Nipple-areola complex prosthesis as a new arsenal for breast reconstruction

Nipple and areola complex (NAC) recreating is primordial to achieve a complete breast reconstruction. Some patients would not benefit or choose to undergo surgical or tattoo NAC reconstruction. Recently, innovative NAC silicone prostheses have been developed that are applied over the skin and come in various shapes, sizes, and colors to match different NAC tones and sizes. Our prospective study aims to evaluate for the first time, to our knowledge, the safety of these prostheses and patients' and surgeons' satisfaction using a 30-day survey. Twenty patients using these NAC prostheses after unilateral breast reconstruction postmastectomy with NAC excision were included. All patients except one (95%) were satisfied/very satisfied with the aspect and symmetry of NAC prostheses compared with native contralateral NAC. All patients were more/much more satisfied with their body image and self-esteem using the NAC prostheses. Except for 2 (90%), no participant presented any skin reaction, infection, or erosion. Most patients (68.75%) used the prosthesis every day, and others-occasionally. All participants stated they would recommend these prostheses to other women as a temporary or definitive solution. With these promising results demonstrating a high safety and satisfaction rate, we are confident that this simple, safe, noninvasive, and cost-effective device should be proposed to all patients to improve the management of breast reconstruction and offer body integrity to patients. Health insurance should consider reimbursement for these prostheses in patients after mastectomy or with NAC deformation after trauma, surgery, or congenital.

Adipose-Derived Stromal Cells within a Gelatin Matrix Acquire Enhanced Regenerative and Angiogenic Properties: A Pre-Clinical Study for Application to Chronic Wounds

This study evaluates the influence of a gelatin sponge on adipose-derived stromal cells (ASC). Transcriptomic data revealed that, compared to ASC in a monolayer, a cross-linked porcine gelatin sponge strongly influences the transcriptome of ASC. Wound healing genes were massively regulated, notably with the inflammatory and angiogenic factors. Proteomics on conditioned media showed that gelatin also acted as a concentrator and reservoir of the regenerative ASC secretome. This secretome promoted fibroblast survival and epithelialization, and significantly increased the migration and tubular assembly of endothelial cells within fibronectin. ASC in gelatin on a chick chorioallantoic membrane were more connected to vessels than an empty sponge, confirming an increased angiogenesis in vivo. No tumor formation was observed in immunodeficient nude mice to which an ASC gelatin sponge was transplanted subcutaneously. Finally, ASC in a gelatin sponge prepared from outbred rats accelerated closure and re-vascularization of ischemic wounds in the footpads of rats. In conclusion, we provide here preclinical evidence that a cross-linked porcine gelatin sponge is an optimal carrier to concentrate and increase the regenerative activity of ASC, notably angiogenic. This formulation of ASC represents an optimal, convenient and clinically compliant option for the delivery of ASC on ischemic wounds.

Isolation and Characterization of Stem Cells from the Anal Canal Transition Zone in Pigs

BACKGROUND

Utilization of autologous stem cells has been proposed for the treatment of anal incontinence despite a lack of understanding of their mechanism of action and of the physiological healing process of anal sphincters after injury.

AIMS

We aim to develop a technique allowing isolation and further study of local mesenchymal stem cells, directly from anal canal transition zone in pig.

METHODS

Anal canal was resected "en bloc" from two young pigs and further microdissected. The anal canal transition zone was washed and digested with 0.1% type I collagenase for 45 min at 37 °C. The isolated cells were plated on dishes in mesenchymal stem cell medium and trypsinized when confluent. Cells were further used for flow cytometry analysis and differentiation assays.

RESULTS

The anal canal transition zone localization was confirmed with H&E staining. Following culture, cells exhibited a typical "fibroblast-like" morphology typical of stem cells. Isolated cells were positive for CD90 and CD44 but negative for CD14, CD34, CD45, CD105, CD106, and SLA-DR. Following incubation with specific differentiation medium, isolated cells differentiated into adipocytes, osteoblasts, and chondrocytes, confirming in vitro multipotency.

CONCLUSIONS

Herein, we report for the first time the presence of mesenchymal stem cells in the anal canal transition zone in pigs and the feasibility of their isolation. This preliminary study opens the path to the isolation of human anal canal transition zone mesenchymal stem cells that might be used to study sphincters healing and to treat anal incontinence.

NADPH oxidase 4 is dispensable for skin myofibroblast differentiation and wound healing

Differentiation of fibroblasts to myofibroblasts is governed by the transforming growth factor beta (TGF-β) through a mechanism involving redox signaling and generation of reactive oxygen species (ROS). Myofibroblasts synthesize proteins of the extracellular matrix (ECM) and display a contractile phenotype. Myofibroblasts are predominant contributors of wound healing and several pathological states, including fibrotic diseases and cancer. Inhibition of the ROS-generating enzyme NADPH oxidase 4 (NOX4) has been proposed to mitigate fibroblast to myofibroblast differentiation and to offer a therapeutic option for the treatment of fibrotic diseases. In this study, we addressed the role of NOX4 in physiological wound healing and in TGF-β-induced myofibroblast differentiation. We explored the phenotypic changes induced by TGF-β in primary skin fibroblasts isolated from Nox4-deficient mice by immunofluorescence, Western blotting and RNA sequencing. Mice deficient for Cyba, the gene coding for p22^phox, a key subunit of NOX4 were used for confirmatory experiments as well as human primary skin fibroblasts. In vivo, the wound healing was similar in wild-type and Nox4-deficient mice. In vitro, despite a strong upregulation following TGF-β treatment, Nox4 did not influence skin myofibroblast differentiation although a putative NOX4 inhibitor GKT137831 and a flavoprotein inhibitor diphenylene iodonium mitigated this mechanism. Transcriptomic analysis revealed upregulation of the mitochondrial protein Ucp2 and the stress-response protein Hddc3 in Nox4-deficient fibroblasts, which had however no impact on fibroblast bioenergetics. Altogether, we provide extensive evidence that NOX4 is dispensable for wound healing and skin fibroblast to myofibroblast differentiation, and suggest that another H₂O₂-generating flavoprotein drives this mechanism.

