Regenerative potential of the sural neuroadipofascial flap in the treatment of chronic ulcers of the lower third of the leg.

OBJECTIVE: Surgical reconstruction of soft tissue defects in the distal third of the lower limbs has always been challenging for surgeons. The adipofascial flaps are made up of vascularized adipose tissue, which plastically conforms to the site to be reconstructed with its rich presence of stem cells. In this study, we resumed our case history of reverse neuroadipofascial sural flap, and we evaluated the stability of the scar to verify if this type of reconstruction can ensure long-term results and its regenerative power. PATIENTS AND METHODS: In this retrospective cohort study, we analyzed 32 patients who had undergone lower limb reconstruction with the sural neuroadipovenous flap. RESULTS: A total of 32 patients were included in the study. The average age was 62.2 years. Chronic skin ulcer was the cause of the defects in 13 (40.6%) patients, chronic wound after trauma in 7 (21.9%) patients, wheel bedsores in 4 (12.5%) patients, osteomyelitis in 5 (15.6%) patients, exposed internal hardware in 2 (6.3%) patients, dog bite in 1 (3.1%). The site defect comprised 11 heels (34.4%), 4 external malleoli (12.5%), three medial malleoli (9.4%), 12 lower third of the leg (37.5%), and two dorsa of the foot (6.3%). In all cases, defects were covered with reverse sural island flap. The dimension of the flap ranged from 5 to 9 cm in length and from 3 to 7 in width. Six patients showed early or later postoperative complications. CONCLUSIONS: The neuroadipofascial sural flap is versatile, fast, and easy-to-perform to cover a chronic defect in the distal part of the lower limb, including both the malleoli and the heel, due to its long vascular pedicle. Consistent with the studies carried out in other districts, the present study confirms the remarkable regenerative power of the vascularized adipose tissue at the level of complex wounds of the lower third of the leg.

Hyaluronic Acid: Redefining Its Role.

The discovery of several unexpected complex biological roles of hyaluronic acid (HA) has promoted new research impetus for biologists and, the clinical interest in several fields of medicine, such as ophthalmology, articular pathologies, cutaneous repair, skin remodeling, vascular prosthesis, adipose tissue engineering, nerve reconstruction and cancer therapy. In addition, the great potential of HA in medicine has stimulated the interest of pharmaceutical companies which, by means of new technologies can produce HA and several new derivatives in order to increase both the residence time in a variety of human tissues and the anti-inflammatory properties. Minor chemical modifications of the molecule, such as the esterification with benzyl alcohol (Hyaff-11® biomaterials), have made possible the production of water-insoluble polymers that have been manufactured in various forms: membranes, gauzes, nonwoven meshes, gels, tubes. All these biomaterials are used as wound-covering, anti-adhesive devices and as scaffolds for tissue engineering, such as epidermis, dermis, micro-vascularized skin, cartilage and bone. In this review, the essential biological functions of HA and the applications of its derivatives for pharmaceutical and tissue regeneration purposes are reviewed.

Hyperbaric oxygen therapy in Plastic Surgery practice: case series and literature overview.

Hyperbaric oxygen therapy (HBOT) is the use of 100% oxygen at pressures more than atmospheric. Several approved applications and indications exist for HBOT in the literature. Non-healing wounds, such as diabetic and vascular insufficiency ulcers, have 1 Clinic of Plastic and Reconstructive Surgery, Department of Neurosciences, University Hospital of Padova, Padova, Italy 2 Department of Physiology, University of Padova, Padova, Italy Corresponding author: Ilaria Tocco-Tussardi, e-mail: ilaria.toccotussardi@gmail.com © Copyright 2019, CIC Edizioni Internazionali, Romabeen a major area of application, and the use of HBOT as an adjunct has been approved by several studies and trials. HBOT is also indicated for acute soft tissue infections like clostridial myonecrosis, necrotising soft tissue infections, as also for traumatic wounds, crush injury, compartment syndrome, and compromised skin grafts and flaps. Another major area of application of HBOT is radiation-induced wounds. With increasing availability of chambers and studies proving the benefits of use, HBOT should be considered as an essential part of the overall management strategy for plastic surgeons.

Antiseptics for burns: a review of the evidence.

The burn patient is easily subject to colonization by microorganisms and infection, due to reduced defence capabilities and immune dysfunction. Moreover, burn units and intensive care units are characterized by a selection of resistant bacterial strains. If the burn patient is not adequately cared for in terms of infection prevention and control, sepsis is inevitable. Nowadays, several different antiseptics and antiseptic dressings are used in the topical treatment of burns, each with positive and negative effects. Topical antiseptics allow control of bacterial load, but they can also cause cytotoxicity and reduce healing rate. Choosing the most effective antiseptic is crucial to preventing infection from compromising wound healing. The present study aims to review the available literature in order to highlight evidence on the use of topical antiseptics in burns.

