Myofibroblasts reside in the middle dermis of the keloids but do not predict the response to injection therapies: a double-blinded, randomized, controlled trial.

Introduction: Keloids form as a pathological response to skin wound healing, and their etiopathology is poorly understood. Myofibroblasts, which are cells transformed from normal fibroblasts, are believed to contribute to pathological scar formation in wounds. Methods: We carried out a double-blinded randomized controlled trial (RCT) comparing the efficacy of intralesional 5-fluorouracil (5-FU) and triamcinolone (TAC) injections in treating keloids. A total of 43 patients with 50 keloids were treated with either intralesional TAC or 5-FU injections, and their clinical response was evaluated. Biopsies were collected before, during, and after injection therapy from the active border of a keloid. To understand the role of myofibroblasts in keloids, we conducted an immunohistochemical analysis to identify myofibroblasts [α-smooth muscle actin (αSMA)] from the biopsies. We first defined the three histologically distinct regions-superficial, middle, and deep dermis-in each keloid. Results: We then demonstrated that myofibroblasts almost exclusively exist in the middle dermis of the keloids as 80% of the cells in the middle dermis were αSMA positive. However, both the percentage of myofibroblasts as well as the area covered by them was substantially lower in the superficial and deep dermis than in the middle dermis of the keloids. Myofibroblasts do not predict the clinical response to intralesional injection therapies. There is no difference in the myofibroblast numbers in keloids or in the induced change in myofibroblasts between the responders and non-responders after treatment. Discussion: This study demonstrates that myofibroblasts reside almost exclusively in the middle dermis layer of the keloids, but their numbers do not predict the clinical response to intralesional injection therapies in the RCT.

Adipose tissue as a source of growth factors to promote wound healing: a human study of skin graft donor sites.

OBJECTIVE: In the microenvironment of wound sites, naturally occurring growth factors are crucial for cell migration, opsonisation, chemotaxis, differentiation and angiogenesis. Exogenous growth factors, such as platelet-rich plasma (PRP) and adipose tissue, also improve healing. METHOD: In the present within-subject study, we described the effects of PRP and adipose tissue extract (ATE) on skin graft donor site wound healing in patients requiring split-thickness skin grafts. Each patient, having at least two donor sites, received both control (no growth factor) and experimental (PRP or ATE) treatments. Wounds were evaluated on days 5, 7, 10, 15, 30 and 60. Digital photography and spectral images were used to analyse haemoglobin and melanin content, and re-epithelialisation area. Pain was assessed by visual analogue scale. Scar characteristics were scored on days 30 and 60. Biomaterial samples were analysed for growth factor and protein content. RESULTS: The study included 24 patients (18 male and six female; mean age: 59.1 years). PRP was topically applied to wounds in 11 patients (13 donor sites) and ATE in 13 patients (15 sites). ATE-treated donor sites exhibited significantly accelerated wound re-epithelialisation on days 5 and 7 compared with control sites (p=0.003 and 0.04, respectively). PRP accelerated healing on day 7 compared with control sites (p=0.001). Additionally, the application of ATE improved scar quality on days 30 and 60 (p=0.0005 and 0.02, respectively). Pain scores did not differ significantly between treatments. CONCLUSION: In this study, both growth factor sources stimulated wound healing. ATE is an alternative source of growth factors that promote early wound healing and improve scar quality.

Surgical and oncological outcomes after hindquarter amputation for pelvic sarcoma.

AIMS: Survival rates and local control after resection of a sarcoma of the pelvis compare poorly to those of the limbs and have a high incidence of complications. The outcome for patients who need a hindquarter amputation (HQA) to treat a pelvic sarcoma is poor. Our aim was to evaluate the patient, tumour, and reconstructive factors that affect the survival of the patients who undergo HQA for primary or recurrent pelvic sarcoma. METHODS: We carried out a retrospective review of all sarcoma patients who had undergone a HQA in a supraregional sarcoma unit between 1996 and 2018. Outcomes included oncological, surgical, and survival characteristics. RESULTS: A total of 136 patients, with a mean age of 51 (12 to 83) underwent HQA, 91 for a bone sarcoma and 45 for a soft tissue sarcoma. The overall survival (OS) after primary HQA for a bone sarcoma was 90.7 months (95% confidence interval (CI) 64.1 to 117.2). In patients undergoing a secondary salvage HQA it was 90.3 months (95% CI 58.1 to 122.5) (p = 0.727). For those treated for a soft tissue sarcoma (STS), the mean OS was 59.3 months (95% CI 31.1 to 88.6) for patients with a primary HQA, and 12.5 months (95% CI 9.4 to 15.5) for those undergoing a secondary salvage HQA (p = 0.038). On multivariate analysis, high histological grade (hazard ratio (HR) 2.033, 95% CI 1.127 to 3.676; p = 0.018) and a diagnosis of STS (HR 1.653, 95% CI 1.027 to 2.660; p = 0.039) were associated with a poor prognosis. The 30-day mortality for patients with curative intent was 0.8% (1/128). For those in whom surgery was carried out with palliative intent it was 33.3% (2/6) (p = 0.001). In total, 53.7% (n = 73) of patients had at least one complication with 23.5% (n = 32) requiring at least one further operation. Direct closure was inferior to flap reconstruction in terms of complete primary wound healing (60.0% (3/5) vs 82.0% (82/100); p = 0.023). CONCLUSION: In carefully selected patients HQA is associated with satisfactory overall survival, with a low risk of perioperative mortality, but considerable morbidity. However, caution must be exercised when considering the procedure for palliation due to the high incidence of early postoperative mortality. Cite this article: Bone Joint J 2020;102-B(6):788-794.

