Management of Acute and Traumatic Wounds With Negative-Pressure Wound Therapy With Instillation and Dwell Time.

BACKGROUND: A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds. METHODS: A systematic review was performed analyzing articles from major clinical databases. Only clinical studies ≥10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included. RESULTS: One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported. CONCLUSION: NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.

Sacral and Ischial Pressure Ulcer Management With Negative-Pressure Wound Therapy With Instillation and Dwell.

BACKGROUND: The addition of topical fluid instillation, a programmable "dwell" time and a novel foam-wound interface to the established wound healing benefits of negative-pressure wound therapy (NPWT) works synergistically to benefit patients with complex wounds. This engineering breakthrough for wound care has been termed NPWT with instillation and dwell (NPWTi-d), and the new foam dressings are reticulated open cell foam dressings specifically designed for use with NPWTi-d. This combined technology has shown promise in chronic, complex wounds and has potential for the management of sacral and ischial pressure wounds. METHODS: A qualitative comprehensive review was performed analyzing articles from PubMed and Medline that reported on the use of NPWTi-d in sacral or ischial pressure ulcers. Case series and case reports were predominant, and results of cases specific to sacral and ischial pressure wounds were extracted from larger studies and summarized for presentation. RESULTS: Compared with conventional NPWT alone, NPWTi-d has been shown to help irrigate the wound, remove fibrinous debris, and promote granulation tissue formation. This is associated with a decreased number of operative debridements and decreased hospital length of stay. CONCLUSIONS: This technology is rapidly demonstrating expanded utilization in hospitalized patients with chronic sacral and ischial pressure ulcers. When used correctly, NPWTi-d serves as an effective "bridge to defined endpoint": whether that is a flap reconstruction, skin grafting, or discharge home with a stable chronic wound and simplified wound care.

Negative pressure wound therapy with instillation: International consensus guidelines update.

The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi-d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi-d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi-d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi-d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi-d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis.

BACKGROUND: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed. RESULTS: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. CONCLUSIONS: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.

Prepectoral Breast Reconstruction with Fenestrated Acellular Dermal Matrix: A Novel Design.

Fenestrated acellular dermal matrix (ADM) has improved patient outcomes in both direct-to-implant and 2-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap to enhance the breast reconstruction experience. We present a novel, surgeon-designed shaped fenestrated ADM, placed in the recently repopularized prepectoral pocket for anterior coverage of implants in direct-to-implant and 2-stage breast reconstruction. A retrospective review of 10 patients (18 breasts) who underwent direct-to-implant or 2-stage breast reconstruction utilizing fenestrated shaped ADM in the prepectoral plane at a major academic institution in 2016 was conducted. Sixteen breasts (88.9%) underwent direct-to-implant reconstruction, and 2 breasts (11.1%) received tissue expanders. All reconstructions were performed using FlexHD Pliable ADM with surgeon-designed shape and fenestrations. The average implant size was 544.4 cc (±137.2 cc). The average intraoperative tissue expander fill volume measured 450 cc (90% of tissue expander size). The single expander case utilized 1 office fill (day 21) for full expansion. Major complications requiring reoperation within 90 days postoperatively were observed in 22.2% (4 breasts) of reconstructions. Three breasts (16.7%) due to partial mastectomy flap necrosis, 1 breast (5.5%) explantation due to infection. There was no seroma or capsular contracture. Prepectoral reconstruction with shaped fenestrated ADM is safe with high intraoperative fill volumes and facilitates more direct-to-implant reconstructions. Patients undergo fewer postoperative expansions, experience less time to full expansion, and subjectively report less pain. Patients benefit from improved cosmetic outcomes with better shape and no functional loss or animation deformity.

Trends in Rhinoplasty Research: A 20-Year Bibliometric Analysis.

