["PLASTICS" DURING THE WAR OF "IRON SWORDS" - THE ROLE OF A SPECIALIST IN PLASTIC AESTHETIC AND RECONSTRUCTIVE SURGERY].

INTRODUCTION: A war usually requires a new or adjusted set up and needs of all caregivers according to the "new" status. The current war in Israel began on the 7.10.2023. The Israeli Ministries of Defense and Health were in a new status in which they had to complete new requirements according to the use of new weapons, and in numbers and types of injuries that overwhelmed the system from the day the war began. In the past, we published evidence that in times of terror, as in times of war, epidemiology of injuries changes and requires adjustments in human resources, surgical tools and consumables in the Israeli health and defense systems. This article aims to describe the role of specialists in plastic, aesthetic and reconstructive surgery and the first response according to the existing system divided into prevention, preparedness, response and rehabilitation. In the long term rapid response, recruitment of human resources, abilities and flexibility of the system enables overcoming a sudden "new" status as in war, terror and mass casualty events.

Personalised burn treatment: bedside electrospun nanofibre scaffold with cultured autologous keratinocytes: a case study.

Nearly four decades after cultured epidermal autografts (CEA) were first used for the treatment of extensive burn wounds, the current gold standard treatment remains grafting healthy autologous skin from a donor site to the damaged areas, with current skin substitutes limited in their clinical use. We propose a novel treatment approach, using an electrospun polymer nanofibrous matrix (EPNM) applied on-site directly on the CEA-grafted areas. In addition, we propose a personalised treatment on hard-to-heal areas, in which we spray suspended autologous keratinocytes integrated with 3D EPNM applied on-site, directly onto the wound bed. This method enables the coverage of larger wound areas than possible with CEA. We present the case of a 26-year-old male patient with full-thickness burns covering 98% of his total body surface area (TBSA). We were able to show that this treatment approach resulted in good re-epithelialisation, seen as early as seven days post CEA grafting, with complete wound closure within three weeks, and to a lesser extent in areas treated with cell spraying. Moreover, in vitro experiments confirmed the feasibility of using keratinocytes embedded within the EPNM: cell and culture viability, identity, purity and potency were determined. These experiments show that the skin cells are viable and can proliferate within the EPNM. The results presented are of a promising novel strategy for the development of personalised wound treatment, integrating on-the-spot 'printed' EPNM with autologous skin cells, which will be applied at the bedside, over deep dermal wounds, to accelerate healing time and wound closure.

The COVID-19 Pandemic Changed the Prevalence of Plastic Surgery in Israel.

BACKGROUND: In late 2019, a new strain of coronavirus (coronavirus disease 2019 [COVID-19]) spread rapidly throughout the world. The American Society of Plastic Surgeons reported a pandemic-related surge in the demand for aesthetic surgery compared to the same popularity of procedures prior to the pandemic. OBJECTIVES: To determine whether this phenomenon also occurred in Israel. METHODS: We collected data from three leading private medical centers in Tel Aviv. Data were compared for the years 2019 and 2020 by surgical procedure. Number of orthopedic, gynecologic, and hand procedures served as control data. RESULTS: We present a detailed pandemic-related timeline relevant to aesthetic surgery in Israel. Overall, the demand for aesthetic surgery increased, with a marked trend toward body contouring procedures. CONCLUSIONS: The Israeli aesthetic surgery market was affected by the COVID-19 pandemic, with a post-closure surge. The popularity and number of procedures are unique to the Israeli market.

Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial.

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms achieved similar reductions in wound area, non-viable tissue area and wound healing scores during the debridement period. There were no significant differences between the arms in the incidence of complete wound closure (41% in the EsxcharEx arm vs. 53% in the gel vehicle arm) and in the mean time to complete wound closure (70.0 ± 32.8 days in the EsxcharEx arm vs. 65.7 ± 38.4 days in gel vehicle arm). There were no significant safety issues and EscharEx demonstrated a favourable benefit to risk profile.

A Retrospective Review of an Off-label Bromelain-based Selective Enzymatic Debridement (Nexobrid®) in the Treatment of Deep, Partial, and Full Thickness Burns and Hard to Heal Wounds.

