Injection of SVF combined with HBO2 improves viability of unfavorably designed flaps.

PURPOSE: Soft-tissue reconstruction is complicated by ischemia and reperfusion injury. Animal trials have documented the independent healing benefits of hyperbaric oxygen preconditioning (HBOP) and stem cell delivery in cutaneous flaps. We explored the role of HBOP and stem cell delivery in flap preconditioning and survival. METHODS: We designed a randomized controlled trial to assess the effects of hyperbaric oxygen preconditioning and stromal vascular fraction (SVF) delivery on flap survival. Of the first 24 guinea pigs, six received neither HBOP nor injections, and six underwent HBOP without injections. Of the remaining 12 animals, six received SVF or saline injections in the absence of HBOP. The final six animals received autologous SVF injections or saline injections followed by four HBOP treatments. To enhance clinical relevance, a group of 6 animals underwent HBOP prior to SVF or saline injections. Thereafter, an unfavorably designed cutaneous flap was elevated and assessed via study-blinded observer, as well as by quantification of TUNEL-positive cells. RESULTS: Distal necrosis of the tissue flap was more extensive in the no-intervention group (45% of flap). Flaps treated with HBOP only and those treated with SVF injections demonstrated only 38.2% and 27.1% distal necrosis. The most significant difference occurred in the combination HBOP and SVF group, where distal necrosis was only 21.1% of the flap (p ≤ 0.05). SVF delivery immediately prior to flap elevation further minimized distal necrosis of the flap to 15.6%. These findings were mirrored by the TUNEL assay. CONCLUSIONS: Combining HBOP and SVF improves flap viability.

Reliability of photographic analysis of wound epithelialization assessed in human skin graft donor sites and epidermolysis bullosa wounds.

BACKGROUND: In many clinical trials on cutaneous healing, wound closure is the primary endpoint and single most important outcome parameter, making precise assessment of this time point one of utmost importance. The assessment of wound closure can be performed either by subjective clinical inspection or with a variety of methodologies anticipated to provide more objective data. The aim of this study was to examine intra- and interrater variability of blinded photographic analysis of wound closure of human partial thickness wounds, as well as the reliability of remote photographic analysis of wounds with that of direct clinical assessment. METHODS: Two plastic surgeons, a dermatologist, and a maxillofacial surgeon constituted our rater panel. High-resolution images of patient wounds derived from two randomized controlled clinical trials (EU Clinical Trials Register numbers EudraCT 2009-017418-56 (registered 12 January 2010) and EudraCT 2010-019945-24 (registered 13 July 2010)) were individually assessed by the blinded, experienced study raters. The reliability of photographic image analysis was tested using intraclass and interclass correlation. The validity of photographic image analysis was correlated with clinical assessments of documented time to heal from the study centers' files. RESULTS: The results demonstrated that the mean intraclass correlation coefficient of all four examiners was excellent (r = 0.79; 95% confidence interval (CI), 0.61, 1.00)). The interrater correlation coefficient was good (r = 0.67; 95% CI, 0.57, 1.00)) and therefore acceptable. The agreement between remote visual assessment and clinical assessment at the time of healing was good (r = 0.64; 95% CI, 0.52, 0.76)) with an overall difference of about 1 day. CONCLUSIONS: Remote photographic analysis of cutaneous wounds is a feasible instrument in clinical open-label studies to evaluate time to wound closure. We found that it was a reliable method of measuring wound closure that correlated satisfactorily with clinical judgment, bolstering the potential relevance in the current era of evolving application and dependency in the field of telemedicine. TRIAL REGISTRATION: EU Clinical Trials Register EudraCT numbers 2009-017418-56 (date of registration: 12 January 2010) and 2010-019945-24 (date of registration: 13 July 2010).

Reduction of diabetic foot ulcer healing times through use of advanced treatment modalities.

Diabetic wounds are a major health care problem associated with delayed healing and high amputation rates. This review systematically evaluated newer wound care therapies for the treatment of diabetic wounds. More recent means of approaching diabetic foot ulcers include various dressings, off-loading shoes, and bioengineered skin constructs and growth factors. Electrical stimulation, phototherapy, electromagnetic fields, and shockwave therapy have been further proposed as potential treatments. A brief overview of these treatments is presented using peer-reviewed evidenced-based literature. A review of the literature demonstrated that treatment of diabetic wounds has focused on either prevention of the wounds in the form of off-loading shoes or adequate protective dressings or on direct treatment of wounds with bioengineered skin constructs, growth factors, or medical devices that accelerate wound healing. The authors' conclusion, following extensive literature review, is that although excellent national and international guidelines exist regarding suggested approaches to the treatment of the diabetic foot ulcer, there is no definitive or universal consensus on the choice of specific treatment modalities. The importance of optimizing comorbidities and the disease state, hemodynamics, local and peripheral skin and wound care, and metabolic challenges while reducing biological and bacterial burden and minimizing trauma remain the primary approach, followed by choice of the most appropriate treatment material or product.

Surgical advances in burn and reconstructive plastic surgery: new and emerging technologies.

This article introduces and discusses several biophysical and cellular modalities that are being tested or used in clinical practice to optimize wound bed preparation, effect soft tissue coverage, and improve the quality of the inevitable and resultant scar. Among these promising technologies is the use of electrical stimulation to mimic a physiologic current of injury in an effort to accelerate re-epithelialization and the wound healing process. Over the past several years an on-site individualized regenerative medicine kit has become commercially available (ReCell, Avita Medical), utilizing well-established laboratory techniques of cell separation without the need for cell cultivation in an effort to expand and promote wound coverage and end result.