BACKGROUND: Rhinoplasty is a popular aesthetic and reconstructive surgical procedure. It is one of the top five surgical cosmetic procedures performed worldwide. OBJECTIVES: To evaluate global trends in rhinoplasty research spanning 20 years between 1994 and 2013. METHODS: The top 15 plastic surgery and otolaryngology journals containing rhinoplasty research were determined using impact factors (IF). A database of rhinoplasty articles from 1994 to 2013 was created to include the following classifications: IF, authors' geographic location, study design, level of evidence (LOE), and pertinence to aesthetic or reconstructive rhinoplasty. Productivity index and productivity share were calculated for each region. RESULTS: A total of 1244 rhinoplasty articles were included in the database. The mean IF among the 15 journals increased from 0.75 in 1994 to 1.90 in 2013 (p < 0.001). The majority of rhinoplasty publications were clinical in study design (91.0%) and were predominantly of weaker LOE (level IV: 42.4%; level V: 33.2%). The USA led in proportion of total rhinoplasty publications by volume and productivity index (37.9%, 41.2%), followed by Asia (29.1%, 28.2%) and Western Europe (18.8%, 18.2%). The majority of articles published were classified as aesthetic (60.4%), whereas 30.6% were reconstructive; there was a significant increase in the proportion of aesthetic rhinoplasty articles published per year (p = 0.009). CONCLUSIONS: The USA has consistently been the most productive country in rhinoplasty research. However, its lead has diminished over the last 20 years. The trend in rhinoplasty research appears to be toward aesthetic rather than reconstructive topics. Attention should be given to producing stronger LOE studies. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Readability of Online Materials for Rhinoplasty.

BACKGROUND: Rhinoplasty is a popular aesthetic and reconstructive surgical procedure. However, little is known about the content and readability of online materials for patient education. The recommended grade level for educational materials is 7th to 8th grade according to the National Institutes of Health (NIH). This study aims to assess the readability of online patient resources for rhinoplasty. METHODS: The largest public search engine, Google, was queried using the term "rhinoplasty" on February 26, 2016. Location filters were disabled and sponsored results excluded to avoid any inadvertent search bias. The 10 most popular websites were identified and all relevant, patient-directed information within one click from the original site was downloaded and saved as plain text. Readability was analyzed using five established analyses (Readability-score.com, Added Bytes, Ltd., Sussex, UK). RESULTS: Analysis of ten websites demonstrates an average grade level of at least 12th grade. No material was at the recommended 7th to 8th grade reading level (Flesch-Kincaid, 11.1; Gunning-Fog, 14.1; Coleman-Liau, 14.5; SMOG 10.4; Automated Readability, 10.7; Average Grade Level, 12.2). Overall Flesch-Kincaid Reading Ease Index was 43.5, which is rated as "difficult." CONCLUSION: Online materials available for rhinoplasty exceed NIH-recommended reading levels, which may prevent appropriate decision-making in patients considering these types of surgery. Outcomes of this study identify that Plastic Surgeons should be cognizant of available online patient materials and make efforts to develop and provide more appropriate materials. Readability results can also contribute to marketing strategy and attracting a more widespread interest in the procedure.

Adipose-Derived Tissue in the Treatment of Dermal Fibrosis: Antifibrotic Effects of Adipose-Derived Stem Cells.

Treatment of hypertrophic scars and other fibrotic skin conditions with autologous fat injections shows promising clinical results; however, the underlying mechanisms of its antifibrotic action have not been comprehensively studied. Adipose-derived stem cells, or stromal cell-derived factors, inherent components of the transplanted fat tissue, seem to be responsible for its therapeutic effects on difficult scars. The mechanisms by which this therapeutic effect takes place are diverse and are mostly mediated by paracrine signaling, which switches on various antifibrotic molecular pathways, modulates the activity of the central profibrotic transforming growth factor ß/Smad pathway, and normalizes functioning of fibroblasts and keratinocytes in the recipient site. Direct cell-to-cell communications and differentiation of cell types may also play a positive role in scar treatment, even though they have not been extensively studied in this context. A more thorough understanding of the fat tissue antifibrotic mechanisms of action will turn this treatment from an anecdotal remedy to a more controlled, timely administered technology.

Deconstructing negative pressure wound therapy.

Since its introduction 20 years ago for the treatment of chronic wounds, negative pressure wound therapy use has expanded to a variety of other wound types. Various mechanisms of action for its efficacy in wound healing have been postulated, but no unifying theory exists. Proposed mechanisms include induction of perfusion changes, microdeformation, macrodeformation, exudate control and decreasing the bacterial load in the wound. We surmise that these different mechanisms have varying levels of dominance in each wound type. Specifically, negative pressure wound therapy is beneficial to acute open wounds because it induces perfusion changes and formation of granulation tissue. Post-surgical incisional wounds are positively affected by perfusion changes and exudate control. In the context of chronic wounds, negative pressure wound therapy removes harmful and corrosive substances within the wounds to affect healing. When skin grafts and dermal substitutes are used to close a wound, negative pressure wound therapy is effective in promoting granulation tissue formation, controlling exudate and decreasing the bacterial load in the wound. In this review, we elucidate some of the mechanisms behind the positive wound healing effects of negative pressure wound therapy, providing possible explanations for these effects in different wound types.

