Role of angiogenesis and angiogenic factors in acute and chronic wound healing

Angiogenesis plays a crucial role in wound healing by forming new blood vessels from preexisting vessels by invading the wound clot and organizing into a microvascular network throughout the granulation tissue.This dynamic process is highly regulated by signals from both serum and the surrounding extracellular matrix environment.Vascular endothelial growth factor,angiopoietin,fibroblast growth factor and transforming growth factor-beta are among the potent angiogenic cytokines in wound angiogenesis.Specific endothelial cell ECM receptors are critical for morphogenetic changes in blood vessels during wound repair.In particular integrin(αvβ3)receptors for fibrin and fibronectin,appear to be required for wound angiogenesis:αvβ3 is focally expressed at the tips of angiogenic capillary sprouts invading the wound clot,and any functional inhibitors ofαvβ3 such as monoclonal antibodies,cyclic RGD peptide antagonists,and peptidomimetics rapidly inhibit granulation tissue formation.In spite of clear knowledge about influence of many angiogenic factors on wound healing,little progress has been made in defining the source of these factors,the regulatory events involved in wound angiogenesis and in the clinical use of angiogenic stimulants to promote repair.

Inflatable pressure garment device for pressure therapy after chest wall keloid operation and radiotherapy

Aim: Keloids often occur on the chest wall, with high recurrence rates despite surgery and radiotherapy. Garment pressure therapy is commonly used to treat hypertrophic scars and keloids. Irregularity of the chest wall surface can inhibit the effects of the garment pressure therapy. This clinical study is to determine the effect of inflatable pressure garment in preventing keloid recurrence after keloid operation and radiotherapy. Methods: Chest wall keloid was removed and radiotherapy was administered at the surgical sites on the 1st and 7th postoperative days in 61 patients. An inflatable pressure garment device was designed and its pressure effect was confirmed by comparing it with the general pressure garment at the sites of the right and left infraclavicular area, manubrium and sternal area between breasts. The keloid patients were treated with inflatable pressure garment device 1 month after the operation. The clinical results were observed. Results: The detected pressures were 0.26 ± 0.21, 0.49 ± 0.16, 0.53 ± 0.10 and 0.91 ± 0.17 kPa at the sites of the right infraclavicular area, the manubrium area, the left infraclavicular area and sternal area between breasts with the general pressure garment. These were obvious lower (P < 0.05) than that generated with the inflatable pressure garment device of which the average pressures were 7.26 ± 0.41, 7.6 ± 0.32, 9.02 ± 0.54 and 10.31 ± 0.14 kPa at the corresponding sites.Sixty-one patients were treated with this device after keloid surgical excision and radiotherapy. Satisfactory results were observed. Conclusion: Appropriate and effective pressure can be generated with inflatable pressure garment on the chest wall. This device may be useful in preventing chest wall keloid recurrence after keloid operation and radiotherapy.

Efficacy and safety of poly-D,L-lactic acid microspheres as subdermal fillers in animals

Aim:This animal study aims to examine the efficacy and safety of poly-D,L-lactic acid(PDLLA)microspheres as subdermal fillers.Methods:Thirty 2-week-old male Sprague Dawley rats were used as test animals,and 0.5 mL filler solutions were injected into the subdermal tissues on their backs.Groups of five rats were randomly selected and sacrificed for examination on the 2nd,4th,8th,12th,16th,and 20th weeks after injection.Clinical and histological examinations were performed via the hematoxyline-eosin and immunohistochemical(IHC)staining of injected sites after collecting the injected masses.The body weights of the rats were measured,and the presence of filler substance in other organs was determined.Results:Injected volumes were stable from the 2nd to the 20th week after injection,and no abnormalities were observed around the injection sites.The injected substance did not migrate to the surrounding tissues.In IHC staining experiments,myofibroblasts were observed from the 2nd week,and collagen was detected from the 4th week.Myofibroblast was observed in the spaces between and inside the microspheres in the 8th week after injection,whereas type I collagen was found between and inside the microspheres at 8th and 12th weeks,respectively.Conclusion:The animal experiments confirm the efficacy and safety of injectable PDLLA as a subdermal filler.