BACKGROUND: Rapid and selective bromelain-based enzymatic debridement provides a non-surgical alternative for the eschar removal in deep burns, which allows for early debridement of large surface areas, accurate evaluation of burn and wound depth, and the need for skin grafting. OBJECTIVES: To evaluate the efficacy of application of a bromelain-based selective enzymatic debridement (Nexobrid®) beyond the manufacturer's guidelines for use in burns > 48 hours as well as chemical, electrical, and pediatric burns, and chronic wounds. METHODS: This retrospective review included records collected between January 2017 and April 2019, from male and female patients aged 8 months to 99 years with deep burns or wounds treated with bromelain-based selective enzymatic debridement. RESULTS: Of the 33 patients who received the bromelain-based selective enzymatic debridement agent beyond the manufacturer's guidelines, 25 (76%) were observed to have successful debridement of the eschar, 8 (24%) were observed to have little effect on the burn eschar. Sixteen required further surgery after debridement. Clinical data on the use of bromelain-based selective enzymatic debridement agents are limited, but these results suggest the capacity to effectively debride burns > 48 hours (late presentation burns), use for pediatrics and for chemical and electrical burns, and apply to hard to heal full thickness chronic wounds. CONCLUSIONS: Bromelain-based selective enzymatic debridement was found to be an effective treatment modality beyond the recommended guidelines including late presentation burns and chronic wounds. This debridement method warrants further consideration when making clinical decisions concerning burn and wound care.

Standardization of Burn Patients Transfer: Implementation of a Transfer Request Form to Israel's National Burn Center.

BACKGROUND: Burn injuries are an extreme form of traumatic injury and are a global health issue. The Israeli National Burn Unit at the Sheba Medical Center, a tertiary level 1 trauma center and hence the national referral center, treats burn patients admitted both directly and referred from other medical centers. The transfer and handover of patients is a critical step in patient care. In Israel, to date, there is no standardized and accepted transfer request form for burn patients from one medical facility to another. OBJECTIVES: To construct a transfer request form to be used in all future burn patient referrals. METHODS: After reviewing publicly available international transfer forms and comparing them to the admission checklist used at our unit, a structured transfer request form was constructed. RESULTS: After a pilot study period, testing the form in various scenarios and adapting it, the first standardized transfer form for burn patients in Israel in both English and Hebrew was implemented beginning May 2020. CONCLUSIONS: Implementation of a standardized transfer process will improve communication between healthcare professionals to help maintain a continuum of care. We believe that implementation of a burn transfer form in all future referrals can standardize and assure better care for burn patients, thus improving overall patient care.

[MOHS MICROGRAPHIC SURGERY FOR CUTANEOUS MALIGNANT LESIONS EXCISION: EXPERIENCE OF A SINGLE TERTIARY MEDICAL CENTER IN ISRAEL].

AIMS: To review the literature, to present the experience with MMS of a single medical center in Israel and to compare findings to worldwide MMS trends. BACKGROUND: Mohs Micrographic Surgery (MMS) is a surgical technique that examines all of the cutaneous malignancy margins during surgery through precise mapping. This technique achieves the highest cure rates for cutaneous malignancies, while sparing normal tissue. The incidence of cutaneous malignancy is rising worldwide. The volume of Mohs surgeries increases as well. Therefore, physicians should gain knowledge about MMS utility in the treatment of cutaneous malignancy. This study is the first to be conducted is Israel and it aimed to present trends in the utilization of MMS. METHODS: A retrospective review of all MMS performed from 2012 to 2018 at the Sheba Medical Center. RESULTS: Overall, MMS technique was used in 3,795 cases. There was an upward trend in the utility volume of MMS during study period, from 372 cases in the year 2012 to 702 cases in 2017. We found an upward trend in the volume of MMS procedures within patients groups in the ages 65 to 74 and 75 years old and older. Male patients presented a double fold upward trend, in comparison to the female group. CONCLUSIONS: The upward trends found in this study correlate with the worldwide MMS trends and the rising incidence of cutaneous malignancy in Israel. More specialists are needed due to the increase in demand of MMS procedures.

