A single-stage bilayered skin reconstruction using Glyaderm® as an acellular dermal regeneration template results in improved scar quality: an intra-individual randomized controlled trial.

Background: Absence of almost the entire reticular dermal layer is inherent to the use of autologous split-thickness skin grafting (STSG) to close full-thickness wounds, often resulting in hypertrophic scars and contractures. Many dermal substitutes have been developed, but unfortunately most have varying results in terms of cosmetic and/or functional improvement as well as patient satisfaction, in addition to high costs. Bilayered skin reconstruction using the human-derived glycerolized acellular dermis (Glyaderm®) has been reported to result in significantly improved scar quality using a two-step procedure. Unlike the necessary two-step procedure for most commercially available dermal substitutes, in this study we aimed to investigate the use of Glyaderm® in a more cost-effective single-stage engrafting. This is a method which, if autografts are available, is preferred by the majority of surgeons given the reduction in costs, hospitalization time and infection rate. Methods: A prospective, randomized, controlled, intra-individual, single-blinded study was performed, investigating the simultaneous application of Glyaderm® and STSG vs. STSG alone in full-thickness burns or comparable deep skin defects. During the acute phase, bacterial load, graft take and time to wound closure were assessed and were the primary outcomes. Aesthetic and functional results (secondary outcomes) were evaluated at 3, 6, 9 and 12 months follow-up using subjective and objective scar measurement tools. Biopsies for histological analysis were taken at 3 and 12 months. Results: A total of 66 patients representing 82 wound comparisons were included. Graft take (>95%), pain management and healing time were comparable in both groups. At 1 year follow-up, the overall Patient and Observer Scar Assessment Scale assessed by the patient was significantly in favour of sites where Glyaderm® was used. Not infrequently, patients attributed this difference to improved skin sensation. Histological analysis showed the presence of a well-formed neodermis, with donor elastin present for up to 12 months. Conclusions: A single-stage bilayered reconstruction with Glyaderm® and STSG results in optimal graft take without loss of Glyaderm® nor the overlaying autografts due to infection. The presence of elastin in the neodermis was demonstrated during long-term follow-up in all but one patient, which is a crucial factor contributing to the significantly improved overall scar quality as evaluated by the blinded patients. Trial registration: The trial was registered on clinicaltrials.gov and received the following registration code: NCT01033604.

Comparison of Glyaderm with different dermal substitute matrices in a porcine wound model.

Background: The closure of extensive burn wounds with widely expanded autologous split-thickness skin grafts (STSG) is associated with undesirable scar formation and contraction, due to the lack of dermis. Various materials for dermal replacement have been developed, either of xenogeneic, allogeneic or synthetic origin and are placed in the wound underneath a thin STSG in order to improve scar quality. In this study, a porcine wound model was used to compare several commercially available acellular dermal substitutes with an acellular dermal substitute prepared from glycerol preserved human skin: GlyadermⓇ. Methods: Antigenic components of the allografts were removed by incubation in the 0.06 M NaOH solution. In the first experiments, the dermal substitutes were applied to full thickness wounds and covered simultaneously with STSG. Controls were covered with STSG only. The wound healing response was analyzed for 8 weeks, both macroscopically and histologically. The Mann-Whitney U test was used for statistical analysis. In the second series of experiments, GlyadermⓇ was applied in a two-stage procedure in comparison to Integra. The STSG was placed on the dermal substitutes one week later. Results: In the first series, the inflammatory response and myofibroblast influx in GlyadermⓇ were limited, indicating possible beneficial outcomes on final wound healing results. The survival of the STSG on the acellular dermis was lower compared to the control wounds. Second series: the take of the STSG was the same as in the controls, but additionally wound contraction was reduced. The application of GlyadermⓇ was non-inferior to Integra. Conclusion: GlyadermⓇ can be successfully used for the reduction of wound contraction when applied in a two-stage procedure.