Preoperative considerations, operative preparation,and postoperative care for rib cartilage use in rhinoplasty

Rib cartilage is the most reliable material for structural support and dorsal augmentation in Asian rhinoplasty with its robust strength and bountiful amount. Its value is incomparable especially in complex, cartilage-depleted revision surgery or major reconstruction. There are many articles regarding harvesting and carving of rib cartilage in rhinoplasty,however, only few has focused on preoperative and postoperative issues. Preoperatively, evaluating cartilage availability, assessing quality and quantity of cartilage, and choosing the cartilage to harvest are necessary. Although easily overlooked, proper postoperative management of rib cartilage rhinoplasty patients is key to prevent infection and heighten patient satisfaction. Here in, I would like to introduce how I evaluate rib cartilage rhinoplasty patients preoperatively and manage them postoperatively to maximize the surgical results.

Immediate iliac bone graft reconstruction of post ablative defect of benign mandibular pathology - a systematic review

Aim: Autogenous iliac crest bone graft is frequently used in immediate reconstruction of post ablation defect of benign mandibular pathologies. The aim of this study was to conduct a systematic literature review on the complication and failure rates with this technique and factors associated with failure. Methods: The initial literature search in PubMed and Cochrane databases identified 915 articles. Result: Of these, 7 were included in the final review. The majority of the studies were retrospective in nature. These articles encompassed 127 procedures with non-vascularized iliac crest bone graft;with complication rate of 13.3%and failure rate of 3.1%, most complications did not result in failure. All failures were due to infection with no main factor associated with failure. Conclusion: Use of non-vascularized iliac crest bone graft for immediate mandibular reconstruction appears to be associated with low complication and failure rates in carefully selected cases.

Tissue conditioning-strategies to improve perfusion and reduce ischemia-reperfusion injury

Ischemia as well as ischemia-reperfusion injury (IRI) can cause serious tissue damage and therefore is a feared complication in reconstructive surgery. This is the reason why researchers around the world invest their efforts to improve tissue viability after ischemic events. Tissue conditioning offers a broad scope of different techniques which can be applied pre-, peri- or postoperatively to adapt the affected tissue to the subsequent stress during and after ischemia to prevent or minimize IRI. The different ways of tissue conditioning in flap surgery include surgical delay, ischemic conditioning, remote ischemic conditioning as well as thermic preconditioning and other techniques, using growth factors, pharmaceutical agents, extracorporeal shock waves as well as stemm cells. Therefore, we want to shed some light on the effects of ischemia and ischemia-reperfusion injury and further illustrate the different strategies of tissue conditioning with special concern to flap surgery but also regarding wound healing in general.

Global facial rejuvenation, new technique

Facial aging is the combination of multiple effects such as sun exposure, tobacco, environmental stress and smog, reflecting the cumulative and dynamic effects of time on the skin, soft tissues and the deep structural components of the face that show an important change structural features of the skin and loss of facial volume. There are many different techniques currently used to perform face lifting, the ultimate goal is to get good results with respect for patient safety. This article describes a new approach to facial rejuvenation combining superficial musculoaponeurotic system (SMAS) plication elements on four vectors, with a blepharoplasty to achieve a lasting improvement in facial aging. The plication of the SMAS on the suture provides three vectors of elevation under the skin in the middle rhytidectomy, linked to the Lorè fascia and to the third platys elevation vector behind the ear. The blepharoplasty technique is often unavoidable in the execution of the global facial rejuvenation. This allows obtaining excellent results both in terms of aesthetic and of a good patient empowerment. This new surgical technique, called 'KORU technique', was used on 31 patients between October 2010 and October 2012, producing lasting results, reducing injuries and respecting anatomical planes. This approach can be safely and easily performed under local anesthesia as an isolated midface procedure, respecting and safeguarding the facial nerve. This type of chiropractic technique can be used by young surgeons.

Hyaluronic acid: a versatile biomaterial in tissue engineering

The design and application of hyaluronic acid (HA)-based scaffolds to control cell response and construct ideal tissue engineering products have been of great interest in the past few decades. This review provides an overview of the biological properties of HA to better understand how to engineer a cell-scaffold composite that is qualified in tissue engineering;important tissue engineering applications of HA including cartilage tissue engineering;and lastly, the problems of the current research on HA. All the data described above were collected and analyzed from PubMed, EMBASE and Medline.