Les patients brûlés sont facilement colonisés et infectée, en raison de diminution des capacités de défense et de la fonction immunitaire. En outre, les services de réanimation et les CTB ont une prévalence élevée de bactéries multirésistantes. Si les mesures préventives et les soins sont mal conduits, la survenue d'infection est inéluctable. Actuellement, de nombreux antiseptiques et pansements antiseptiques sont disponibles, chacun avec ses avantages et inconvénients. Ils ont en effet la capacité de diminuer la charge bactérienne locale, mais sont susceptibles d'obérer la cicatrisation par cytotoxicité. Le choix de l'antiseptique peut donc être crucial. Cette revue de la littérature a pour but de dégager des données factuelles concernant l'usage des antiseptiques chez les brûlés.

What We Know About the Pathogenesis of Idiopathic Pulmonary Fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive lung disease of unknown cause, occurring in adults, limited to the lungs and associated with the pathologic and radiologic pattern of usual interstitial pneumonia. Prognosis is poor, and most patients die of respiratory failure within 3 to 6 years from the onset of symptoms. Although our understanding of the pathogenesis of IPF has improved over the past two decades, the mechanisms responsible for this disorder have not been clearly defined. Aging is the single most important risk factor, but genetic, environmental, and diverse exogenous factors such as smoking, viral infections, chronic tissue injury (i.e., gastroesophageal reflux disease, traction injury) play contributory roles. In this review, we focus on pathogenetic mechanisms that we think are crucial for the initiation of the fibrotic process and for its progressive evolution. In the early stage of the disease, in the context of the permissive genetic background combined with the presence of specific risk factors, alveolar epithelial cells play a leading role. Subsequent evolution of the fibrotic process and its lethal progression is likely due to the abnormal tissue repair process that takes place in the lung and to the inability to counteract this process. In this phase of the disease, fibroblasts assume a crucial role. Current pharmacological treatment strategies for IPF have only modest value, principally by slowing the course of disease progression. Unfortunately, improvement or cure has not yet been achieved with pharmacological agents. The challenge for the future is to improve the comprehension of the mechanisms involved in the inception and evolution of IPF and their articulated interactions. This is fundamental not only to conceive and develop new drugs against this dreadful disease but also to apply different therapeutic approaches such as drug repositioning and personalized therapies in the management of IPF.

Complicaciones intra y postquirúrgicas de exodoncias en un programa de atención comunitaria de la FOUBA en Junín de los Andes / Intra and postsurgical tooth extraction complications at a FOUBA community dentistry program in Junin de los Andes

El objetivo de este estudio fue analizar la incidencia de complicaciones intra y postquirúrgicas de extracciones simples en 5 días de atención comunitaria en Junín de los Andes, provincia de Neuquén, Argentina. Se realizaron 109 extracciones dentales en 74 de los pacientes que concurrieron al centro único de atención, entre el 27 y 31 de octubre de 2014, presentando piezas dentarias con indicación de extracción. Las complicaciones más frecuentemente encontradas fueron la fractura de la tabla ósea vestibular, la fractura de la corona de la pieza dentaria y el dolor posoperatorio. Complicaciones de frecuencia intermedia fueron el trismus, la alveolitis, la laceración de los tejidos blandos y la fractura de la raíz de la pieza dentaria. Se registró un caso de hemorragia primaria y una inyección accidental dentro de un vaso sanguíneo. Cuando se comparó estadísticamente la presencia de complicaciones pre y posquirúrgicas entre cirugías que duraron menos de 30 minutos y 30 minutos más, se encontró una asociación significativa; para ambas complicaciones, el porcentaje fue mayor en el segundo grupo. La práctica de extracciones simples ocasionalmente conlleva tener que manejar complicaciones. Es importante que el odontólogo general sea capaz de prevenirlas, diagnosticarlas y tratarlas. Reducir los tiempos operatorios parecería ser una medida clave para disminuir las probabilidades de aparición de complicaciones intra y posquirúrgicas.