Epigenetic remodeling of downstream enhancer regions is linked to selective expression of the IL1F10 gene in differentiated human keratinocytes

Interleukin (IL)-38, encoded by the IL1F10 gene, is a member of the IL-1 family of cytokines. IL-38 is constitutively expressed in epithelia in healthy humans, and in particular in epidermal keratinocytes in the skin. IL-38 expression is closely correlated with keratinocyte differentiation. The aim of this study was to further characterize the regulation of IL1F10 expression and the mechanisms involved in its selective induction in differentiated human keratinocytes. We observed coordinated expression of two IL1F10 transcripts, transcribed from two different promoters, upon differentiation of primary human keratinocytes. Using ENCODE datasets and ChIP-qPCR on ex vivo isolated normal human epidermis, we identified regulatory regions located downstream of the IL1F10 gene, which displayed features of differentiated keratinocyte-specific enhancers. Expression of the IL1F10 gene was linked to changes in the epigenetic landscape at these downstream enhancer regions in human epidermis. Overexpression of the transcription factors KLF4 and TAp63β in an immortalized normal human keratinocyte (iNHK) cell line promoted the expression of mRNA encoding the differentiation markers keratin 10 and involucrin, and of IL1F10. ChIP-qPCR experiments indicated that KLF4 and TAp63β overexpression also modified the chromatin state of the proximal downstream enhancer region, suggesting a role for KLF4 and TAp63β in directly or indirectly regulating IL1F10 transcription. In conclusion, expression of the IL1F10 gene in differentiated keratinocytes in normal human epidermis involves coordinated transcription from two promoters and is linked to epigenetic remodeling of enhancer regions located downstream of the gene.

Defining the Ideal Breast Reconstruction Procedure After Mastectomy From the Patient Perspective: A Retrospective Analysis

Background:

An increasing number of breast cancer patients undergo immediate or secondary breast reconstruction, but the ideal method in terms of patient satisfaction remains ambiguous. We compared the 3 most common breast reconstruction techniques to determine patient satisfaction and objective outcomes.

Methods:

Retrospective study of 184 patients with breast cancer who underwent a reconstructive procedure between 1993 and 2011 at our institution. Procedures evaluated were implant-based reconstruction (IBR) alone, latissimus dorsi (LD) flap reconstruction with/without implant, and deep inferior epigastric perforator (DIEP) free flap reconstruction. A retrospective patient satisfaction questionnaire was sent to all women. Twenty patients from each subgroup were matched to conduct a standardized objective assessment of the sensitivity of their reconstructed breast. A blinded photographic evaluation was also performed by 3 independent observers to assess the esthetic aspect and symmetry.

Results:

DIEP obtained significantly higher average scores regarding the esthetic outcome, immediate reconstruction impact, and overall score in the questionnaire evaluation. The IBR had the best results in the somatosensory evaluation, with DIEP scoring better than LD. DIEP received higher scores on average than LD for the criteria of size and symmetry in the esthetic evaluation. No statistically significant differences were observed between IBR and DIEP.

Conclusions:

Good results were reported overall for all breast reconstruction procedures, with more reserved scores for LD. The DIEP reconstruction appeared to be the most satisfactory and best experienced reconstruction method for patients, despite the complexity of the intervention. Clinicians should be encouraged to consider DIEP as the principal choice for breast reconstruction.

IL-25 participates in keratinocyte-driven dermal matrix turnover and is reduced in Systemic Sclerosis epidermis

OBJECTIVES

Evidence shows that dysfunctional SSc keratinocytes contribute to fibrosis by altering dermal homeostasis. Whether interleukin-25 (IL-25), an IL-17 family member regulating many epidermal functions, takes part in skin fibrosis is unknown. Here we address the role of IL-25 in skin fibrosis.

METHODS

The expression of IL-25 was evaluated by immunofluorescence and in situ hybridization in 10 SSc and 7 healthy donors (HD) skin biopsies. Epidermal equivalents (EE) reconstituted by primary HD keratinocytes were used as a model to study transcriptomic changes induced by IL-25 in the epidermis. RNA expression profile in EE was characterized by RNAseq. The conditioned medium (CM) from primary SSc and HD keratinocytes primed with IL-25 was used to stimulate fibroblasts. IL-6, IL-8, MMP-1, type-I collagen (col-I), and fibronectin production by fibroblasts was assessed by ELISA.

RESULTS

SSc epidermis expressed lower levels of IL-25 compared with HD. In EE, IL-25 regulated several molecular pathways related to wound healing and ECM remodeling. Compared with control CM, the CM from IL-25-primed keratinocytes enhanced the fibroblast production of MMP-1, IL-6, IL-8, but not of Col-I nor fibronectin. However, IL-25 significantly reduced the production of Col-I when applied directly to fibroblasts. The activation of keratinocytes by IL-25 was receptor-dependent and evident after a very short incubation time (10 min), largely mediated by IL-1, suggesting enhanced and specific release of preformed mediators.