Preoperative planning and breast implant selection for volume difference management in asymmetrical breasts

Aim: To assess volume management in patients presenting with breast asymmetry and ptosis. Methods: Retrospectively collected data was analysed. The patients were divided into 3 groups. Group A included patients who had volumetric difference alone and had different size implants alone. Group B included patients who had volumetric difference with breast ptosis requiring mastopexy with different size implants. Group C included patients who presented with breast asymmetry with ptosis and had same size implants on both sides with different volume breast reduction. Results: Subgroup A1 included 145 patients who had larger implants placed on right side. Subgroup A2 included 95 patients who had larger implants on the left side. Subgroup B1 included 7 patients who had larger implants on the right. Subgroup B2 included 13 patients who had larger implant on the left side. Subgroup C1 included 7 patients who had larger reduction on right side. Subgroup C2 included 11 patients who had larger reduction on left. Conclusion: When different volume implants are used, the vast majority of the patients do not require a volume difference of more than 60 mL. When the breast is larger on the right then larger mean volumes are used on left side to offset the larger right breast.

Clinical neurophysiology and imaging of nerve injuries:preoperative diagnostic work-up and postoperative monitoring

Peripheral nerve injuries are a heterogeneous group of lesions that may occurs secondary to various causes.Several different classifications have been used to describe the pathophysiological mechanisms leading to the clinical deficit,from simple and reversible compression-induced demyelination,to complete transection of nerve axons.Neurophysiological data localize,quantify,and qualify(demyelination vs.axonal loss)the clinical and subclinical deficits.High-resolution ultrasound can demonstrate the morphological extent of nerve damage,fascicular echotexture(epineurium vs.perineurium,focal alteration of the cross-section of the nerve,any neuromas,etc.),and the surrounding tissues.High field magnetic resonance imaging provides high contrast neurography by fat suppression sequences and shows structural connectivity through the use of diffusion-weighted sequences.The aim of this review is to provide clinical guidelines for the diagnosis of nerve injuries,and the rationale for instrumental evaluation in the preoperative and postoperative periods.While history and clinical approach guide neurophysiological examination,nerve conduction and electromyography studies provide functional information on conduction slowing and denervation to assist in monitoring the onset of re-innervation.High-resolution nerve imaging complements neurophysiological data and allows direct visualization of the nerve injury while providing insight into its cause and facilitating surgical treatment planning.Indications and limits of each instrumental examination are discussed.

Modified lower eyelid blepharoplasty improves aesthetic outcomes in patients with hypoplastic malar prominences

Aim: Aging affects the appearance of the eyelids and the surrounding malar region. Blepharoplasty improves the aesthetic appearance of this region, and multiple variants of the procedure have been reported. We here report our technique for modified lower lid blepharoplasty and cheek lift for patients with hypoplastic malar regions, which was introduced after observing prominent lower orbital rims in patients with flat malar prominences after blepharoplasty. Methods: This technique combines standard canthopexy and cheek-lift for rejuvenation of the mid-face with redraping of orbital fat and concurrent sub orbicularis oculi fat pad (SOOF) lift to 'double-breast' the lower orbital margin. Data on 33 patients who had undergone this modified lower lid blepharoplasty was collected retrospectively. Results: Thirty-three patients underwent the modified lower lid blepharoplasty resulting in smooth and youthful appearance of the malar region that was consistent and sustained. No recurrence of V-deformity was observed on a median follow-up of 14 months. twenty-two (66.6%) and 11 (33.3%) patients were pleased and satisfied with postoperative outcomes respectively. Three (9.1%) patients experienced minor postoperative complications and no major complication was observed. Conclusion: The proposed modified lower lid blepharoplasty is a safe and effective alternative to the existing technique with improved aesthetic outcomes and therefore is recommended in patients with flat malar prominences.

The key to costal cartilage in rhinoplasty

Autologous costal cartilage is an excellent source of graft in rhinoplasty due to its rich supply,durability,versatility,and functionality.For a long time,rhinoplasty surgeons have been critical of using autologous costal cartilage based on the potential for associated complications including donor site morbidities,postoperative pain,warping,and long operation time.Even with this criticism,costal cartilage is still a gra昀material of choice in cartilage depleting revision rhinoplasty.Recently,there has been a steady increase in costal cartilage use even in primary augmentation rhinoplasty,especially in Asian.