The objective of this study was to analyze the incidence of intra and postoperative complications of simple extractions in 5 days of community care in Junín de los Andes, province of Neuquén, Argentina. A total of 109 dental extractions were performed in 74 patients who attended the single care center between October 27 and 31, 2014, presenting teeth with indication of extraction. The most frequent complications were the fracture of the buccal bone table, the fracture of the crown of the tooth and the postoperative pain. Complications of intermediate frequency were trismus, alveolitis, laceration of the soft tissues and fracture of the root of the tooth. There was a case of primary haemorrhage and an accidental injection into a blood vessel. When statistically comparing the presence of pre and postsurgical complications between surgeries that lasted less than 30 minutes and 30 minutes more, a significant association was found; for both complications, the percentage was higher in the second group. The practice of simple extractions occasionally entails having to handle complications. It is important that the general dentist be able to prevent, diagnose and treat them. Reducing operative times seems to be a key measure to decrease the chances of intraoperative and postoperative complications.

Polyurethane foam-covered breast implants: a justified choice?

OBJECTIVE: Even if the safety of the polyurethane prosthesis has been the subject of many studies and professional and public controversies. Nowadays, polyurethane covered implants are very popular in plastic surgery for the treatment of capsular contracture. MATERIALS AND METHODS: We have identified 41 papers (1 is a communication of the FDA) by using search browsers such as Pubmed, Medline, and eMedicine. Eleven manuscripts have been used for an introduction, and the remaining thirty have been subdivided into three tables whose results have been summarized in three main chapters: (1) capsular formation and contracture, (2) complications, (3) biodegradation and cancer risk. RESULTS: (1) The polyurethanic capsule is a well defined foreign body reaction characterized by synovial metaplasia, a thin layer of disarranged collagen fibers and a high vascularization. These features make possible a "young" capsule and a low occurrence of capsular contracture even over a long period (10 years); (2) the polyurethane implants may be difficult to remove but there is no evidence that they cause an increase in the other complications; (3) there is no evidence of polyurethane related cancer in long-term studies (after 5 years). CONCLUSIONS: Polyurethane foam covered breast implants remain a valid choice for the treatment of capsular contracture even if it would be very useful to verify the ease of removal of the prosthesis and to continue investigations on biodegradation products.

Multiple symmetric lipomatosis: a rare disease and its possible links to brown adipose tissue.

AIM: Aim of this study is an updated review of our case series (72 patients) as well as available literature on the Multiple Symmetric Lipomatosis (MSL), a rare disease primarily involving adipose tissue, characterized by the presence of not encapsulated fat masses, symmetrically disposed at characteristic body sites (neck, trunk, proximal parts of upper and lower limbs). DATA SYNTHESIS: The disease is more frequent in males, associated to an elevated chronic alcohol consumption, mainly in form of red wine. Familiarity has been reported and MSL is considered an autosomic dominant inherited disease. MSL is associated to severe clinical complications, represented by occupation of the mediastinum by lipomatous tissue with a mediastinal syndrome and by the presence of a somatic and autonomic neuropathies. Hyper-alphalipoproteinemia with an increased adipose tissue lipoprotein-lipase activity, a defect of adrenergic stimulated lipolysis and a reduction of mitochondrial enzymes have been described. The localization of lipomatous masses suggests that MSL lipomas could originate from brown adipose tissue (BAT). Moreover, studies on cultured pre-adipocytes demonstrate that these cells synthetize the mitochondrial inner membrane protein UCP-1, the selective marker of BAT. Surgical removal of lipomatous tissue is to date the only validated therapeutic approach. CONCLUSIONS: MSL is supposed to be the result of a disorder of the proliferation and differentiation of human BAT cells.

Decellularized omentum as novel biologic scaffold for reconstructive surgery and regenerative medicine.

Homologous tissues, such as adipose tissue, may be an interesting source of acellular scaffolds, maintaining a complex physiological three-dimensional (3D) structure, to be recellularized with autologous cells. The aim of the present work is to evaluate the possibility of obtaining homologous acellular scaffolds from decellularization of the omentum, which is known to have a complex vascular network. Adult rat and human omenta were treated with an adapted decellularization protocol involving mechanical rupture (freeze-thaw cycles), enzymatic digestion (trypsin, lipase, deoxyribonuclease, ribonuclease) and lipid extraction (2-propanol). Histological staining confirmed the effectiveness of decellularization, resulting in cell-free scaffolds with no residual cells in the matrix. The complex 3D networks of collagen (azan-Mallory), elastic fibers (Van Gieson), reticular fibers and glycosaminoglycans (PAS) were maintained, whereas Oil Red and Sudan stains showed the loss of lipids in the decellularized tissue. The vascular structures in the tissue were still visible, with preservation of collagen and elastic wall components and loss of endothelial (anti-CD31 and -CD34 immunohistochemistry) and smooth muscle (anti-alpha smooth muscle actin) cells. Fat-rich and well vascularized omental tissue may be decellularized to obtain complex 3D scaffolds preserving tissue architecture potentially suitable for recellularization. Further analyses are necessary to verify the possibility of recolonization of the scaffold by adipose-derived stem cells in vitro and then in vivo after re-implantation, as already known for homologus implants in regenerative processes.

