In Vivo Comparison of Synthetic Macroporous Filamentous and Sponge-like Skin Substitute Matrices Reveals Morphometric Features of the Foreign Body Reaction According to 3D Biomaterial Designs.

Synthetic macroporous biomaterials are widely used in the field of skin tissue engineering to mimic membrane functions of the native dermis. Biomaterial designs can be subclassified with respect to their shape in fibrous designs, namely fibers, meshes or fleeces, respectively, and porous designs, such as sponges and foams. However, synthetic matrices often have limitations regarding unfavorable foreign body responses (FBRs). Severe FBRs can result in unfavorable disintegration and rejection of an implant, whereas mild FBRs can lead to an acceptable integration of a biomaterial. In this context, comparative in vivo studies of different three-dimensional (3D) matrix designs are rare. Especially, the differences regarding FBRs between synthetically derived filamentous fleeces and sponge-like constructs are unknown. In the present study, the FBRs on two 3D matrix designs were explored after 25 days of subcutaneous implantation in a porcine model. Cellular reactions were quantified histopathologically to investigate in which way the FBR is influenced by the biomaterial architecture. Our results show that FBR metrics (polymorph-nucleated cells and fibrotic reactions) were significantly affected according to the matrix designs. Our findings contribute to a better understanding of the 3D matrix tissue interactions and can be useful for future developments of synthetically derived skin substitute biomaterials.

Ischaemic Preconditioning Suppresses Necrosis of Adipocutaneous Flaps in a Diabetic Rat Model Regardless of the Manner of Preischaemia Induction.

Ischaemic insult in the skin flaps is a major problem in reconstructive surgery particularly in patients with diabetes mellitus. Here, we sought to investigate the effectiveness of ischaemic preconditioning (IP) on diabetic skin flaps in rat animal model. Hundred Wistar rats (90 streptozotocin treated animals and 10 nondiabetic controls) were used. Diabetes mellitus was confirmed by measuring glucose level in blood, HbA1c, and ketonuria. We used blood vessel clamping, hind limb tourniquet, and NO donors (Spermine/NO complex) to induce short-term ischaemia of tissues that will be excised for skin flaps. Animals were followed for 5 days. Flaps were photographed at day 5 and percent of necrosis was determined using planimetry. Significant decrease in percent of necrotic tissue in all groups that received preconditioning was observed. Results show that ischaemic preconditioning suppresses flap necrosis in diabetic rats irrespective of direct or remote tissue IP and irrespective of chemically or physically induced preischaemia. Spermine/NO complex treatment 10 minutes after the flap ischaemia suppressed tissue necrosis. Treatment with NO synthase inhibitor L-NAME reversed effects of IP showing importance of NO for this process. We show that IP is a promising approach for suppression of tissue necrosis in diabetic flaps and potential of NO pathway as therapeutic target in diabetic flaps.

Ship's doctors qualifications required for cruise ships: Recruiter's comments on the German-Norwegian debate.

This contribution is intended to fertilise the current discussion of ship's doctors qualifications required for cruise ships. Therefore 10 points are added to the debate containing different considerations focussing on the recommendations of the German Society of Maritime Medicine, the American College of Emergency Physicians (ACEP's) Health Care Guidelines for Cruise Ship Medical Facilities and the different skills a ship's doctor should have from the perspective of the recruiter.

Accidental inclusions following blast injury in esthetical zones: ablation by a hydrosurgery system.

In case of blast injuries, traumatic tattoos can result from accidental inclusions of intradermal pigmented particles. To avoid these tattoos, especially in esthetical areas like the head and neck region and the hands, the primary goal in our treatment is to remove all particles and foreign bodies. Superficial foreign bodies can easily be removed by brushes or dermabrasion. Deeper lesions are a challenge for plastic surgeons, because they are not so easily removed. Ablation by a water jet surgical tool, the Versajet-system (Smith & Nephew Inc, Andover, MA), enables the removal of nearly all particles and foreign bodies, which sustained a blast injury of the face or the hands. Aim of this paper is to describe the method of using this hydrosurgery system in blast injuries in esthetical zones and its advantages by presenting cases of two patients of us.

Prospective randomized phase II Trial of accelerated reepithelialization of superficial second-degree burn wounds using extracorporeal shock wave therapy.