CONCLUSIONS

These results show that IL-25 participates to skin homeostasis and its decreased expression in SSc may contribute to skin fibrosis by favoring ECM deposition over degradation.

Adipose-derived stem cell spheroids are superior to single-cell suspensions to improve fat autograft long-term survival

Autologous fat transplantation is a widely used procedure for surgical reconstruction of tissues. The resorption rate of this transplantation remains high and unpredictable, reinforcing the need of adjuvant treatments that increase the long‐term stability of grafts. Adipose‐derived stem cells (ASC) introduced as single cells in fat has been shown clinically to reduce the resorption of fat grafts. On the other hand, the formulation of ASC into cell spheroids results in the enhancement of their regenerative potential. In this study, we developed a novel method to produce highly homogeneous ASC spheroids and characterized their features and efficacy on fat transplantation. Spheroids conserved ASC markers and multipotency. A regenerative gene expression profile was maintained, and genes linked to autophagy were upregulated whereas proliferation was decreased. Their secreted proteome was enriched in comparison with single‐cell ASC suspension. Addition of spheroids to fat graft in an animal model of transplantation resulted in a better graft long‐term stability when compared to single ASC suspension. In conclusion, we provide a novel method to manufacture homogenous ASC spheroids. These ASC spheroids are superior to ASC in single‐cell suspension to improve the stability of fat transplants, reinforcing their potential in reconstructive surgery.

Free-flap breast reconstruction: cost analysis in the Swiss healthcare system

AIM OF THE STUDY

Breast cancer is the most common type of malignancy among women. Mastectomy maintains an essential role in oncological therapy and led to the development of breast reconstruction procedures. The deep inferior epigastric perforator (DIEP) free flap became in the last decade a popular approach for breast reconstruction. Although this procedure is known to be more complex than other techniques, it offers one of the highest patient satisfaction rates. However, the cost-effectiveness of this technique has rarely been assessed; and the real cost coverage by health insurance has never been studied. This study estimated the real cost of immediate DIEP free flap breast reconstruction after unilateral mastectomy and evaluated the cost coverage by healthcare insurers according to the diagnosis-related group (DRG) reimbursement scheme in Switzerland.

METHODS

Medical files of 20 consecutive patients who underwent immediate DIEP free-flap breast reconstruction between 2012 and 2017 were reviewed retrospectively. Billing data according to DRG rates were compared with an estimation of the real cost generated by the procedure.

RESULTS

The mean charge according to the DRG model for one-stage DIEP free-flap reconstruction was CHF 29,573 (CHF 19,256–64,741). The mean real estimated cost was CHF 33,416 (CHF 20,633–47,036). Seven different DRG codes were used between 2012 and 2017, each offering a different definition and compensation.

CONCLUSION

The DRG pricing scheme evolves through annual revisions. Progressively, more specific codes were created and used, allowing a better cost coverage for the procedure. Since 2017, the use of the dedicated code J01B has resulted in adequate cost coverage of the procedure. Since it has been widely accepted that DIEP breast reconstruction has advantages such as high patient satisfaction, we encourage the inclusion of this procedure in the reconstructive arsenal of breast cancer centres in Switzerland.

[Training in reconstructive surgery in sub-Saharan Africa : the « 2nd Chance » model]

Based in Geneva since 2010, 2^nd Chance's mission is the development of reconstructive surgery care in resource-limited countries with a focus on sub-Saharan Africa, through teaching and advocacy activities. We develop the surgical management of patients on the one hand, providing training for African surgical teams. On the other hand, we support surgical procedures for patients, in the areas of reconstructive surgery, giant goiters, obstetric fistulas and anesthesia so that quality care is guaranteed for the long term. Despite the hurdles caused by the COVID crisis, training programs resumed at the end of 2020, with the implementation of the 2021-2025 strategy focusing on patient care and follow-up in the surgical setting through improved peri-operative safety and prevention of complications.

Angiogenesis Is Differentially Modulated by Platelet-Derived Products

Platelet-derived preparations are being used in clinic for their role in tissue repair and regenerative processes. The release of platelet-derived products such as autologous growth factors, cytokines and chemokines can trigger therapeutic angiogenesis. In this in vitro study, we evaluated and compared the ability of three platelet-derived preparations: platelet-rich-plasma (PRP), PRP-hyaluronic acid (PRP-HA) and platelet lysates (PL) at various concentrations (5–40%) to modulate human umbilical vein endothelial cells (HUVEC) biological effects on metabolism, viability, senescence, angiogenic factors secretion and angiogenic capacities in 2D (endothelial tube formation assay or EFTA) and in 3D (fibrin bead assay or FBA). HUVEC exocytosis was stimulated with PRP and PRP-HA. Cell viability was strongly increased by PRP and PRP-HA but mildly by PL. The three preparations inhibit HUVEC tube formation on Matrigel, while PRP enhanced the complexity of the network. In the fibrin bead assay (FBA), PRP and PRP-HA stimulated all steps of the angiogenic process resulting in massive sprouting of a branched microvessel network, while PL showed a weaker angiogenic response. Secretome profiling revealed modulation of 26 human angiogenic proteins upon treatment with the platelet derived preparations. These in vitro experiments suggest that PRP and PRP-HA are effective biological therapeutic tools when sustained therapeutic angiogenesis is needed.

