The Evolution of Current Concept of the Reconstructive Ladder in Plastic Surgery: The Emerging Role of Translational Medicine.

Plastic surgeons have used the reconstructive ladder for many decades as a standard directory for complex trauma reconstruction with the goal of repairing body structures and restoring functionality. This consists of different surgical maneuvers, such as secondary intention and direct tissue closure, as well as more complex methods such as local tissue transfer and free flap. The reconstructive ladder represents widely known options achievable for tissue reconstruction and wound closure that puts at the bottom rung the simplest methods of reconstruction and strengthens the complexity by moving upward. Regenerative medicine and surgery constitute a quickly spreading area of translational research that can be employed by minimally invasive surgical strategies, with the aim of regenerating cells and tissues in vivo in order to reestablish normal function through the intrinsic potential of cells, in combination with biomaterials and appropriate biochemical stimuli. These translational procedures have the aim of creating an appropriate microenvironment capable of supporting the physiological cellular function to generate the desired cells or tissues and to generate parenchymal, stromal, and vascular components on demand, and above all to produce intelligent materials capable of determining the fate of cells. Smart technologies have been grown that give extra "rungs" on the classic reconstructive ladder to integrate a more holistic, patient-based approach with improved outcomes. This commentary presents the evolution of the traditional concept of the reconstructive ladder in the field of plastic surgery into a new course with the aim of achieving excellent results for soft tissue reconstruction by applying innovative technologies and biologically active molecules for a wide range of surgical diseases.

A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach.

Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation.

Combined use of WEB2170 and HBO therapy can reduce ischemia and reperfusion injury to the skeletal muscle in a rabbit model.

Ischemia/reperfusion injury is regarded as the main cause of failure in revascularization of limbs and transfer of free flaps in the so called nonreflow phenomenon. This type of damage is caused by the production of free radicals, above all, of neutrophils that release great quantities of extracellular superoxide through the action of a membrane enzyme. In our study we used 40 white rabbits. Rabbit rectus femoris muscle is perfused by a single artery and vein and is therefore a valuable model for study of ischemia-induced reperfusion injury of skeletal muscle. The objective of this study was to individualize a valid method of protection for the muscle from damage by ischemia-induced reperfusion injury. We have tested the effectiveness of WEB2170, a PAF antagonist, of hyperbaric oxygen therapy one (HBO), and of combined employment of WEB2170 and HBO. The results show that both PAF and HBO play important protective roles against damage from ischemia/reperfusion injury, and that the combined employment of both therapies has a synergistic effect. We propose therefore a new therapeutic protocol for the prevention of damage resulting from ischemia/reperfusion injury with the simultaneous employment of this PAF and HBO.

Delayed microsurgical reconstruction of the extremities for complex soft-tissue injuries.

The treatment of severe wounds of the extremities, characterized by large posttraumatic tissue loss, represents a clinical problem difficult to resolve, especially when the lesion is surrounded by large areas of ischemic distrophic tissue which progressively aggravate and extend the initial lesion, with frequent exposure of bone and joint structures making the amputation of the limb an inevitable outcome. The authors present their experience based on combined treatments by medical support methods such as hyperbaric oxygen (HBO) and vacuum-assisted closure therapy (VAC) and microsurgical reconstruction of the limbs, within a precise therapeutic protocol. The use of this protocol in appropriate times and ways allowed us to successfully treat severe posttraumatic sequelae of the limbs, avoiding the delayed healing typical of these pathologies, both on the donor site of the flap and on the repaired area, and avoiding unsuitable microsurgical reconstruction of limbs, allowing satisfactory morpho-functional restoration and a reduction of the hospitalization period.