BACKGROUND: As extracorporeal shock wave therapy (ESWT) can enhance healing of skin graft donor sites, this study focused on shock wave effects in burn wounds. METHODS: A predefined cohort of 50 patients (6 with incomplete data or lost to follow-up) with acute second-degree burns from a larger study of 100 patients were randomly assigned between December 2006 and December 2007 to receive standard therapy (burn wound debridement/topical antiseptic therapy) with (n = 22) or without (n = 22) defocused ESWT (100 impulses/cm at 0.1 mJ/mm) applied once to the study burn, after debridement. Randomization sequence was computer-generated, and patients were blinded to treatment allocation. The primary endpoint, time to complete burn wound epithelialization, was determined by independent, blinded-observer. A worst case scenario was applied to the missing cases to rule out the impact of withdrawal bias. RESULTS: Patient characteristics across the 2 study groups were balanced (P > 0.05) except for older age (53 ± 17 vs. 38 ± 13 years, P = 0.002) in the ESWT group. Mean time to complete (≥95%) epithelialization (CE) for patients that did and did not undergo ESWT was 9.6 ± 1.7 and 12.5 ± 2.2 days, respectively (P < 0.0005). When age (continuous variable) and treatment group (binary) were examined in a linear regression model to control the baseline age imbalance, time to CE, age was not significant (P = 0.33) and treatment group retained significance (P < 0.0005). Statistical significance (P = 0.001) was retained when ESWT cases with missing follow-up were assigned the longest time to CE and when controls with missing follow-up were assigned the shortest time to CE. CONCLUSIONS: In this randomized phase II study, application of a single defocused shock wave treatment to the superficial second-degree burn wound after debridement/topical antiseptic therapy significantly accelerated epithelialization. This finding warrants confirmation in a larger phase III trial (ClinicalTrials.gov identifier: NCT01242423).

Method for autologous single skin cell isolation for regenerative cell spray transplantation with non-cultured cells.

BACKGROUND: There is a therapeutic gap for patients with deep partial thickness wounds (Grade IIb) of moderate size that were initially not treated with split- or mesh grafting to avoid overgrafting, but developed delayed wound healing around two weeks after injury--at which time grafting is typically not indicated anymore. Delayed wound healing is often associated with esthetically unsatisfactory results and sometimes functional problems. An innovative cell isolation method for cell spray transplantation at the point of care, which eliminates cell culture prior to treatment, was implemented for this population of burn patients in our center. METHODS: Autologous skin cell spray transplantation was initiated by taking healthy skin. The dermal/epidermal layers were separated using enzymatic digestion with 40 min dispase application, followed by 15 min trypsin application for basal kerationcyte isolation, 7 min cell washing by centrifugation, followed by transferring the cells for spraying into Ringer lactate solution. The procedure was performed on site in a single session immediately following the biopsy. After sharp wound debridement, cells were immediately transplanted by deposition with a cell sprayer for even distribution of the cell suspension. RESULTS AND CONCLUSIONS: Eight patients were treated (mean age 30.3 years, mean burn total body surface area 14%, mean Abbreviated Burn Severity Index (5 points). The mean time to complete re-epithelialization was 12.6 days. All patients exhibited wound healing with improved esthetic and functional quality. Our initial experience for the use of non-cultured cells using a two-enzyme approach with cell washing suggests shortened time for wound closure, suggesting that the method may potentially avoid longer-term complications.

"The Maestro": a pioneering plastic surgeon--Sir Archibald McIndoe and his innovating work on patients with burn injury during World War II.

This article describes McIndoe's revolutionary methods of burn treatment and rehabilitation of patients with burn injury and outlines his personality traits that made him one of the most important plastic surgeons of the twentieth century. As a consultant plastic surgeon to the Royal Air Force, he set up a plastic surgery unit in the Queen Victoria Hospital in East Grinstead. By using biographical data and photography, McIndoe's work on burns treatment and the challenges he faced are presented. Before World War II, little was known about the treatment of severe burns and their complications, and even less was done about the rehabilitation and social reintegration of patients with burn injury. McIndoe changed all that by developing new techniques for the management and reconstruction of burn injuries. He helped his patients become and get accepted as a normal part of society again. The patients with burn injury treated by him formed the Guinea Pig Club. Sir Archibald Hector McIndoe, a charismatic plastic surgeon with an uncanny instinctive knowledge of psychology, recognized early that the rehabilitation of a burned patient was as important as the reconstruction of his physical body. His therapeutic approach to patients with burn injury was mental and physical.