Production of Autologous Platelet-Rich Plasma for Boosting In Vitro Human Fibroblast Expansion

There is currently great clinical interest in the use of autologous fibroblasts for skin repair. In most cases, culture of skin cells in vitro is required. However, cell culture using xenogenic or allogenic culture media has some disadvantages (i.e., risk of infectious agent transmission or slow cell expansion). Here, an autologous culture system is developed for the expansion of human skin fibroblast cells in vitro using a patient's own platelet-rich plasma (PRP). Human dermal fibroblasts are isolated from the patient while undergoing abdominoplasty. Cultures are followed for up to 7 days using a medium supplemented with either fetal bovine serum (FBS) or PRP. Blood cell content in PRP preparations, proliferation, and fibroblast differentiation are assessed. This protocol describes the method for obtaining a standardized, non-activated preparation of PRP using a dedicated medical device. The preparation requires only a medical device (CuteCell-PRP) and centrifuge. This device is suitable under sufficient medical practice conditions and is a one-step, apyrogenic, and sterile closed system that requires a single, soft spin centrifugation of 1,500 x g for 5 min. After centrifugation, the blood components are separated, and the platelet-rich plasma is easily collected. This device allows a quick, consistent, and standardized preparation of PRP that can be used as a cell culture supplement for in vitro expansion of human cells. The PRP obtained here contains a 1.5-fold platelet concentration compared to whole blood together, with a preferential removal of red and white blood cells. It is shown that PRP presents a boosting effect in cell proliferation compared to FBS (7.7x) and that fibroblasts are activated upon PRP treatment.

Submammary placement of neurostimulator devices: broadening the spectrum of cosmetic techniques

Deep brain neurostimulators (DBS) have enabled thousands of individuals to overcome movement disorders, thus offering them a new chance for social integration while enhancing their self-esteem. A classic DBS consists of a central implantable pulse generator (IPG) and its respective wires and leads that extend to the scalp to reach the brain. The classic positioning of the generator is currently subcutaneous, usually just below the clavicle or in the abdominal wall. As DBS systems are of a substantial size, this subcutaneous placement leads to unsightly and visible devices, particularly in thin patients. We report two cases of female patients who benefited from our technique to hide the IPG under the breast parenchyma. IPGs were placed through an inframammary incision in a subglandular pocket, similar to the technique used for implant-based breast augmentation. In the first case, the devices were implanted in a subglandular pocket and replaced 5 years later due to battery life limitation. In the second case, the devices were replaced from a subclavicular position to a submammary one. No major or minor complications were observed. Both patients reported an excellent level of satisfaction with the aesthetic and functional outcome. Despite the significant quality of life improvement of patients with DBS, the ideal implantation of the generator should also take into consideration the comfort and cosmetic aspects. Our approach has the potential to markedly improve the aesthetic outcome of such an intervention.

Level of evidence: Level V, therapeutic study.

Dysfunctional Keratinocytes Increase Dermal Inflammation in Systemic Sclerosis: Results From Studies Using Tissue-Engineered Scleroderma Epidermis

OBJECTIVE

Evidence suggests that keratinocyte-fibroblast interactions are abnormal in systemic sclerosis (SSc). The present study was undertaken to investigate potential epidermal dysfunction in SSc and its effects on dermal homeostasis.

METHODS

Epidermal equivalents (EEs) were generated using keratinocytes from 6 healthy donors and 4 individuals with SSc. Skin and EE expression of markers of proliferation, differentiation, and activation was evaluated by immunohistochemistry. The transcriptomic profile of SSc EEs and healthy donor EEs was identified by RNA sequencing. EE conditioned medium (CM) was used to stimulate fibroblasts, and their production of interleukin-6 (IL-6), IL-8, matrix metalloproteinase 1 (MMP-1), type I collagen, and fibronectin was assessed by enzyme-linked immunosorbent assay.

RESULTS

Compared to healthy donor EEs, SSc EEs exhibited aberrant differentiation, enhanced expression of activation markers, and a lower rate of basal keratinocyte mitosis, reproducing most of the abnormalities observed in SSc epidermis. RNA sequencing analysis revealed that, compared to healthy donor EEs, SSc EEs were characterized by lower expression of homeobox gene family members and by enhanced metabolic and oxidative stress molecular pathways. EE CM enhanced fibroblast production of IL-6, IL-8, MMP-1, type I collagen, and fibronectin (P < 0.05). Except for type I collagen and fibronectin, this effect was 2-fold higher in the presence of CM generated form SSc EEs. IL-1 was responsible, at least in part, for keratinocyte-dependent fibroblast activation.

CONCLUSION

SSc EEs recapitulate the in vivo characteristics of SSc epidermis, demonstrating that SSc keratinocytes have an intrinsically altered differentiation program, possibly due to the dysregulation of genes from the homeobox family. The increased metabolic and oxidative stress associated with SSc epidermis may contribute to chronic inflammation and fibrosis of the dermis.