Breast prostheses and connective tissue disease (CTD): myth or reality?

Since their first appearance, breast prostheses have been criticized as being both responsible for and giving rise to systemic disease. The literature contains many reports on the subject, and theories were controversial from the 1980s to the 2000s. The aim of this review was to gather together the most important studies on breast prostheses and systemic disease, with particular attention to connective tissue disease (CTD), in order to verify any relationship between silicone breast implants and the occurrence of pathologies.

Weight gain related to treatment with atypical antipsychotics is due to activation of PKC-ß.

Atypical antipsychotics (APDs) are currently used in clinical practice for a variety of mental disorders such as schizophrenia, bipolar disorder and severe behavioral disturbances. A well-known disadvantage of using these compounds is a propensity for weight gain, resulting frequently in obesity. The mechanisms underlying pharmacologically induced weight gain are still controversial. The objective of this study was to evaluate in vitro the effects of different APDs on adipogenic events in cultured human pre-adipocytes and in rat muscle-derived stem cells (MDSCs), aiming to identify a common intracellular event contributable to these drugs. Culture behavior was evaluated in terms of cell proliferation, lipid accumulation, gene expression and morphological features. Results indicate that APDs influence adipogenic events through changes in the differentiation and proliferation of pre-adipocytes and MDSCs that are brought on by protein kinase C-ß (PKC-ß) activation. These data identify a signaling route that could be a potential target of pharmacological approaches for preventing the weight gain associated with APD treatment.

Hyaluronan based porous nano-particles enriched with growth factors for the treatment of ulcers: a placebo-controlled study.

The present study describes the production of hyaluronan based porous microparticles by a semi-continuous gas anti-solvent (GAS) precipitation process to be used as a growth factor delivery system for in vivo treatment of ulcers. Operative process conditions, such as pressure, nozzle diameter and HYAFF11 solution concentrations, were adjusted to optimize particle production in terms of morphology and size. Scanning electron microscopy (SEM) and light scattering demonstrated that porous nano-structured particles with a size of 300 and 900 nm had a high specific surface suitable for absorption of growth factors from the aqueous environment within the polymeric matrix. Water acted as a plasticizer, enhancing growth factor absorption. Water contents within the HYAFF11 matrix were analyzed by differential scanning calorimetry (DSC). The absorption process was developed using fluorescence dyes and growth factors. Immunohistochemical analysis confirmed the high efficiency of absorption of growth factor and a mathematical model was generated to quantify and qualify the in vitro kinetics of growth factor release within the polymeric matrix. In vivo experiments were performed with the aim to optimize timed and focal release of PDGF to promote optimal tissue repair and regeneration of full-thickness wounds.

Psychopathologic aspects of body dysmorphic disorder: a literature review.

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by the patient's excessive concern with an imagined or minor defect in physical appearance. Patients with BDD often have been observed in aesthetic surgery settings seeking surgical enhancement at a reported prevalence of 6% to 15%. Published studies in the general population tend to aggregate a prevalence of 0.7% to 2.3%. This review aimed to search the literature for data on the prevalence, psychopathologic aspects, and comorbidity of BDD, and to provide an update on current BDD research. Relevant literature was identified by searching the Medline, PubMed, PsycINFO, and EMBASE databases. The following search words were used alone or in combination when appropriate: "body dysmorphic disorder," "somatoform disorder," "obsessive compulsive spectrum disorder," "personality disorders," "presurgical counseling," "aesthetic surgery," "cosmetic surgery," and "plastic surgery." Further articles were sourced from the reference lists of the articles ascertained through the search. Recent findings include the relationship between BDD and the obsessive-compulsive spectrum, treatment of BDD based on pharmacologic and psychological approaches, and the hypothesis that the often distinguished delusional and nondelusional variants of BDD very likely are the expression of a single disorder with varying degrees of severity. Retrospective outcome studies suggest that patients affected by BDD typically do not benefit from surgical treatment. In contrast, serotonin reuptake inhibitors and cognitive-behavior therapy appear to be good practice in addressing the disorder. Further research is needed to identify effective interventions for patients who do not respond to these treatment methods.