[DIRECT TO IMPLANT IMMEDIATE BREAST RECONSTRUCTION USING THE FASCIAL SYSTEM IN THE INFRAMAMMARY FOLD, WITHOUT THE USE OF ACELLULAR DERMAL MATRIX].

AIMS: We present our experience of direct to implant breast reconstruction with total musculofascial coverage, without the use of ADM. BACKGROUND: The prevalence of one-stage breast reconstruction with silicone implants has increased markedly in recent years. This is attributed to advances in the surgical technique of mastectomy and to the increased rate of preventive mastectomy. The use of Acellular Dermal Matrix (ADM) became a common practice. Notwithstanding, ADM utilization may lead to higher postoperative complication rates. METHODS: Between 2015 to 2018, a prospective study was conducted at the Sheba Medical Center including all patients undergoing mastectomy and immediate breast reconstruction. In this study, we included patients who underwent direct to implant reconstruction with total musculofascial coverage, without the use of ADM. We gathered demographic, oncologic and surgical features, including post-operative complications, along with aesthetic outcome. RESULTS: A total of 20 patients (25 breasts) underwent direct to implant breast reconstruction with total musculofascial coverage. The overall complication rate was 24% (6 breasts). Minor complications (5 breasts, 20%) were manifested as delayed wound healing, minimal capsular contracture, skin necrosis and minor infection. A major complication of capsular contracture occurred in one patient. Corrective surgery due to aesthetic outcome was offered to 36% of the patients. nevertheless, only 16% chose to undergo an aesthetic reoperation. CONCLUSIONS: Immediate direct to implant breast reconstruction with total musculofascial coverage is an attractive option for single stage breast reconstruction with excellent aesthetic outcomes and low complication rates. Presumably, with a careful patient selection, the complication rates can be reduced even further.

A systematic review of Calendula officinalis extract for wound healing.

Use of complementary and alternative medicine for wound healing is influencing mainstream medical practice. This systematic review evaluates the role of Calendula officinalis flower extract as monotherapy compared to control for wound healing in vivo. Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus (up to April 2018) with 14 studies meeting the inclusion criteria, comprising 7 animal experiments and 7 clinical trials. Findings from the review on acute wound healing showed faster resolution of the inflammation phase with increased production of granulation tissue in the test groups treated with extract. These findings were consistent in five animal studies and one randomized clinical trial. Chronic wound healing studies were varied. Two clinical control studies on venous ulcers demonstrated decreased ulcer surface area compared to controls. Another randomized clinical trial demonstrated no improvement for the calendula group in diabetic leg ulcer healing. Burn healing similarly showed mixed results. Two animal studies demonstrated a prophylactic effect for the administration of calendula extract prior to burn injury. A randomized clinical trial of patients suffering from partial to full thickness burns demonstrated no benefit for topical application of calendula extract compared to controls. Two randomized clinical trials assessed the potential for extract to prevent acute post radiation dermatitis, with one study showing improvements compared to trolamine, while the other found no improvement compared to aqua gel cream. Animal studies provide moderate evidence for improved recovery from the inflammation phase and increased production of granulation tissue in calendula extract treatment groups. This review identified some evidence for the beneficial effects of C. officinalis extract for wound healing, consistent with its role in traditional medicine. There is a need for larger, well-designed randomized control trials to assess the effect of calendula on wound healing including complications.

Purpose-built national burns center: The Israeli experience.

The opening of the National Burns Center (NBC) in Sheba Medical Center (SMC) in 2014 was a keystone point in the development of specialized burns trauma services for Israel to ensure burn care and disaster planning at international standards. The NBC is a purpose-built, level 1 burns trauma center that receives patients from Israel, Gaza, West Bank, and abroad. Hosting six intensive care and four step-down burns beds, the center serves as a referral center for patients in other health-care facilities with indication for hospitalization. In the present study, we describe the planning, design, and organization of the NBC at the SMC with reference to some of the key areas and considerations in its conception and development. With the improved survival rates of patients with extensive burns and the demographics and characteristics among burn-injury patients in Israel, the NBC has the capacity to be the center of excellence in burns care, teaching, and research within the Middle East.

Q-Switched Nd:YAG Laser Removal of Facial Amateur Tattoos in Patients With Fitzpatrick Type VI: Case Series.