Granulomas and nongranulomatous nodules after filler injection: Different complications require different treatments

Dermal fillers are widely used for facial rejuvenation and reconstruction and present fewer risks than surgical approaches. Nevertheless, several complications may occur, including nodule formation. A nodule is a clinical sign corresponding to different etiologies, such as overcorrection, infection, allergic reaction, or granuloma. However, their treatment represents a diagnostic challenge. We present a retrospective review of 26 consecutive patients who underwent a biopsy for facial nodule formation more than 3 months after filler injections, to determine the diagnosis of the nodule and type of filler used. All patients were women (mean age, 57.8 years). Some patients suffered from different localizations: lip, 14 cases; nasolabial folds, 6; cheeks, 5; infraorbital region, 5; the glabella, 2; the temporal region, 1; and chin, 1 case. Only 5 (19.2%) patients knew the type of filler used, and in another 4 cases, the injector was able to provide some information. In 65.4% of cases, the filler type was unknown. Histopathological analysis revealed a "granulomatous" nodule in 30 sites and a "non-granulomatous" nodule in 4 cases. Concerning the type of filler, 5 different histopathological patterns were found. Our results demonstrate that a clinical history and histopathological analysis whether to confirm or not to confirm the diagnosis of granuloma and to identify the type of filler are essential tools to achieve an accurate diagnosis of the problem-oriented treatment of nodules after dermal filler injections. We propose an algorithm for the management of nodules after filler injection.

Severe frostbite complication after cryolipolysis: A case report

This case report describes a full-thickness frostbite complication following cryolipolysis for subcutaneous fat reduction performed in a non-medical esthetic clinic. The deep and large abdominal wound (15 × 12 cm) required hospitalization and multiple surgical debridement before a two-step direct closure. Even though cryolipolysis is considered as a non-invasive and safe technique to reduce local adiposity, it could present some side-effects and complications. Health-care professionals should be aware of these risks and inform their patients about its potential sequelae.

Optimisation of phytochemical characteristics and antioxidative properties of Foeniculum vulgare Mill. seeds and Ocimum basilicum L. leaves superfine powders using new parting process

INTRODUCTION

Fennel (Foeniculum vulgare Mill.) and basil (Ocimum basilicum L.) are two aromatic medicinal plants. Recently, a new parting process which is named CDS "Comminution and to control Diffraction Sieving" is taken into consideration and its positive effect on the extraction of bioactive compounds from the plants, without any solvent, is reported.

OBJECTIVE

Study the effect of CDS on phytochemical properties of superfine powders of fennel seeds and basil leaves.

METHODS

Fennel seeds and basil leaves superfine powders were fractionated as follows: 100-180 μm, 180-315 μm, 315-500 μm, > 500 μm and unsieved superfine powders. Extraction of polyphenols was carried out using hydromethanolic maceration. The essential oils were extracted by maceration with dichloromethane. The antioxidant activities were evaluated by DPPH (2,2-diphenyl-1-picrylhydrazyl) assay. Using liquid chromatography ultraviolet electrospray ionisation mass spectrometry (LC-UV-ESI-MS), concentrations of characterised phenolic compounds were measured. The essential oils compositions were characterised using gas chromatography mass spectrometry (GC-MS).

RESULTS

In fennel seeds, the 100-180 μm fraction had maximum antioxidant activity and LC-UV-ESI-MS analyses proved that the best extraction of certain polyphenols was obtained in the 100-180 μm fraction. In basil leaves, the best antioxidant activity corresponded to the 315-500 μm fraction and LC-UV-ESI-MS analyses showed that the polyphenols were concentrated in the < 315 μm fractions. For both plants, GC-MS presented that the essential oils were concentrated in the 315-500 μm fraction.

CONCLUSION

CDS as a new green parting process leads to improve the phytochemical properties of these two superfine plant powders in the specific granulometric classes.

Interleukin-38 interacts with destrin/actin-depolymerizing factor in human keratinocytes

Interleukin (IL)-38 is a member of the IL-1 family of cytokines, which was proposed to exert anti-inflammatory effects. IL-38 is constitutively expressed in the skin, where keratinocytes are the main producing cells. Little information is currently available concerning IL-38 biology. Here, we investigated the subcellular localization and interaction partners of the IL-38 protein in human keratinocytes. IL-38 expression was reduced in primary keratinocytes grown in monolayer (2D) cultures. We thus used IL-38 overexpressing immortalized normal human keratinocytes (NHK/38) to study this cytokine in cell monolayers. In parallel, differentiation of primary human keratinocytes in an in vitro reconstructed human epidermis (RHE) 3D model allowed us to restore endogenous IL-38 expression. In NHK/38 cells and in RHE, IL-38 was mainly cell-associated, rather than released into culture supernatants. Intracellular IL-38 was preferentially, although not exclusively, cytoplasmic. Similarly, in normal human skin sections, IL-38 was predominantly cytoplasmic in the epidermis and essentially excluded from keratinocyte nuclei. A yeast two-hybrid screen identified destrin/actin-depolymerizing factor (DSTN) as a potential IL-38-interacting molecule. Co-immunoprecipitation and proximity ligation assay confirmed this interaction. We further observed partial co-localization of IL-38 and DSTN in NHK/38 cells. Endogenous IL-38 and DSTN were also co-expressed in all epidermal layers in RHE and in normal human skin. Finally, IL-38 partially co-localized with F-actin in NHK/38 cells, in particular along the cortical actin network and in filopodia. In conclusion, IL-38 is found predominantly in the cytoplasm of human keratinocytes, where it interacts with DSTN. The functional relevance of this interaction remains to be investigated.