A Systematic Review and Meta-Analysis of Rhinoplasty Using the Rhinoplasty Outcome Evaluation Scale.

Background: The purpose was to evaluate the role and impact of the rhinoplasty outcome evaluation (ROE) in rhinoplasty. Objectives: To systematically review the ability of ROE to assess rhinoplasty outcome in the very recent surgical approaches. Data Sources: Searching MESH terms "rhinoplasty" and "rhinoplasty and ROE" on PubMed, Scopus, Embase, Google Scholar, and other major literature databases. Study Eligibility Criteria: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses model was adopted for eligibility criteria. Participants and Interventions: A first large screening on 1,660 papers allowed the final retrieval of 896 reports, of which only 101 were eligible for all the inclusion criteria, which allowed finally to select a group of 12 reports published in the time range 2018-2021. Study Appraisal and Synthesis Methods: Meta-regression with Durbin-Watson test, checking of meta-analysis bias with Rosenthal's estimator, and heterogeneity through the I 2 statistics were performed. The analysis included a Mantel-Haenszel test and associated or meta-analysis. Results: Twelve eligible and qualified papers were included in the meta-analysis, out of 1,263 patients, from 1,660 papers. ROE confirmed previous reports about its ability to discriminate preoperative from postoperative outcome (50/100), as from the different rhinoplasty approaches, a value very close to the functional Nasal Obstruction Symptom Evaluation scale. This study strengthens the role of ROE in the evaluation of rhinoplasty outcomes encouraging further research to improve ROE scale on different cultural habits and geographical areas. Limitations: The main limitations were due to the weak inclusion and exclusion criteria, methodological flaws with the statistical analysis, and poor data synthesis and evaluation in many papers about ROE.

Exokine and the Youth-Boosting Treatment Based on One's Own Serum: Wheat and Chaff.

Within the field of skin rejuvenation, clinicians have broadened the application of proven therapies toward antiaging medicine. Specifically, both platelet-rich plasma (PRP) and autologous-conditioned serum (ACS) have received great consideration among experts for novel indications. While the medical research focused on ACS is strengthened in their evidence and supported by promising outcomes, much more debates exist regarding the efficacy of PRP. Despite limited supporting literature to date, physicians and surgeons should be encouraged to explore the use of these approaches and in shedding further light on their potential benefits by contributing new evidence from basic and clinical scientific investigation.

Lip Reshaping with LOVE Approach: A Prospective Analysis Based on Two Hyaluronic Acid Fillers.

Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups. METHODS: This was a prospective, single-center study of women aged 20-70 years seeking nonsurgical lip enhancement or asymmetry correction. Three equally sized groups were formed based on patient age: 20-34, 35-45, and 46 years or older. Individualized treatment plans were developed taking into account patient preferences expressed in a pre-injection questionnaire. Treatment used one or more of the three modules of LOVE: lip shape [vermilion border, Vycross (VYC)-17.5]; volume (vermilion body, VYC-17.5); and hydration (submucosal area, VYC-12). Follow-up lasted 6 months. RESULTS: Sixty patients were enrolled (mean age: 41.3 ± 13.3 years; n = 20 per age group), all of whom were White. Most were treated with all three LOVE modules. Mean filler quantities increased with age: 20-34 years, 1.1 ± 0.1 mL; 35-45 years, 1.5 ± 0.1 mL; 46 years or older, 1.6 mL ± 0.2 mL. Mean patient satisfaction at 4 weeks [on a seven-point scale from 0 (extremely dissatisfied) to 6 (extremely satisfied)] was 4.8-4.9 in each age group. Apart from minor and transient edema/bruising, there was only one complication: a case of lumps that resolved with home massage. CONCLUSION: The LOVE approach is safe and effective across a range of ages, with high levels of patient satisfaction.

Safety guidelines for nonsurgical facial procedures during COVID-19 outbreak.