Augmentation mastopexy and augmentation mammoplasty:an analysis of 1,406 consecutive cases

Aim:Simultaneous augmentation mastopexy is a challenging operation for esthetic plastic surgeons.Complication and revision rates following augmentation mammoplasty or mastopexy are less commonly seen when these two procedures are performed separately.However,when the two procedures are combined,the complication rate is reported exponentially higher when compared with its individual component carried out separately.The current retrospective chart review is a comparative analysis of the two procedures performed by a single surgeon.Methods:Retrospective data were collected using patient’s charts.All patients who had augmentation mammoplasty(Group A)or simultaneous augmentation with mastopexy(Group B)in muscle splitting biplane using round cohesive gel textured silicone implants by a single surgeon were included.Results:A total of 1,406 patients had consecutive augmentation mammoplasty or simultaneous augmentation mastopexy.Augmentation mammoplasty(Group A)included 1,298 and simultaneous augmentation with mastopexy(Group B)had 108 patients,respectively.The mean age of the patients in Group A and B was 29.6 years and 32.2 years,respectively(P=0.006).The mean size of the implants in Group A and B was 340 mL and 308 mL(P=0.001),respectively.Wound infection in Group A and B was seen in 0.6%and 3.7%,respectively.Wound breakdown was seen in 1.1%in Group A as compared to 6.5%in Group B(P=0.001).Revision surgeries were performed in 1.4%and 11.1%of Group A and B,respectively(P=0.001).Conclusion:There was a statistically and clinically significant higher rate of complications and revision rate noted in simultaneous augmentation with mastopexy(Group B)as compared to augmentation mammoplasty alone(Group A).However,the rise in complications rate is sum of the complications of the two individual components performed and not exponential.

Synergistic effect of hyperbaric oxygen preconditioning and hydrogen-rich saline in ameliorating rat flap ischemia/reperfusion injury

Aim:This study was conducted to evaluate the synergistic effects of hyperbaric oxygen(HBO)preconditioning and hydrogen-rich saline(HRS)treatment on skin flap survival and apoptosis in a rat ischemia/reperfusion(IR)skin flap model.Methods:Male Sprague-Dawley rats were randomly divided into five groups:one sham surgery group(sham group)and four surgery groups(IR group,HBO group,HRS group,and HBO+HRS group).An extended epigastric adipocutaneous flap(6 cm×9 cm)was raised over the abdomen in each animal of all five groups.The last four groups underwent 6 h of IR management and were treated,respectively,with normal saline,HBO,HRS(HRS,0.8 mmol/L),or a combined approach(HBO and HRS).On the 3rd postoperative day,flap survival rate and perfusion condition,apoptotic index,caspase-3 activity,protein expression of pASK1 and Bcl-2/Bax ratio,and Bcl-2 messenger RNA(mRNA)expression were assessed.Results:Prior studies have shown the protective effects of HBO and HRS,both of which have been associated with an increase in flap survival.Compared to the IR group,the flaps in the HBO,HRS,and HBO+HRS groups showed better perfusion and a larger survival area with a low number of apoptotic cells,low caspase-3 activity and pASK1 expression,and a high Bcl-2/Bax ratio and Bcl-2 mRNA expression.Of these groups,the HBO+HRS group showed the best flap survival.Conclusion:Both HBO and HRS treatments increase the rate of flap survival,while the synergistic application of HBO and HRS showed a higher survival rate as compared to individual treatments of each.The potential regulation of apoptosis with the use of these two modalities may improve skin flap survival.

Current role in facial allograft transplantation:what have we learned?

Face transplant(FT)has evolved enormously in the last 10 years since the successful completion of the first facial transplant.This procedure has become a new reconstructive option for complex facial deformities to restore the anatomy of patients with severely disfigured faces.The authors review the literature and discuss the main surgical,immunological,and ethical aspects as well as the results described in patients undergoing FT.To date there have been more than thirty FT worldwide.The main indication was post-traumatic deformity.In all cases a standard immunosuppression was performed with three drugs,although acute rejection episodes were observed,that could be controlled with conventional immunosuppressive regimen.Overall,functional and aesthetic results have been excellent at short-term and high satisfaction rate exceeded initial expectations,although long-term data are still scarce.Major complications were opportunistic infections.Five deaths that occurred have reopened the ethical debate about the potential complications and concerns of providing informed consent to recipients.Continuous progresses in microsurgical techniques and preoperative planning have promoted the evolution from partial to full FT.All these are on the basis of accurate and careful selection of well-motivated candidates.The next challenge will be getting new immunosuppressive treatment strategies.Although clinical experience has demonstrated the FT viability,it is still considered an experimental procedure in which we have much to learn to define its true role in the current reconstructive surgery and resolve major technical,medical and ethical problems involved.