The Bagautdinov dressing method: negative pressure wound therapy in a patient with an allergy to acrylate adhesive.

Current embodiments of negative pressure wound therapy (NPWT) create a hermetically sealed chamber at the surface of the body using polyurethane foam connected to a vacuum pump, which is then covered by a flexible adhesive drape. Commercially available NPWT systems routinely use flexible polyethylene films that have a sticky side, coated with the same acrylate adhesives used in other medical devices such as ECG leads and grounding pads. Severe reactions to the acrylate adhesives in these other devices, although uncommon, have been reported. We describe the case of a 63-year-old woman with an intractable leg ulcer resulting from external-beam radiotherapy (XRT). Treatment with a standard commercial NPWT system induced severe inflammation of the skin in direct contact with drape adhesive. We successfully administered prolonged, outpatient NPWT to the patient using an alternative method (first described by Bagautdinov in 1986), using plain polyethylene film and petrolatum. The necessary hermetic seal is achieved by smearing the skin with petrolatum before applying the polyethylene film and activating the vacuum pump. The Bagautdinov method is a practical solution to the problem of adapting NPWT to patients with contact sensitivity or skin tears related to the adhesive compounds in the flexible drapes. Its use of a circumferential elastic wrap to maintain constant pressure on the seal probably limits the Bagautdinov technique to the extremities.

Venous Thromboembolism: A Comparison of Chronic Spinal Cord Injury and General Surgery Patients in a Metropolitan Veterans Affairs Hospital.

BACKGROUND: Venous thromboembolic events result in significant morbidity, mortality, and costly therapeutic interventions. As medical resource allocation strategies are becoming more pervasive, appropriate risk stratification and prophylactic regimens are essential. Previous studies have shown a decreased incidence of perioperative venous thromboembolism in the chronic spinal cord injury population. The question remains of whether chronic spinal cord injury is protective against venous thromboembolism. METHODS: A retrospective review of all cases involving chronic spinal cord injury patients who underwent plastic and reconstructive surgery operations (n = 424) and general surgery patients (n = 777) with a primary outcome of deep venous thrombosis or pulmonary embolism within 90 days of surgery was performed. RESULTS: The incidence of postoperative deep venous thrombosis in the control and spinal cord injury groups was 1.7 percent and 0.2 percent, respectively (p = 0.027). However, such significance was not observed with regard to postoperative pulmonary embolism incidence (p = 0.070). Collectively, the incidence of postoperative venous thromboembolism-specifically, deep venous thrombosis or pulmonary embolism-was significantly greater in the general surgery population (p = 0.014). A nearly 10-fold increased risk of venous thromboembolism was seen among the control group (1.9 percent versus 0.2 percent) despite administration of optimal prophylaxis. CONCLUSIONS: This study demonstrates a profoundly low incidence of venous thromboembolism among chronic spinal cord injury patients compared with general surgery patients. Future efforts to elucidate how chronic spinal cord injury confers a protective mechanism may potentially influence the evolution of venous thromboembolism prevention guidelines, and spark the development of alternative prophylactic agents or customized application of prevention efforts.

Plastic Surgery and Acellular Dermal Matrix: Highlighting Trends from 1999 to 2013.

The last decade has ushered in a rapidly expanding global discussion regarding acellular dermal matrix (ADM) applications, economic analyses, technical considerations, benefits, and risks, with recent emphasis on ADM use in breast surgery. This study aims to evaluate global trends in ADM research using bibliometric analysis. The top nine Plastic Surgery journals were determined by impact factor (IF). Each issue of the nine journals between 1999 and 2013 was accessed to compile a database of articles discussing ADM. Publications were further classified by IF, authors' geographic location, study design, and level of evidence (LOE, I-V). Productivity index and productivity share were calculated for each region. In total, 256 ADM articles were accessed. The annual global publication volume increased significantly by 4.2 (0.87) articles per year (p<0.001), with a mean productivity index of 36.3 (59.0). The mean impact factor of the nine journals increased significantly from 0.61 (0.11) to 2.47 (0.99) from 1993 to 2013 (p<0.001). Despite this increase in the global ADM literature, the majority of research was of weaker LOE (level I: 2.29% and level II: 9.17%). USA contributed the most research (87%), followed by Asia (4.76%) and Western Europe (4.71%). USA contributed the greatest volume of research. Regarding clinical application of ADM, the majority of publications focused on ADM use in breast surgery, specifically breast reconstruction (154 articles, 60.2%). The majority of research was of lower LOE; thus, efforts should be made to strengthen the body of literature, particularly with regard to cost analysis.