BACKGROUND: The novel coronavirus (COVID-19) pandemic is expected to last for an extended time, making strict safety precautions for office procedures unavoidable. The lockdown is going to be lifted in many areas, and strict guidelines detailing the infection control measures for aesthetic clinics are going to be of particular importance. METHODS: A virtual meeting was conducted with the members (n = 12) of the European Academy of Facial Plastic Surgery Focus Group to outline the safety protocol for the nonsurgical facial aesthetic procedures for aesthetic practices in order to protect the clinic staff and the patients from SARS-CoV-2 infection. The data analysis was undertaken by thematic and iterative approach. RESULTS: Consensus guidelines for nonsurgical facial aesthetic procedures based on current knowledge are provided for three levels: precautions before visiting the clinic, precautions during the clinic visit, and precautions after the clinic visit. CONCLUSIONS: Sound infection control measures are mandatory for nonsurgical aesthetic practices all around the world. These may vary from country to country, but this logical approach can be customized according to the respective country laws and guidelines.

Fasting induces ANGPTL4 and reduces LPL activity in human adipose tissue.

OBJECTIVE: Studies in mice have shown that the decrease in lipoprotein lipase (LPL) activity in adipose tissue upon fasting is mediated by induction of the inhibitor ANGPTL4. Here, we aimed to validate this concept in humans by determining the effect of a prolonged fast on ANGPTL4 and LPL gene and protein expression in human subcutaneous adipose tissue. METHODS: Twenty-three volunteers ate a standardized meal at 18.00 h and fasted until 20.00 h the next day. Blood was drawn and periumbilical adipose tissue biopsies were collected 2 h and 26 h after the meal. RESULTS: Consistent with previous mouse data, LPL activity in human adipose tissue was significantly decreased by fasting (-60%), concurrent with increased ANGPTL4 mRNA (+90%) and decreased ANGPTL8 mRNA (-94%). ANGPTL4 protein levels in adipose tissue were also significantly increased by fasting (+46%), whereas LPL mRNA and protein levels remained unchanged. In agreement with the adipose tissue data, plasma ANGPTL4 levels increased upon fasting (+100%), whereas plasma ANGPTL8 decreased (-79%). Insulin, levels of which significantly decreased upon fasting, downregulated ANGPTL4 mRNA and protein in primary human adipocytes. By contrast, cortisol, levels of which significantly increased upon fasting, upregulated ANGPTL4 mRNA and protein in primary human adipocytes as did fatty acids. CONCLUSION: ANGPTL4 levels in human adipose tissue are increased by fasting, likely via increased plasma cortisol and free fatty acids and decreased plasma insulin, resulting in decreased LPL activity. This clinical trial was registered with identifier NCT03757767.

Complications and management after a nonsurgical rhinoplasty: A literature review.

Nonsurgical rhinoplasty with injectable fillers has become an increasingly popular option in recent years. Their rise in popularity has been driven by a number of factors, including their minimally invasive nature and the cost lower than surgical option. Physicians should keep in mind that there are many possible complications, especially in the hands of a novice injector. Fortunately, most complications are minor and transient in nature, although the patient may consider them aesthetically displeasing and unacceptable. Major complications are rare; however, an inadequate treatment can produce transient to permanent damage for the patient. A review of the medical literature from 2002 was performed to gather information on main complications after nasal injections using the databases of the National Library of Medicine, Ovid MEDLINE, and Cochrane Library. Understanding the basic anatomical knowledge of the midface, especially the vascular system, is fundamental to prevent the appearance of complications. However, recognize immediately the symptoms and know the correct treatment in case of complications is the only way to minimize permanent bad outcome.

Anatomical Variations in the Course of Labial Arteries: A Literature Review.