INTRODUCTION: Q-switched neodymium:YAG (Nd:YAG) lasers are reported to be gold standard for laser tattoo removal. In particular, the Q-switched Nd:YAG laser at 1064 nm is widely recognized for the removal of blue/black amateur tattoos. However, treatment modalities in Fitzpatrick Type VI skin carry a greater risk of complications including alterations in pigmentation compared to fairer skin (Fitzpatrick Type I-IV skin). Therefore, the aim of this case series was to describe with the use of the Q-Switched Nd:YAG laser, the removal of carbon-based amateur tattoos on patients with Fitzpatrick Type VI skin as an effective and safe method. METHODS: Twenty- five patients with Fitzpatrick type VI skin, from Ethiopian origins, with facial tribal tattoos, were treated with the Q- Switched Nd:YAG laser at 1064 nm. Digital images were taken upon every treatment and the clearance rates of the tattoo was evalu- ated by imaging software. RESULTS: We observed an average tattoo clearance rate of 95% among the 45 facial tattoos in 25 patients presented in the case series with minimal pigmentary and textual changes evident. DISCUSSION: These positive aesthetic results have a signi cant psychosocial impact on the lives of those with Fitzpatrick Type VI skin, in particular the Ethiopian Jewish population. J Drugs Dermatol. 2016;15(11):1448-1452..

The Impact of Autologous Fat Grafting on Breast Cancer: An Experimental Model Using Magnetic Resonance Imaging.

BACKGROUND: Although fat grafting is a common technique to repair defects after breast cancer reconstruction surgery and has a low complication rate, the relation between fat grafting and the risk of breast cancer is unknown. Clinical trials to investigate this connection can elucidate the benefits and potential risks of fat grafting in oncology patients. OBJECTIVES: To establish an efficient experimental model, using magnetic resonance imaging (MRI) scans, for comparing different breast tumor study groups post-fat grafting. METHODS: Breast tumor cells were injected into immunocompromised mice. After tumors formed they were removed. Liposuction was performed in a female human donor and fat was collected. Cells were extracted from the fat by enzymatic digestion. Immunocompromised mice were randomized into four groups: a preliminary experiment group and three equal groups according to the type of fat graft: (i) fresh fat enriched with adipose-derived mesenchymal stem cells (AdMSCs), (ii) fresh fat without cell enrichment, and (iii) no fat injected. Tumor volume was assessed by serial MRI scans. RESULTS: The rate of tumor growth was higher in the enriched fat group compared to the non-enriched fat group. CONCLUSIONS: This experimental model is an effective measurable method, allowing future investigation of the effect of autologous fat on breast cancer.

Adipocytes Viability After Suction-Assisted Lipoplasty: Does the Technique Matter?

BACKGROUND: Suction-assisted lipoplasty (SAL; liposuction) is an established aesthetic procedure in plastic surgery. The main parameters differentiating one method of lipoplasty from another are safety, consistency of results, and other more technical parameters. Due to the recent popularity of lipotransfer, the quality of extracted fat has become a relevant parameter. We compare the viability of extracted adipocytes after dry SAL, hyper-tumescent PAL (power-assisted lipoplasty), and water-assisted lipoplasty (WAL). METHODS: We used fluorescent microscopy to differentiate viable from necrotic/apoptotic cells after liposuction using each of the mentioned methods. RESULTS: The ratio of living cells between the three methods was significantly different with dry liposuction yielding inferior ratios (p = 0.011). When omitting extreme results, we found that the body-jet technique (WAL) yielded higher ratios of living cells than the hyper-tumescent technique (p < 0.001). The total number of cells was highest in the hyper-tumescent method (p = 0.013). CONCLUSIONS: Our results indicate that the hyper-tumescent technique yields the highest number of cells, whereas the body-jet technique yields the highest living cells ratio. The dry technique is clearly inferior to both. NO LEVEL ASSIGNED: 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 .

[BURNS IN ISRAEL: DEMOGRAPHIC, ETIOLOGIC AND CLINICAL FEATURES, 2004-2010].