Fate of systemically and locally administered adipose-derived mesenchymal stromal cells and their effect on wound healing

There is increasing interest in the use of adipose‐derived mesenchymal stromal cells (ASCs) for wound repair. As the fate of administered cells is still poorly defined, we aimed to establish the location, survival, and effect of ASCs when administered either systemically or locally during wound repair under physiological conditions. To determine the behavior of ASCs, a rat model with wounds on the dorsal aspect of the hind paws was used and two treatment modes were assessed: ASCs administered systemically into the tail vein or locally around the wound. ASCs were transduced to express both firefly luciferase (Fluc) and green fluorescent protein to enable tracking by bioluminescence imaging and immunohistological analysis. Systemically administered ASCs were detected in the lungs 3 hours after injection with a decrease in luminescent signal at 48 hours and signal disappearance from 72 hours. No ASCs were detected in the wound. Locally administered ASCs remained strongly detectable for 7 days at the injection site and became distributed within the wound bed as early as 24 hours post injection with a significant increase observed at 72 hours. Systemically administered ASCs were filtered out in the lungs, whereas ASCs administered locally remained and survived not only at the injection site but were also detected within the wound bed. Both treatments led to enhanced wound closure. It appears that systemically administered ASCs have the potential to enhance wound repair distally from their site of entrapment in the lungs whereas locally administered ASCs enhanced wound repair as they became redistributed within the wound bed.

Keloid treatment: what about adjuvant radiotherapy?

Background: Keloids are debilitating fibrous skin proliferations with a high recurrence rate after surgical treatment. Postoperative radiotherapy (PORT) is a well-tolerated adjuvant treatment to reduce the risk of recurrence, but the optimal regimen for this combined treatment remains unknown. The aim of this study is to evaluate the efficacy of combining surgical excision and immediate PORT.

Methods: We retrospectively reviewed the records of patients with keloid lesions treated with adjuvant PORT in the period 2005–2014 at Geneva University Hospitals. Main outcomes were the rates of complications and recurrence in patients with a minimal follow-up of 1 year, including the Patient and Observer Scar Assessment Scale satisfaction scores.

Results: 10 patients with 16 keloids were eligible (mean follow-up, 37 months). Only one recurrence was reported (6%). In 12.5% of cases, mild erythema appeared in the early postoperative period. No major complications were observed. The overall patient and observer satisfaction rate was excellent.

Conclusion: Surgical excision combined with immediate PORT is an effective and easy treatment with good esthetic results and an acceptable recurrence rate. It should be considered for patients with persistent keloid formation after failure of other treatments and those at high risk of relapse.

[Keloid treatment : Where do we stand ?]

Keloids are debilitating skin lesions that develop often as a result of minor skin lesions. Unlike hypertrophic scars, their main clinical feature is the tendency to extend beyond the initial limits of the wound. They can be responsible for pain and itching and may appear several months after the trauma. Their pathophysiology remains unknown but various mechanisms seem to be involved. Their management includes invasive and non-invasive approaches. At present, there is no satisfactory method or consensus on their management. Since the risk of recurrence after treatment is particularly high, a combination of different methods is proposed. In this article, we present the therapeutic strategy used in our institution concerning these problematic lesions.

Autologous Platelet-Rich Plasma (CuteCell PRP) Safely Boosts In Vitro Human Fibroblast Expansion

Nowadays autologous fibroblast application for skin repair presents an important clinical interest. In most cases, in vitro skin cell culture is mandatory. However, cell expansion using xenogeneic or allogenic culture media presents some disadvantages, such as the risk of infection transmission or slow cell expansion. In this study, we investigated an autologous culture system to expand human skin fibroblast cells in vitro with the patient's own platelet-rich plasma (PRP). Human dermal fibroblasts were isolated from patients undergoing abdominoplasty, and blood was collected to prepare nonactivated PRP using the CuteCell™ PRP medical device. Cultures were followed up to 7 days using a medium supplemented with either fetal bovine serum (FBS) or PRP. Fibroblasts cultured in medium supplemented with PRP showed dose-dependently significantly higher proliferation rates (up to 7.7 times with 20% of PRP) and initiated a faster migration in the in vitro wound healing assay compared with FBS, while chromosomal stability was maintained. At high concentrations, PRP changed fibroblast morphology, inducing cytoskeleton rearrangement and an increase of alpha-smooth muscle actin and vimentin expression. Our findings show that autologous PRP is an efficient and cost-effective supplement for fibroblast culture, and should be considered as a safe alternative to xenogeneic/allogenic blood derivatives for in vitro cell expansion. Impact Statement Autologous dermal fibroblast graft is an important therapy in skin defect repair, but in vitro skin cell culture is mandatory in most cases. However, cell expansion using xenogeneic/allogenic culture media presents some disadvantages, such as the risk of infection transmission. We demonstrated that an autologous culture system with the patient's own platelet-rich plasma is an efficient, cost-effective, and safe supplement for fibroblast culture. As it respects the good manufacturing practices and regulatory agencies standards, it should be considered as a potent alternative and substitute to xenogeneic or allogenic blood derivatives for the validation of future clinical protocols using in vitro cell expansion.

Muscular Versus Non-Muscular Free Flaps for Soft Tissue Coverage of Chronic Tibial Osteomyelitis

BACKGROUND

Eradication of chronic tibial osteomyelitis necessitates aggressive debridement is often followed by soft tissue reconstruction. Muscular flaps are said to be more effective than non-muscular flaps for infection treatment, while fasciocutaneous and perforator flaps are considered to be less invasive and offering a better aesthetic result.

METHODS

In this study, we reviewed 24 consecutive cases of chronic tibial osteomyelitis treated according to a specific protocol in a tertiary hospital. Soft tissue coverage was done with either muscular or non-muscular free flaps. Infection recurrence and complications were compared between different flap types. Additionally, we assessed the long-term functional and aesthetic results and patient’s satisfaction.