BACKGROUND: Nonsurgical lip enhancement using dermal fillers is a very popular procedure. The trend for enlarged lips has been popularized by media and social media. The lips have considerable aesthetic and functional importance, in addition to having a complex anatomy. Serious complications, including vascular compromise or occlusion leading to cutaneous necrosis and blindness, can occur as the result of lip enhancement using dermal fillers. Therefore, aesthetic practitioners require an in-depth understanding of the anatomy and vasculature of the lips and the perioral area prior to providing lip enhancement using dermal fillers. OBJECTIVES: This literature review aimed to summarize existing data describing the origin, path, and depth of the superior and inferior labial arteries, and to help aesthetic practitioners in providing safer injections to the lips. METHODS: A literature search was carried out to summarize the available data describing the origin, path, and depth of the labial arteries. RESULTS: Analysis of the literature revealed that the labial arteries display great variability with respect to path (distribution), presence, and location. CONCLUSIONS: Increasing the volume of lips through injections of dermal filler needs to be undertaken with caution, and awareness of the anatomical variation in artery location and path is a crucial concept that is essential when injecting the lips.

Effectiveness, Longevity, and Complications of Facelift by Barbed Suture Insertion.

BACKGROUND: Minimally invasive facelift techniques involving barbed suture insertion have become popular among patients who wish to correct facial tissue ptosis. OBJECTIVES: The authors sought to determine the effectiveness, longevity, complications, and postoperative sequelae associated with facelift by means of barbed polydioxanone (PDO) threads. METHODS: A total of 160 consecutive patients who underwent facelift with barbed threads were evaluated retrospectively. For malar augmentation and correction of nasolabial grooves, 2 or 3 PDO threads (23 gauge) were placed per side; for treatment of mandibular lines, 2 to 4 PDO threads (21 gauge) were inserted per side. RESULTS: Immediately after suture placement and for 1 month postoperatively, patients experienced improvement in facial tissue ptosis. This aesthetic result declined noticeably by 6 months and was absent by 1 year. The overall complication rate in the early postoperative period was 34% (55 of 160 patients). Eighteen patients (11.2%) had superficial displacement of the barbed sutures, 15 (9.4%) experienced transient erythema, 10 (6.2%) had infection, 10 (6.2%) experienced skin dimpling, and 2 (1.2%) had temporary facial stiffness. CONCLUSIONS: Placement of barbed threads yields instantaneous improvement in facial ptosis that is no longer apparent by 1 year. Given this transient benefit and the complication rate of 34%, we recommend limiting this procedure to patients with contraindications for more invasive facial surgery.

Thread-Lift Sutures: Still in the Lift? A Systematic Review of the Literature.

BACKGROUND: In 2006, Villa et al. published a review article concerning the use of thread-lift sutures and concluded that the technique was still in its infancy but had great potential to become a useful and effective procedure for nonsurgical lifting of sagged facial tissues. As 11 years have passed, the authors now performed again a systematic review to determine the real scientific current state of the art on the use of thread-lift sutures. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database and using the Medical Subject Headings search term "Rhytidoplasty." "Rhytidoplasty" and the following entry terms were included by this Medical Subject Headings term: "facelift," "facelifts," "face Lift," "Face Lifts," "Lift," "Face," "Lifts," "Platysmotomy," "Platysmotomies," "Rhytidectomy," "Rhytidectomies," "Platysmaplasty," "and "Platysmaplasties." The Medical Subject Headings term "Rhytidoplasty" was combined with the following search terms: "Barbed suture," "Thread lift," "APTOS," "Suture suspension," "Percutaneous," and "Silhouette suture." RefWorks was used to filter duplicates. Three of the authors (H.A.G., B.C., and B.L.) performed the search independently. RESULTS: The initial search with all search terms resulted in 188 articles. After filtering the duplicates and the articles about open procedures, a total of 41 articles remained. Of these, the review articles, case reports, and letters to the editor were subsequently excluded, as were reports dealing with nonbarbed sutures, such as Vicryl and Prolene with Gore-Tex. This resulted in a total of 12 articles, seven additional articles since the five articles reviewed by Villa et al. CONCLUSIONS: The authors' review demonstrated that, within the past decade, little or no substantial evidence has been added to the peer-reviewed literature to support or sustain the promising statement about thread-lift sutures as made by Villa et al. in 2006 in terms of efficacy or safety. All included literature in the authors' review, except two studies, demonstrated at best a very limited durability of the lifting effect. The two positive studies were sponsored by the companies that manufacture the thread-lift sutures.