BACKGROUND: The treatment of burn patients plays a major role in the health system, requiring numerous resources and extensively long hospitalizations. The treatment involves Intensive Care Units and the entire medical and para-medical staff. Currently, Israel has 5 designated burn units, strategically scattered all over the country. Recently, due to some major burn disasters, reevaluation of the demography, etiology and clinical features of burns has been conducted. OBJECTIVES: The study entails quantity and quality evaluations of burn victims in Israel between the years 2004 and 2010, identification of high risk populations and recent demographic, etiological and clinical trends. METHODS: A data analysis was conducted of all the burn patients hospitalized in Israel's 5 trauma centers' burn units between the years 2004 and 2010 according to the Israeli Trauma Registry (ITR). RESULTS: Between the years 2004 and 2010, 5270 burn victims were hospitalized in five trauma centers burn units. The average hospitalization period was 11.67 days, while the mortality rate was 3.72%. High risk populations were identified as babies up to 2 years old and the non-Jewish population. DISCUSSION: High risk populations were identified, such as young babies and the non-Jewish population. These groups should be addressed specifically with proper publicity and information. Even though mortality rates were stable, the mean hospitalization length is declining over the years, possibly secondary to advanced dressing and ambulatory treatments.

Efficacy of transfer form implementation for adult burn patients between institutions to the Israeli National Burn Center.

Burns are serious injuries associated with significant morbidity and mortality. In Israel, burn patients are often transferred between facilities. However, unstructured and non-standardized transfer processes can compromise the quality of patient care and outcomes. In this retrospective study, we assessed the impact of implementing a transfer form for burn management, comparing two populations: those transferred before and after the transfer form implementation. This study included 47 adult patients; 21 were transferred before and 26 after implementing the transfer form. We observed a statistically significant improvement in reporting rates of crucial information obtained by Emergency Room clinicians and inpatient management indicators. Introducing a standardized transfer form for burn patients resulted in improved communication and enhanced primary management, transfer processes, and emergency room preparation. The burns transfer form facilitated accurate and comprehensive information exchange between clinicians, potentially improving patient outcomes. These findings highlight the importance of structured transfer processes in burn patient care and emphasize the benefits of implementing a transfer form to streamline communication and optimize burn management during transfers to specialized burn centers.

Spincare System Demonstrates Safety and Efficacy in Treating Partial-Thickness Burns.

Partial-thickness burns are the most common form of burns, affecting the dermis and possibly resulting in scarring and infection. The Spincare System is a new device that uses electrospinning technology to create a temporary skin-like matrix that can be applied to wounds. This study evaluated the performance, safety, and efficacy of Spincare in treating superficial to partial-thickness burns not considered for surgery. A prospective single-arm, open-label, multicenter study was conducted in 3 adult burn units across Israel. Forty-four patients with superficial to intermediate burns of up to 10% of TBSA were enrolled. Spincare was applied to the wounds, and follow-up visits were performed on days 7, 14, and 21 and months 3 and 6 posttreatment. Thirty-one patients with 36 wounds completed the day 21 visit. The mean wound healing area on day 21 was 97.26 ± 9.41%, and the mean healing time was 12.8 ± 4.3 days. Only one moderate adverse event was observed concerning the treatment, and it is important to acknowledge the potential progression of this hypertrophic scar into a keloid. This study demonstrated that Spincare is a safe and effective device for treating superficial to intermediate partial-thickness burns. Spincare achieved rapid and complete wound healing with a low incidence of adverse events.

Comparison of stationary and dynamic fractional CO2 laser modalities of large burns treatment: Experimental laboratory model.

OBJECTIVES: To experimentally compare two fractional ablative CO2 laser handpieces intended for the treatment of large area burn scars. Each handpiece coverage rate, depth of penetration and application time were measured and compared in a simulation model of large area burns scars using a dynamic/roller handpiece (small footprint) and a stationary/stamping handpiece (large footprint). METHODS: A 30 W fractional ablative CO2 laser was applied using 2 different handpieces and footprints on a A4 size paper stack. The handpieces were a stationary (stamping) handpiece with 7 × 7 (49 pixels/square shape) and dynamic (roller) handpiece with 7 × 1 (7 pixels/single row shape). For both handpieces the laser settings were fixed at "High" power (30 W), providing an energy level of 100 mJ/pixel. Both handpieces were applied perpendicular to the surface, with the process repeated for the dynamic handpiece with an angled operation. The depth of laser penetration was assessed by the number of pages of paper having visible holes and burn area coverage time measured under each handpiece/condition. RESULTS: The application time was faster and the penetration deeper for the dynamic handpiece compared to the stationary handpiece in both the perpendicular and angled conditions. This study has practical implications for lasers operators to improve time efficacy in large area scars with improved clinical endpoints. CONCLUSION: The fractional ablative dynamic handpiece demonstrated superior application efficiency compared to the stationary handpiece in the simulated treatment of large surface area burn scars, reducing treatment time with improved depth of penetration.