RESULTS

Muscular flap was used in 13 patients (13 latissimus dorsi and 1 serratus anterior) and 11 patients underwent fasciocutaneous/perforator flaps [1 anterolateral thigh flap, 4 lateral arm flaps, 5 thoracodorsal artery perforator (TAP) flaps and 1 radial forearm flap]. Infection was resolved for 84.6% of patients in the muscular flaps group and 90.9% in the non-muscular flaps group. None of the patients with muscular flaps were satisfied with the aesthetic appearance of their reconstructed leg when compared to 83.3% of patients with non-muscular flaps. Also, a slight regain of touch sensitivity was acknowledged in the non-muscular flap group compared to the muscular.

CONCLUSION

In this study of adult chronic tibial osteomyelitis cases, we demonstrated that fasciocutaneous and perforator free flaps offer a comparable efficacy to the muscle flaps for infection treatment, with a significantly higher patient satisfaction and aesthetic result.

Reactive Oxygen Species and NOX Enzymes Are Emerging as Key Players in Cutaneous Wound Repair

Our understanding of the role of oxygen in cell physiology has evolved from its long-recognized importance as an essential factor in oxidative metabolism to its recognition as an important player in cell signaling. With regard to the latter, oxygen is needed for the generation of reactive oxygen species (ROS), which regulate a number of different cellular functions including differentiation, proliferation, apoptosis, migration, and contraction. Data specifically concerning the role of ROS-dependent signaling in cutaneous wound repair are very limited, especially regarding wound contraction. In this review we provide an overview of the current literature on the role of molecular and reactive oxygen in the physiology of wound repair as well as in the pathophysiology and therapy of chronic wounds, especially under ischemic and hyperglycemic conditions.

* Microcomputed Tomography Technique for In Vivo Three-Dimensional Fat Tissue Volume Evaluation After Polymer Injection

Tissue engineering technologies are new and promising techniques in fat tissue reconstruction. However, to assess their efficacy before any clinical application, in vivo experiments are mandatory. This study assesses whether microcomputed tomography (CT) scan imaging is suitable to analyze in vivo the behavior of injected engineered polymer and changes in fat tissue. The volume of mice inguinal fat pads and the resorption rate of different polymers were analyzed by CT scan for up to 3 months. Different biomaterials were used, including our innovative microspheres loaded with oleic acid. We were able to follow in vivo the polymer and the fat volume of the same animals during a long-term follow-up of 90 days. Semiautomatic three-dimensional quantification allowed to determine the fat volume enhancement after injection, as well as the resorption rate of our product compared to other biomaterials (i.e., polylactic and hyaluronic acid) until 90 days. Our results demonstrate the encouraging proof-of-principle evidence for the application of micro-CT scan technology to follow in vivo biodegradable polymers in a fat tissue engineering approach. This noninvasive technique offers the advantages of the long-term follow-up of fat tissue and synthetic materials in the same animals, which allows both a scientific evaluation of the measurements and the reduction of the number of animals used in in vivo protocols in accordance with the 3 "R" principles governing the use of animals in science.

Immunological reaction after facial hyaluronic acid injection

We report two rare cases of inflammatory reactions with multiple subcutaneous facial painful collections after Hyaluronic acid injections, expose their management and discuss aetiologic hypothesis. Due to unfavourable evolution despite antibiotic treatment, surgical drainage was performed. Immune-mediated delayed hypersensitivity reactions were the most probable cause.

Multi-organ injuries due to a lightning strike: a case report highlighting the importance of a multi-disciplinary approach

The interdisciplinary management of patients with multiple organ injuries after lightning strike is of paramount importance. Cutaneous burns can be associated to other organ injuries requiring emergency and life-support treatment. We report the case of a lightning strike victim who presented with burns as well as cardiologic and neurologic complications.

Hyperbaric oxygen therapy promotes wound repair in ischemic and hyperglycemic conditions, increasing tissue perfusion and collagen deposition

The treatment of chronic wounds remains inconsistent and empirical. Hyperbaric oxygen therapy (HBOT) is a promising method to improve wound repair but there is still a lack of understanding of its mechanisms of action and its indications are not yet clearly defined. We studied the effects of HBOT in four different wound conditions by inflicting bilateral wounds on the dorsal aspect of the feet of nonischemic or ischemic limbs in normoglycemic or hyperglycemic rats. To create an ischemic condition, arterial resection was performed unilaterally. Forty-four animals received HBOT five times a week until complete wound closure. Wound repair was compared with 44 rats receiving standard dressing only. HBOT increased blood flow and accelerated wound closure in ischemic and hyperglycemic wounds, most significantly when the two conditions were combined. Wound contraction and reepithelialization were similarly stimulated by HBOT. The acceleration of wound contraction was not associated with increased myofibroblasts expression, nor fibroblast recruitment or higher cell count in the granulation tissue. Of note, we observed a significant increase in collagen deposition in early time points in ischemic wounds receiving HBOT. This data emphasizes that an early application of HBOT might be crucial to its efficacy. We concluded that wounds where ischemia and hyperglycemia are combined, as it is often the case in diabetic patients, have the best chance to benefit from HBOT.

Facial bone reconstruction with prefabricated vascularized calvarium flaps in children and young adults: Advantages and long-term results

INTRODUCTION

Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps.

METHODS

Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect.

RESULTS

Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child.

CONCLUSIONS

Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children.