Intravital monitoring of microcirculatory and angiogenic response to lactocapromer terpolymer matrix in a wound model.

The aim of this study was to assess the impact of an epidermal substitute, a lactocapromer terpolymer matrix, on microcirculation in wounds. Lactocapromer terpolymer matrices were placed into the dorsal skinfold chamber of mice (n = 10). Untreated chamber preparations served as controls (n = 10). The microcirculation in tissue adjacent to the implant was observed by intravital fluorescence microscopy. Alongside the stable microhaemodynamics, a strong induction of angiogenesis adjacent to the implants was observed. A progressive increase in the functional vessel density was detected throughout the observation time of 10 days. Additionally, a stable and increasing perfusion within the newly developed vascular network in the outer circumference of the matrix was noted. The lactocapromer terpolymer matrix showed no adverse effect on the microcirculation in the host tissue. In contrast, as detected by intravital microscopy, the biomaterial protected the microcirculation and induced angiogenesis.

Accelerated angiogenic induction and vascular integration in a novel synthetic scaffolding matrix for tissue replacement.

PURPOSE: Reduced or delayed neovascularization is a major obstacle with regard to tissue-engineered constructs. The aim of this study was to evaluate the early microvascular response to a novel degradable ε-caprolactone terpolymer matrix. METHODS: ε-caprolactone terpolymer matrices (Suprathel Plus®; Institute of Textile and Process Engineering, Denkendorf, Germany) were implanted into dorsal skinfold chambers of balb/c mice (n=10). Microcirculatory changes were observed by intravital fluorescence microscopy. Scaffolding matrices from PEGT/PBT copolymer were used as controls (n=10). RESULTS: The formation of de novo vascular networks within both scaffolding matrices was noted throughout the experiment. A vascular ingrowth of perfused microvessels into the matrices up to 600 µm apart from the edge was noted within 10 days of implantation. The earliest signs of neoangiogenesis were visible in ε-caprolactone terpolymer matrices on day 1. In both scaffolds the new developed vessels extended centripetally from the border of the matrices towards the center and anastomosed to form a perfused microvascular network. There was significantly earlier onset of vascularization, increased vascularized area and higher vessel density in ε-caprolactone terpolymer matrices compared to PEGT/PBT copolymer matrices were observed. CONCLUSIONS: The scaffolding matrix from ε-caprolactone terpolymer allowed for an earlier and more intense induction of angiogenesis and displayed the tendency to vascularize more rapidly within a shorter period of time after transplantation compared to PEGT/PBT copolymer scaffolds, thus indicating its potential application for tissue engineering purposes.

Prospective randomized trial of accelerated re-epithelization of skin graft donor sites using extracorporeal shock wave therapy.

BACKGROUND: Extracorporeal shock wave therapy may enhance revascularization and repair of healing soft tissue. METHODS: Between January 2006, and September 2007, 28 patients with acute traumatic wounds and burns requiring skin grafting were randomly assigned in a 1:1 fashion to receive standard topical therapy (nonadherent silicone mesh [Mepitel, Mölnlycke Health Care] and antiseptic gel [polyhexanide/octenidine]) to graft donor sites with (n = 13) or without (n = 15) defocused extracorporeal shock wave therapy (ESWT, 100 impulses/cm(2) at 0.1 mJ/mm(2)) applied once to the donor site, immediately after skin harvest. The randomization sequence was computer generated, and the patients were blinded to treatment allocation. The primary endpoint was time to complete donor site epithelialization and was determined by an independent blinded observer. RESULTS: Statistical tests indicated no unbalanced distribution of subject characteristics across the two study groups. Mean times to complete graft donor site epithelialization for patients who did and did not undergo ESWT were 13.9 +/- 2.0 days and 16.7 +/- 2.0 days, respectively (p = 0.0001). CONCLUSIONS: For centers that apply nonadherent gauze dressings and topical antiseptics to skin graft donor sites, application of a single defocused shock wave treatment immediately after skin graft harvest can significantly accelerate donor site epithelialization.