Phenotypic Analysis of Stromal Vascular Fraction after Mechanical Shear Reveals Stress-Induced Progenitor Populations.

BACKGROUND: Optimization of fat grafting continues to gain increasing attention in the field of regenerative medicine. "Nanofat grafting" implements mechanical emulsification and injection of standard lipoaspirate for the correction of superficial rhytides and skin discoloration; however, little is known about the cellular constituents of the graft. Based on recent evidence that various stressors can induce progenitor activity, the authors hypothesized that the shear forces used in common fat grafting techniques may impact their regenerative capacities. METHODS: Lipoaspirates were obtained from 10 patients undergoing elective procedures. Half of each sample was subjected to nanofat processing; the other half was left unchallenged. The viscosity of each sample was measured for computational analysis. The stromal vascular fraction of each sample was isolated, quantified, and analyzed by means of flow cytometry with two multicolor fluorescence antibody panels. RESULTS: Standard lipoaspirate is ideally suited for mechanical stress induction. The mechanical emulsification involved in nanofat processing did not affect cell number; however, viability was greatly reduced when compared with the stromal vascular fraction of standard lipoaspirate. Interestingly, nanofat processing resulted in stress-induced stromal vascular fraction with a higher proportion of endothelial progenitor cells, mesenchymal stem cells, and multilineage differentiating stress-enduring cells. Single-parameter analysis also revealed significant increases in CD34, CD13, CD73, and CD146 of the stress-induced stromal vascular fraction, markers associated with mesenchymal stem cell activity. CONCLUSIONS: Mechanical processing used in techniques such as nanofat grafting induces the up-regulation of progenitor phenotypes consistent with multipotency and pluripotency. These data provide a first step in characterizing the potential regenerative benefits realized through stress induction in fat grafting. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Current concepts related to hypertrophic scarring in burn injuries.

Scarring following burn injury and its accompanying aesthetic and functional sequelae still pose major challenges. Hypertrophic scarring (HTS) can greatly impact patients' quality of life related to appearance, pain, pruritus and even loss of function of the injured body region. The identification of molecular events occurring in the evolution of the burn scar has increased our knowledge; however, this information has not yet translated into effective treatment modalities. Although many of the pathophysiologic pathways that bring about exaggerated scarring have been identified, certain nuances in burn scar formation are starting to be recognized. These include the effects of neurogenic inflammation, mechanotransduction, and the unique interactions of burn wound fluid with fat tissue in the deeper dermal layers, all of which may influence scarring outcome. Tension on the healing scar, pruritus, and pain all induce signaling pathways that ultimately result in increased collagen formation and myofibroblast phenotypic changes. Exposure of the fat domes in the deep dermis is associated with increased HTS, possibly on the basis of altered interaction of adipose-derived stem cells and the deep burn exudate. These pathophysiologic patterns related to stem cell-cytokine interactions, mechanotransduction, and neurogenic inflammation can provide new avenues of exploration for possible therapeutic interventions.

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Tamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The purpose of this study is to determine whether tamoxifen taken at the time of free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap breast reconstruction affects thrombotic complication rates. METHODS: A retrospective review of microvascular breast reconstruction with TRAM/DIEP flaps over the last 20 years was carried out at a single institution. Patients were divided into 2 cohorts: those receiving tamoxifen at the time of reconstruction (tamoxifen cohort) and those not taking tamoxifen (control). Demographic information, procedural characteristics, and rates of microvascular flap complications were compared. RESULTS: Forty-three patients (56 flaps) received tamoxifen at the time of microvascular breast reconstruction, and 185 patients (267 flaps) did not. Patients in the tamoxifen cohort had a lower mean age of 48.9 years (P = 0.013). A greater percentage of patients in the tamoxifen cohort had preoperative radiation (P < 0.0001) and chemotherapy (P = 0.018) and underwent delayed reconstruction (P < 0.0001). There were no significant differences between the 2 cohorts with regard to flap complications including both arterial and venous thrombosis, flap failure, and other local flap complications. CONCLUSIONS: Patients receiving tamoxifen during TRAM/DIEP flap breast reconstruction did not have increased rates of flap thrombosis or failure; therefore, stopping tamoxifen prior to these procedures may not be necessary.