Microneedling: Where do we stand now? A systematic review of the literature.

BACKGROUND: Patients who suffer from scars or wrinkles have several therapeutic options to improve the appearance of their skin. The available treatment modalities that provide desirable results are often overtly invasive and entail a risk of undesirable adverse effects. Microneedling has recently emerged as a non-ablative alternative for treating patients who are concerned with the aesthetic changes that result from injury, disease or ageing. OBJECTIVE: This review aims to evaluate the current evidence in the literature on microneedling. METHODS: A systematic literature review was performed by searching the electronic databases PubMed and Google Scholar. The reviewed articles were analysed and compared on study design, treatment protocol, outcome parameters, efficacy measurement and results to evaluate the strength of the current evidence. RESULTS: Microneedling was investigated in experimental settings for its effects on atrophic acne scars, skin rejuvenation, hypertrophic scars, keloids, striae distensae, androgenetic alopecia, melasma and acne vulgaris. Several clinical trials used randomisation and single-blindation to strengthen the validity of the study outcome. Microneedling showed noteworthy results when used on its own and when combined with topical products or radiofrequency. When compared with other treatments, it showed similar results but was preferred due to minimal side effects and shorter downtime. CONCLUSION: This systematic review positions microneedling as a safe and effective therapeutic option for the treatment of scars and wrinkles. The current literature does show some methodological shortcomings, and further research is required to truly establish microneedling as an evidence-based therapeutic option for treating scars, wrinkles and other skin conditions.

Visualisation of newly synthesised collagen in vitro and in vivo.

Identifying collagen produced de novo by cells in a background of purified collagenous biomaterials poses a major problem in for example the evaluation of tissue-engineered constructs and cell biological studies to tumor dissemination. We have developed a universal strategy to detect and localize newly deposited collagen based on its inherent association with dermatan sulfate. The method is applicable irrespective of host species and collagen source.

Exposed tibial bone after burns: Flap reconstruction versus dermal substitute.

A 44 years old male patient had suffered extensive 3rd degree burns on both legs, undergoing thorough surgical debridement, resulting in both tibias being exposed. Approximately 5 months after the incident he was referred to the Department of Plastic and Reconstructive Surgery of the University Hospital Gent, Belgium, to undergo flap reconstruction. Free flap surgery was performed twice on both lower legs but failed on all four occasions. In between flap surgery, a dermal substitute (Integra(®)) was applied, attempting to cover the exposed tibias with a layer of soft tissue, but also without success. In order to promote the development of granulation tissue over the exposed bone, small holes were drilled in both tibias with removal of the outer layer of the anterior cortex causing the bone to bleed and subsequently negative pressure wound therapy (NPWT) was applied. The limited granulation tissue resulting from this procedure was then covered with a dermal substitute (Glyaderm(®)), consisting of acellular human dermis with an average thickness of 0.25mm. This dermal substitute was combined with a NPWT-dressing, and then served as an extracellular matrix (ECM), guiding the distribution of granulation tissue over the remaining areas of exposed tibial bone. Four days after initial application of Glyaderm(®) combined with NPWT both tibias were almost completely covered with a thin coating of soft tissue. In order to increase the thickness of this soft tissue cover two additional layers of Glyaderm(®) were applied at intervals of approximately 1 week. One week after the last Glyaderm(®) application both wounds were autografted. The combination of an acellular dermal substitute (Glyaderm(®)) with negative pressure wound therapy and skin grafting proved to be an efficient technique to cover a wider area of exposed tibial bone in a patient who was not a candidate for free flap surgery. An overview is also provided of newer and simpler techniques for coverage of exposed bone that could question the universal plastic surgery paradigm that flap surgery is the only way to cover these defects.