Stable muscle atrophy in long-term paraplegics with complete upper motor neuron lesion from 3- to 20-year SCI.

STUDY DESIGN: Unrandomized trial. OBJECTIVES: To investigate the structural and functional relationships and the progression of muscle atrophy up to 20 years of spastic paraplegia. SETTING: Clinical follow-up in Vienna, Austria; muscle biopsies analyzed by light microscopy in Padova and by electron microscopy (EM) in Chieti, Italy. METHODS: Force was measured as knee extension torque; trophism by computer tomography scan; tissue composition and fiber morphology by histopathology and EM. RESULTS: In the long-term group of patients (17.0+/-2.6 years), force and size of thigh muscles were only slightly different from those of mid-term subjects (2.2+/-0.5 years). Histology and ultrastructure confirm that the difference in average size of muscle fibers between long-term and mid-term paralyzed leg muscles is actually very small. In addition, muscle fibers maintain the striated appearance characteristic of normal skeletal fibers even after 14-20 years of paralysis. Ultrastructural alterations of the activating and metabolic machineries, and the presence of fibers with lower motor neuron denervation features, may explain the low-force output and the reduced endurance of paretic muscles. CONCLUSION: The stable muscle atrophy that characterizes long-lasting spastic paraplegia suggests that there are no upper-time limits to begin a training program based on functional electrical stimulation.

Osteogenic and chondrogenic differentiation: comparison of human and rat bone marrow mesenchymal stem cells cultured into polymeric scaffolds.

Hyaluronan-based scaffold were used for in vitro commitment of human and rat bone marrow mesenchymal stem cells (MSC). Cells were cultured either in monolayer and in 3D conditions up to 35 days. In order to monitor the differentiating processes molecular biology and morphological studies were performed at different time points. All the reported data supported the evidence that both human and rat MSC grown onto hyaluronan-derived three-dimensional scaffold were able to acquire a unique phenotype of chondrocytes and osteocytes depending on the presence of specific differentiation inducing factors added into the culture medium without significative differences in term of time expression of extracellular matrix proteins.

Hyaluronan biodegradable scaffold for small-caliber artery grafting: preliminary results in an animal model.

OBJECTIVE: To evaluate a new Hyaluronan-based graft. MATERIAL AND METHODS: Hyaluronan-based grafts (HYAFF 11trade mark tube, diameter 2 mm, length 1.5 cm) were implanted in an end-to-end fashion in the abdominal aorta of 15 rats. Histology, immunohistochemistry and electron microscopy were used to evaluate the results at 7, 21, and 90 days. RESULTS: At day 7, new tissue was observed in the graft coming from both the proximal and distal ends of the aorta. The luminal surface of the regenerating tissue was covered by endothelial cells (CD34(+), VEGFR-2(+), vWF(+)). At day 21, regenerating tissue joined at the centre of the tube. The neo-vessel was formed by smooth muscle cells (Myosin Light Chain Kinase) as well as elastic, and collagen fibres. At day 90 a stable artery segment was formed and the biomaterial was almost completely degraded. Infiltration of neutrophils and lymphocytes was not observed. All animals survived the observation period and there were no signs of stenoses or aneurysms. CONCLUSION: The hyaluronan-based graft allowed complete regeneration of a newly formed vascular tube in which all the cellular and extracellular components are present and organized in a well defined architecture similar to native artery.

Extracellular matrix-enriched polymeric scaffolds as a substrate for hepatocyte cultures: in vitro and in vivo studies.

Tissue engineering is a promising approach to developing hepatic tissue suitable for the functional replacement of a failing liver. The aim of the present study was to investigate whether an extracellular cell matrix obtained from fibroblasts-cultured within scaffolds of hyaluronic acid (HYAFF) could influence the proliferation rate and survival of rat hepatocytes both during long-term culture and after in vivo transplantation. Cultures were evaluated by histological and morphological analysis, a proliferation assay and metabolic activity (albumin secretion). Hepatocytes cultured in extracellular matrix-enriched scaffolds exhibited a round cellular morphology and re-established cell-cell contacts, growing into aggregates of several cells along and/or among fibers in the fabric. Hepatocytes were able to secrete albumin up to 14 days in culture. In vivo results demonstrated the biocompatibility of HYAFF-11 implanted in nude mice, in which hepatocytes maintained small well-organised aggregates until the 35th day. In conclusion, the presence of a fibroblast-secreted extracellular matrix improved the biological properties of the hyaluronan scaffold, favoring the survival and morphological integrity of hepatocytes in vitro and in vivo.