears to comprise a relatively labile pool of ascorbate and is likely to be prone to ascorbate depletion with inadequate dietary intake. This trial was registered at the Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) as ACTRN12611000162910.

An algorithmic approach to perineal reconstruction after cancer resection--experience from two international centers.

AIM: This paper aims to simplify the approach to reconstruction of the perineum after resection of malignancies of the anal canal, lower rectum, vulva, and vagina. MATERIALS AND METHODS: The data were collected from 2 centers, namely, Addenbrooke's Hospital, University of Cambridge, United Kingdom and Christchurch Hospital, University of Otago, New Zealand. All patients who underwent perineal reconstruction from 1997 to 2009 at Christchurch Hospital (13 years) and 2001 to 2009 at Addenbrooke's Hospital (9 years) were included. The diagnosis (indication), primary surgery, reconstructive surgery, complications, tumor outcomes (recurrence and survival), and follow-up were entered into a database (Microsoft Excel; Redmond, Wash). The incidence of previous radiotherapy, requirement for adjuvant radiotherapy, and length of inpatient stay were also recorded. RESULTS: Forty-six patients were identified for this study--13 in New Zealand and 33 in Cambridge. Indications for perineal reconstruction included resection of anal and rectal malignancies (24), vulval and vaginal malignancy (19), perineal sarcoma (1), and perineal squamous cell carcinoma arising in an enterocutaneous fistula (Table 1). The reconstructive strategies adopted included rectus abdominis myocutaneous flaps (26), gluteal fold flaps (9), gracilis V-Y or advancement flaps (7) and others (4), gluteal rotation flaps (1), local flap (2), and free latissimus dorsi flaps (1). CONCLUSIONS: Although various surgeons performed the reconstructive surgeries at 2 different centers, the essential approach remained the same. Smaller defects were best treated by local flaps, whereas the rectus abdominis flap remained the standard option for larger defects that additionally required closure of dead space. On the basis of our 2 center experience, we propose a simple algorithm to facilitate the planning of reconstructive surgery for the perineum.

Ovine forestomach matrix as a substrate for single-stage split-thickness graft reconstruction.

OBJECTIVE: Split skin graft reconstruction of scalp defects often leaves an obvious contour defect. Here, we aimed to demonstrate the use of a decellularized extracellular matrix biomaterial, termed ovine forestomach matrix (OFM), as a substrate for split-thickness skin grafts (STSGs) for scalp reconstruction. METHODS: Following full-thickness tumor excision, OFM was applied directly to skull periosteum, and then an STSG was applied. Participants were monitored for graft take, epithelialization, and cosmetic outcomes. RESULTS: Participants responded well to the procedure with more than 95% graft take in 4 participants, and 100% epithelialization of the grafts after 2 weeks. A 30% graft take was observed in the fifth participant due to local infection and partial necrosis of the graft. Ovine forestomach matrix was remodelled with time and the regenerated dermis was well vascularized and had robust and ordered collagen deposition. CONCLUSIONS: This series demonstrates that OFM can serve as a temporary dermal scaffold to support an overlying STSG and allow for a single-stage grafting procedure.