Emergency pre-hospital care of burn patients.

Intensive care and the surgical therapy of burn injuries have made significant advancements. The immediate care on the scene of the accident, however, is not uniform. There is no 'golden hour' which will decide the further clinical process. The acute estimate of the percentage of the extent of the burns is of little relevance and does not facilitate the admission to a burn unit. The emergency calculation of the volume of intravenous infusion is not advisable. The choice of transport has no discernible impact on the prognosis of the patient. Avoiding hypothermia and perceiving associated trauma can be of crucial prognostic importance in the pre-hospital care of burn patients. Detailed knowledge about the circumstances of the injury is of exceeding importance.

Risk assessment of the application of a plasma jet in dermatology.

Regardless of the fact that several highly efficient antiseptics are commercially available, the antiseptic treatment of chronic wounds remains a problem. In the past, electrical plasma discharges have been frequently used in biometrical science for disinfection and sterilization of material surfaces. Plasma systems usually have a temperature of several hundred degrees. Recently, it was reported that "cold" plasma can be applied onto living tissue. In in vitro studies on cell culture, it could be demonstrated that this new plasma possesses excellent antiseptic properties. We perform a risk assessment concerning the in vivo application of a "cold" plasma jet on patients and volunteers. Two potential risk factors, UV radiation and temperature, are evaluated. We show that the UV radiation of the plasma in the used system is an order of magnitude lower than the minimal erythema dose, necessary to produce sunburn on the skin in vivo. Additionally, thermal damage of the tissue by the plasma can be excluded. The results of the risk assessment stimulate the in vivo application of the investigated plasma jet in the treatment of chronic wounds.

Aetiology and treatment of a previously denervated "tennis" elbow.

The aetiology of the "tennis" elbow is still disputed and treated by numerous different operations. We report 24 patients with treatment-resistant, previously denervated epicondylitis. The revision consisted of complete decompression of the radial nerve from the lateral intermuscular septum to beyond the arcade of Frohse in 24 patients using an anterolateral access. There was a mean period of 31 (10) months between the onset of the condition and the revision. Compared with the preoperative findings, there were improvements in 19 of the 24 patients, with four patients remaining unchanged, and one patient deteriorating. If the condition has been resistant to treatment for some time, complete decompression of the radial nerve is an effective option with few complications compared with further operation on the epicondyle.

Suprathel, a new skin substitute, in the management of partial-thickness burn wounds: results of a clinical study.

OBJECTIVE: A prospective, randomized, bicentric, nonblinded, clinical study was conducted to evaluate the impact on wound healing of Suprathel in partial-thickness burn injuries. Suprathel represents an absorbable, synthetic wound dressing with properties of natural epithelium. METHODS: Thirty patients suffering from second-degree burn injuries were included in the study, with a mean of age 40.4 years old. Burn injuries were randomly selected, partly treated with Omiderm and partly treated with Suprathel. The first gauze change was applied the fifth day postoperatively, followed by regular wound inspection until complete reepithelization. The study focused on patient pain score, healing time, analysis of wound bed, ease of care, and treatment costs. RESULTS: There was no significant difference between the 2 materials tested regarding healing time and reepithelization. There was a significant lower pain score for patients treated with Suprathel (P = 0.0072). Suprathel becomes transparent when applied, thus allowing close monitoring of wound healing. In contrast to Omiderm, Suprathel shows better attachment and adherence to wounds. During the course of healing, it detaches smoothly, without damaging the reepithelized wound surface. Moreover, it reduces the frequency of dressing changes required. Ease of care of Suprathel has been rated outstanding by patients and healthcare professionals. When interviewed, patients reported Suprathel as their treatment preference. As dressing material, Omiderm is more cost-effective than Suprathel. CONCLUSION: Suprathel represents a reliable epidermal skin substitute, with a good impact on wound healing and pain reduction in partial-thickness burn injuries. Although it is less cost-effective than Omiderm, the significant increase of patient comfort makes this material represent a reliable and solid treatment alternative when dealing with partial-thickness burn injuries. Further studies with this synthetic dressing on other types of wounds are warranted.