Stromal vascular fraction: A regenerative reality? Part 2: Mechanisms of regenerative action.

Adipose tissue is a rich source of cells with emerging promise for tissue engineering and regenerative medicine. The stromal vascular fraction (SVF), in particular, is an eclectic composite of cells with progenitor activity that includes preadipocytes, mesenchymal stem cells, pericytes, endothelial cells, and macrophages. SVF has enormous potential for therapeutic application and is being investigated for multiple clinical indications including lipotransfer, diabetes-related complications, nerve regeneration, burn wounds and numerous others. In Part 2 of our review, we explore the basic science behind the regenerative success of the SVF and discuss significant mechanisms that are at play. The existing literature suggests that angiogenesis, immunomodulation, differentiation, and extracellular matrix secretion are the main avenues through which regeneration and healing is achieved by the stromal vascular fraction.

Preparation, Characterization, and Clinical Implications of Human Decellularized Adipose Tissue Extracellular Matrix (hDAM): A Comprehensive Review.

Fat grafting is commonly employed by plastic and reconstructive surgeons to address contour abnormalities and soft-tissue defects; however, because retention rates and thus volume filling effects are unpredictable, there is a search for new and innovative approaches. Initial studies on the use of human decellularized adipose tissue extracellular matrix (hDAM) show promise for its use not only in tissue engineering, but also in fat grafting. In this review, we examine and analyze the literature for the preparation, characterization, and use of hDAM and its derivatives in tissue engineering and plastic surgery applications. All studies reviewed involve physical, chemical, and/or biological treatment stages for the preparation of hDAM; however a distinction should be made between detergent and nondetergent-based processing, the latter of which appears to preserve the native integrity of the hDAM while most-efficiently achieving complete decellularization. Methods of hDAM characterization vary among groups and included simple and immunohistochemical staining, biochemical assays, 3-dimensional (3D) imaging, and mechano-stress testing, all of which are necessary to achieve a comprehensive description of this novel tissue. Finally, we examine the various preclinical models utilized to optimize hDAM performance, which primarily include the addition of adipose-derived stem cells or cross-linking agents. Overall, hDAM appears to be a promising adjunct in fat-grafting applications or even possibly as a stand-alone soft-tissue filler with off-the-shelf potential for commercial applications.

Stromal vascular fraction: A regenerative reality? Part 1: Current concepts and review of the literature.

Stromal Vascular Fraction (SVF) is a heterogeneous collection of cells contained within adipose tissue that is traditionally isolated using enzymes such as collagenase. With the removal of adipose cells, connective tissue and blood from lipoaspirate, comes the SVF, a mix including mesenchymal stem cells, endothelial precursor cells, T regulatory cells, macrophages, smooth muscle cells, pericytes and preadipocytes. In part 1 of our 2-part series, we review the literature with regards to the intensifying interest that has shifted toward this mixture of cells, particularly due to its component synergy and translational potential. Trials assessing the regenerative potential of cultured Adipose Derived Stem Cells (ADSCs) and SVF demonstrate that SVF is comparably effective in treating conditions ranging from radiation injuries, burn wounds and diabetes, amongst others. Aside from their use in chronic conditions, SVF enrichment of fat grafts has proven a major advance in maintaining fat graft volume and viability. Many SVF studies are currently in preclinical phases or are moving to human trials. Overall, regenerative cell therapy based on SVF is at an early investigative stage but its potential for clinical application is enormous.

Surgical Management of Complex Lower-Extremity Trauma With a Long Hindfoot Fusion Nail: A Case Report.

UNLABELLED: High-energy injuries can result in complete or partial loss of the talus. Ipsilateral fractures to the lower limb increase the complexity of surgical management, and treatment is guided by previous case reports of similar injuries. A case of complex lower-extremity trauma with extruded and missing talar body and ipsilateral type IIIB open tibia fracture is presented. Surgical limb reconstruction and salvage was performed successfully with a single orthopaedic implant in a manner not described previously in the literature. The purpose of this case report is to present the novel use of a single orthopaedic implant for treatment of a complex, open traumatic injury. Previous case reports in the literature have described the management of complete or partial talar loss. We describe the novel use of a long hindfoot fusion nail and staged bone grafting to achieve tibiocalcaneal arthrodesis for the treatment of complex lower-extremity trauma. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.