The Implications of a Dermatopathologist's Report on Melanoma Diagnosis and Treatment.

An accurate and comprehensive histopathology report is essential for cutaneous melanoma management, providing critical information for accurate staging and risk estimation and determining the optimal surgical approach. In many institutions, a review of melanoma biopsy specimens by expert dermatopathologists is considered a necessary step. This study examined these reviews to determine the critical primary histopathology Breslow score in which a histopathology review would be most beneficial. Histopathology reports of patients referred to our institute between January 2011 and September 2019 were compared with our in-house review conducted by an expert dermatopathologist. The review focused on assessing fundamental histologic and clinical prognostic features. A total of 177 specimens underwent histopathology review. Significant changes in the Breslow index were identified in 103 cases (58.2%). Notably, in many of these cases (73.2%), the revised Breslow was higher than the initially reported score. Consequently, the T-stage was modified in 51 lesions (28.8%). Substantial discordance rates were observed in Tis (57%), T1b (59%), T3a (67%) and T4a (50%) classifications. The revised histopathology reports resulted in alterations to the surgical plan in 15.3% of the cases. These findings emphasize the importance of having all routine pathologies of pigmented lesions referred to a dedicated cancer center and reviewed by an experienced dermatopathologist. This recommendation is particularly crucial in instances where the histopathology review can potentially alter the diagnosis and treatment plan, such as in melanoma in situ and thinner melanomas measuring 0.6-2.2 mm in thickness. Our study highlights the significant impact of histopathology reviews in cutaneous melanoma cases. The observed changes in Breslow scores and subsequent modifications in T-stage classification underline the need for thorough evaluation by an expert dermatopathologist, especially in cases of melanoma in situ and thin melanomas. Incorporating such reviews into routine practice within dedicated cancer centers can improve diagnostic accuracy and guide appropriate treatment decisions, ultimately leading to better patient outcomes.

Reconstruction of full-thickness defects with bovine-derived collagen/elastin matrix: a series of challenging cases and the first reported post-burn facial reconstruction.

Reconstruction of full-thickness defects may benefit from integration of dermal substitutes, which serve as a foundation for split-thickness skin grafts, thus enhancing short and long-term results. We present a series of 7 patients who were treated between 2010 and 2012 for complicated full-thickness defects by the second-generation collagen/elastin matrix Matriderm® covered by a split-thickness skin graft. The defects resulted from malignancy resection, trauma, and post-burn scar reconstruction. Overall graft take was excellent and no complications were noted regarding the dermal substitute. Graft quality was close to normal skin in terms of elasticity, pliability, texture, and color. Good contour and cushioning of defects in weight bearing areas was also achieved. Matriderm was found to be a useful adjunct to full-thickness defect reconstruction, especially in difficult areas where the desired result is a scar of the highest quality possible.

Novel Technologies in Chronic Wound Care.

In Israel, 20% of wounds do not progress to full healing under treatment with conservative technologies of which 1 to 2% are eventually defined as chronic wounds. Chronic wounds are a complex health burden for patients and pose considerable therapeutic and budgetary burden on health systems. The causes of chronic wounds include systemic and local factors. Initial treatment involves the usual therapeutic means, but as healing does not progress, more advanced therapeutic technologies are used. Undoubtedly, advanced means, such as negative pressure systems, and advanced technologies, such as oxygen systems and micrografts, have vastly improved the treatment of chronic wounds. Our service specializes in treating ulcers and difficult-to-heal wounds while providing a multiprofessional medical response. Herein, we present our experience and protocols in treating chronic wounds using a variety of advanced dressings and technologies.