Reconstruction of palate with buccal fat pad secondary to resection of desmoplastic ameloblastoma

Desmoplastic ameloblastoma(DA)is an unusual variant of ameloblastoma exhibiting important differences in the anatomical distribution,radiographic features and histologic appearance compared with the classic type of ameloblastoma.The purpose of this paper is to report a case of DA in the anterior left maxilla and to describe a simple method of reconstruction with the use of buccal fat pad(BFP).BFP is an excellent choice for reconstruction of small to medium sized defects.It should be manipulated gently and hemostasis should be achieved meticulously during this surgery.It should not be sutured under tension.

The keystone-design perforator-based flap for leg defects: a synthesis of philosophies

Aim:The classical keystone-design flap,although elegantly employed for various trunk defects,has limited movement on the leg.This study aims to modify the keystone–design flaps for leg defects.Methods:A keystone-design flap,in which perforators are identified and dissected,is described specifically for elliptical defects overlying the tibia.Results:It retains the unique advantages of both the perforator island flap concept as well as the keystone-design philosophy.Conclusion:The technique as well as the possibilities of raising such flaps over various areas of the leg is outlined.

Painful scar neuropathy:principles of diagnosis and treatment

Nerve-tissue interactions are critical.Peripheral nerve injuries may involve intraneural and extraneural scar formation and affect nerve gliding planes,sometimes leading to complex clinical presentations.All of these pathological entities involve pain as the main clinical symptom and can be subsumed under the term“painful scar neuropathy”.The authors review the literature on treatment approaches to peripheral nerve scar neuropathy and the outcomes of neurolysis-associated procedures and propose a simple classification and a therapeutic approach to scar neuropathy.The search retrieved twenty-one papers,twenty of which reported pain reduction or resolution with various techniques.There is no consensus on the best therapeutic approach to neuropathic pain due to scar tethering.Most authors report good or excellent results with different techniques,from nerve wrapping with anti-adhesion devices to nerve coverage or wrapping with vascularized tissue.The authors’classification of and therapeutic approach to peripheral nerve scar lesions aims at promoting a logical approach based on the analysis of lesion type(perineural,or endoneural and perineural),pain type(due to traction or external trauma,pain at rest),and number of previous operations.Patients need to be informed that multiple procedures may be required,that outcomes may be partial,and that surgery can potentially worsen preoperative conditions.The review found no evidence for the best therapeutic approach to scar neuropathy,but there is consensus on a multidisciplinary approach.

Revision rhinoplasty using autologous rib cartilage in Asians

A considerable part of revision rhinoplasty in Asians is associated with problems arising from the use of alloplastic implants. Revising alloplast associated problems of the nose mostly requires the use pf autogenous grafting material to minimize complications and maximize favorable outcomes. Although remnant septal cartilage and/or conchal cartilage can be used, as the deformity becomes more severe, adequate revision requires more volume and strength of grafting materials. Autogenous rib cartilage may be the most practical choice in these circumstances. In this review, common causes of revision rhinoplasty in Asians are discussed together with operative techniques with emphasis on the use of autologous rib cartilage.

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Aim:Free tissue transfer is essential for extremity reconstruction following traumatic injuries,oncologic resection,and diabetic complications.However,given the circumferential shape of the arm and leg,a small amount of ongoing edema can prevent a tension-free closure.Additionally,intraoperative thrombosis,vascular disease can lead to proximal exposure of the pedicle or vein grafts.This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle,in comparison with a matched cohort with a tension-free primary closure.Methods:A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution.Flaps that utilized skin grafting for closure were compared to those closed primarily.Adjunct operative procedures,demographics,and complications were evaluated.Results:A total of 71 patients fulfilled the inclusion criteria.The 11 flaps in 10 patients underwent skin grafting over the pedicle.The two cohorts were comparable in age,gender,BMI,and co-morbidities,excluding renal disease which was present in 40%(n=4)of skin grafted group compared to 6.5%(n=4)in the primary closure group.Flap area,operative time,and anastomosis technique were comparable between the two groups.There was no significant difference in the rates of post-operative complications including partial flap loss,complete flap loss,infection.Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group. ;Conclusion:As per the principal,a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle.However,with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.