Histopathology and immunohistochemical analysis of 5-fluorouracil and triamcinolone treated keloids in double-blinded randomized controlled trial.

Keloids are a major complication related to surgical wound healing and very challenging condition to treat. Many treatment options are available, but the efficacy of the treatment is poor in most of cases and some keloids do not respond to the treatment at all. We compared the efficacy of intralesional 5-fluorouracil (5-FU) and triamcinolone (TAC) injections in a double-blind randomized controlled trial (RCT). Forty-three patients with 50 keloid scars were treated with either intralesional TAC or 5-FU-injections over 6 months. We wanted to find out whether biological features (cell density, cell proliferation rate, vascular density, myofibroblast numbers, steroid hormone receptor expression) in keloids could be used to predict the response to therapy and define the biological changes that take place in patients receiving a response. As there was no statistically significant difference in the remission rate between TAC and 5-FU treatments, all patients were combined and analyzed as responders and nonresponders. Although responders have slightly more myofibroblasts than the nonresponders in their keloids in the pretreatment biopsy samples, we could not identify a single predictive factor that could identify those patients that respond to drug injections. The good clinical response to therapy is associated with the simultaneous reduction of myofibroblasts in the keloid. This study demonstrates that myofibroblasts are reduced in number in those keloids that were responsive to therapy, and that both 5-FU and TAC injections are useful for keloid treatment.

Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results.

INTRODUCTION: Pelvic exenteration (PE) is the only curative treatment for certain locally advanced intrapelvic malignancies. PE has high morbidity, and optimal reconstruction of the pelvic floor remains undetermined. MATERIALS AND METHODS: A retrospective chart review was performed at a tertiary university center to assess the surgical and oncological outcomes of 39 PE procedures over a 12-year period. The majority of patients (n = 25) underwent transverse musculocutaneous gracilis (TMG) flap reconstruction for pelvic floor reconstruction. RESULTS: The 1- and 5-year overall survival (OS) was 72% (95%CI 58%-86%) and 48% (95%CI 31%-65%), respectively. In multivariate analysis, lymph node metastasis (HR 3.070, p = 0.024) and positive surgical margins (HR 3.928, p = 0.009) were risk factors for OS. In this population, 71.8% of the patients had at least one complication. The complication rate was 65.4% and 84.6% for patients with versus without flap reconstruction, respectively (p = 0.191). The length of stay was longer for patients with a major complication 16,0 ±â€¯5,9 days vs. 29,4 ±â€¯14,8 days, p = 0,001, but complications did not affect OS. CONCLUSION: For selected patients, PE is a curative option for locally advanced, residual, or recurrent intrapelvic tumors. Pelvic floor and vulvovaginal defects can reliably be reconstructed using TMG flaps. TMG flaps are favored in our institution over abdominal-based flaps because the donor site morbidity is reasonable and TMG does not interfere with enterostomy.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy.

BACKGROUND: Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). METHODS: A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. RESULTS: The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. DISCUSSION: Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri­operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

Adipose tissue extract shows potential for wound healing: in vitro proliferation and migration of cell types contributing to wound healing in the presence of adipose tissue preparation and platelet rich plasma.

Growth factors are the key elements in wound healing signaling for cell migration, differentiation and proliferation. Platelet-rich plasma (PRP), one of the most studied sources of growth factors, has demonstrated to promote wound healing in vitro and in vivo. Adipose tissue is an alternative source of growth factors. Through a simple lipoaspirate method, adipose derived growth factor-rich preparation (adipose tissue extract; ATE) can be obtained. The authors set out to compare the effects of these two growth factor sources in cell proliferation and migration (scratch) assays of keratinocyte, fibroblast, endothelial and adipose derived stem cells. Growth factors involved in wound healing were measured: keratinocyte growth factor, epidermal growth factor, insulin-like growth factor, interleukin 6, platelet-derived growth factor beta, tumor necrosis factor alfa, transforming growth factor beta and vascular endothelial growth factor. PRP showed higher growth factor concentrations, except for keratinocyte growth factor, that was present in adipose tissue in greater quantities. This was reflected in vitro, where ATE significantly induced proliferation of keratinocytes at day 6 (p < 0.001), compared to plasma and control. Similarly, ATE-treated fibroblast and adipose stem cell cultures showed accelerated migration in scratch assays. Moreover, both sources showed accelerated keratinocyte migration. Adipose tissue preparation has an inductive effect in wound healing by proliferation and migration of cells involved in wound closure. Adipose tissue preparation appears to offer the distinct advantage of containing the adequate quantities of growth factors that induce cell activation, proliferation and migration, particularly in the early phase of wound healing.

Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.

BACKGROUND: Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. METHODS: Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. RESULTS: The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. CONCLUSIONS: Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. LEVEL OF EVIDENCE: IV, therapeutic.

The dermis graft: another autologous option for acute burn wound coverage.

BACKGROUND: Split-thickness skin autografts are the gold-standard in providing permanent acute wound closure in major burns. Split-thickness dermal grafts harvested from the same donor site may provide an additional autologous option for permanent acute coverage and increase the number of potential autologous donor sites. MATERIALS AND METHODS: We performed 16 dermis grafts (DG) harvested from the skin of the back in 9 consecutive burn patients. A control donor site consisted of an area of adjacent back skin from which a standard split-thickness skin graft was harvested. The mean age was 63 years (range 23-79 years). The mean initial burn size was 24% TBSA (range 2-40% TBSA). The size of the 16 DG recipient wound beds ranged from 20 to 180 cm2, with mean and median sizes of 62 and 45 cm2, respectively. RESULTS: Dermis graft take was complete in 15/16 cases. All grafts recorded >90% epithelialisation by 4 weeks. There was no significant difference in dermis graft and control donor site healing times (p value 0.05). CONCLUSION: Dermis grafts can provide an additional autologous option for permanent coverage in acute major burn wounds without increasing donor site size or morbidity.

Suprathel(®) causes less bleeding and scarring than Mepilex(®) Transfer in the treatment of donor sites of split-thickness skin grafts.

Split-thickness skin grafts are routine in the treatment of deep dermal burns and various other wounds. Healing of the donor site of the graft has an impact on the total recovery of the patient. We conducted a prospective clinical study at Tampere University Hospital to compare the effect of two adhesive wound dressings, Suprathel(®) and Mepilex(®) Transfer. The donor sites of 22 split-thickness skin grafts were studied, each of which was covered with Suprathel(®) and Mepilex(®) Transfer dressings side by side. Significantly less pain and bleeding was associated with Suprathel(®) treatment compared with Mepilex(®) Transfer (p < 0.05). Suprathel(®) produced a better scar at the three months' follow-up as measured using the Vancouver Scar Scale (VSS). The results show that Suprathel(®) is a better dressing for the donor sites than Mepilex(®) Transfer.

How to assess scar hypertrophy--a comparison of subjective scales and Spectrocutometry: a new objective method.

Scar hypertrophy is a significant clinical problem involving both linear scars from elective surgery and scars caused by trauma or burns. The treatment of hypertrophic scars is often time consuming, and patients may need to be followed up for months or even years. The methods for reliable quantification of scar hypertrophy are at present unsatisfying. We have developed a new, objective method, Spectrocutometry, for documentation and quantification of scar hypertrophy. The instrument is based on standardized digital imaging and spectral modeling and calculates the estimated concentration change of hemoglobin and melanin from the entire scar and also provides standardized images for documentation. Three plastic surgeons have assessed 37 scars from melanoma surgery using Spectrocutometry, the Vancouver scar scale, and the patient and observer scar assessment scale. The intraclass correlation coefficient for the Vancouver scar scale and the patient and observer scar assessment scale was lower than required for reliable assessment (r=0.66 and 0.60, respectively). The intraclass correlation coefficient for Spectrocutometry was high (r=0.89 and 0.88). A Bayesian network analysis revealed a strong dependency between the estimated concentration change of hemoglobin and scar pain. Spectrocutometry is a feasible method for measuring scar hypertrophy. It is shown to be more reliable than subjective rating in assessing linear surgical scars.

Objective scar assessment--a new method using standardized digital imaging and spectral modelling.

INTRODUCTION: Quantitative assessment of scars is needed in clinical practice and in scientific studies. To date, there have been no entirely objective methods available for these purposes. We introduce a new method developed for scar assessment combining standardized digital imaging (SDI) and spectral modelling (SpM). With this method, the estimated concentration changes (ECCs) of haemoglobin and melanin in the scar can be determined quantitatively. PATIENT AND METHODS: In the current study, 22 skin graft donor site (SGDS) wounds were treated with two alternative dressing materials, Suprathel® and Mepilex Transfer®, side by side on the same wound. The SGSD scars were assessed using SDI and SpM. The scars were given subjective ratings by three surgeons using the POSAS and the Vancouver Scar Scale (VSS). The correlations between the ECCs of melanin and haemoglobin and the corresponding subjective ratings were calculated as well as the Intraclass Correlation Coefficient (ICC) of the subjective ratings. RESULTS: There was a statistically significant correlation between the ECCs of melanin and haemoglobin and the subjective ratings. A single observer could reliably assess pigmentation with the POSAS scale (ICC = 0.75) but not vascularity (ICC = 0.51). The reliability ratings of the VSS were unacceptably low. CONCLUSIONS: The ECC values of haemoglobin and melanin give accurate documentation of the scar status. The results also show that the subjective ratings in this study were unreliable especially when interfering pigmentation and increased vascularity were both present at the same time.