NADPH oxidase 4 deficiency leads to impaired wound repair and reduced dityrosine-crosslinking, but does not affect myofibroblast formation

NADPH oxidases (NOX) mediate redox signaling by generating superoxide and/or hydrogen peroxide, which are involved in biosynthetic pathways, e.g. thyroid hormone generation, dityrosine crosslinking, as well as bacterial killing. Data investigating the role of NOX enzymes in cutaneous wound repair is limited and specifically their function in skin myofibroblast expression is unknown. The isoform NOX4 was recently shown to be a pre-requisite for the differentiation of cardiac and pulmonary myofibroblasts. In this study we investigate the role of NOX4 in wound repair using a wound model in NOX4 knockout mice (n=16) and wildtype mice (n=16). Wounds were photographed daily until complete wound closure. Mice were sacrificed at day 3, 7, 14; wound tissue was harvested. NOX4-deficient mice healed significantly slower (22 days, SD=1.9) than wild-type mice (17 days, SD=1.4, p<0.005). However, there was no difference in myofibroblast expression. Strong dityrosine formation was observed, but was significantly weaker in NOX4-/- mice (p<0.05). NOX2, HIF1α and CD31 expression was significantly weaker in NOX4-/- mice (p<0.05). In this study we show for the first time that NOX4 plays a role in cutaneous wound repair. Our data suggests that NOX4 mediates HIF1α expression and neoangiogenesis during wound repair. NOX4 deletion led to a decreased expression of NOX2, implying a role of NOX4 in phagocytic cell recruitment. NOX4 was required for effective wound contraction but not myofibroblast expression. We suggest that myofibroblast contraction in NOX4-deficient mice is less effective in contracting the wound because of insufficient dityrosine-crosslinking of the ECM, providing the first indication for a physiological function of dityrosine crosslinking in higher animals.

Weekly Multi-agent Chemotherapy (CMF-b) for Advanced Non-melanoma Skin Cancer

BACKGROUND/AIM

Advanced unresectable and metastatic non-melanoma skin cancers (NMSC) are rare, but often arise in elderly patients. When surgery or irradiation are no longer feasible, chemotherapy is often precluded by the patient's age and comorbidities. Whether low-dose multi-agent chemotherapy could be an alternative for this vulnerable population in an outpatient setting was the issue examined in this retrospective analysis.

PATIENTS AND METHODS

Twenty-six patients with advanced unresectable or metastatic NMSC received weekly multi-agent chemotherapy with carboplatin at an area under the curve of 2 or 40 mg total dose of cisplatin, with 15 IU total dose of bleomycin, 40 mg total dose of methotrexate, and 500 mg total dose of 5-fluorouracil (CMF-b) until best response, toxicity, or progression of their disease.

RESULTS

Twenty-four patients were treated as outpatients; two were hospitalized. Twenty-three patients were previously treated with surgery or radiotherapy. The median age was 68 years (range=44-100 years). The median number of cycles was 6 (range=1 to 17). The overall response rate was 61.5% (seven complete remissions, nine partial remissions) for the entire cohort and 63.6% (two complete remissions and five partial remissions) for patients >80 years. The median duration of response was 6.1 months (range=1.6-63 months). Responses longer than 6 months were obtained in 11/26 (42.3%) of the entire cohort and in 4/11 (36.3%) patients >80 years. Symptom improvement was observed in 17 patients (65.3%). Toxicity was acceptable, with grade 3 renal failure (n=1) and grade 3 or 4 myelotoxicity (n=2).

CONCLUSION

CMF-b is a safe, weekly low-dose multi-agent regimen that offers palliation for vulnerable patients with NMSC.

Liver Trauma During Combined Liposuction and Abdominoplasty: A Rare but Potentially Lethal Complication

Liposuction is a well-established procedure that is generally safe. However, rare complications can occur. The authors report on a 38-year-old woman who underwent combined abdominoplasty and liposuction at a private clinic. Four hours after the procedure, severe hypovolemic shock developed and required emergency transfer to a tertiary-care center. After primary fluid resuscitation, abdominal ultrasonography and computerized tomography revealed severe right-sided liver trauma, with active bleeding and free intra-abdominal fluid. Two attempts at right hepatic artery embolization failed to fully control the bleeding, and surgical hemostasis was required. After a 2-week hospitalization, the patient was discharged, and she returned to work 3 months later. Although it appears that this is the first reported case of liver trauma during liposuction, this potential complication should be kept in mind and identified early to permit efficient and effective management.

Long-term follow-up of cadaveric breast augmentation: what can we learn?

Breast augmentation with cadaveric fat graft has long been available to patients in Eastern European countries, primarily in the Soviet Union and Eastern Germany. Most such procedures were performed from the 1970s to the 1990s. Although only a few case reports have been published, all of which involved complications that appeared several years after the procedure, it appears that, surprisingly, this nonvascularized and incompatible immunologic tissue is relatively well tolerated. We present the case of a 45-year-old Russian woman who underwent breast explantation, due to breast hardness and pain, 15 years after breast augmentation with cadaveric fat grafting. Through genetic studies, we confirmed that the host and the graft were HLA incompatible. Moreover, results of analyses excluded the possibility of an acute or chronic immunologic rejection by the host. We suppose that the early complications that often occur in such cases might result from a nonspecific, inflammatory reaction induced by acute tissue ischemia and necrosis, and the late local complications that occur years later may relate more to chronic inflammation, due to nonvascularized tissue, than to immunologic rejection. Therefore, we propose that different mechanisms may explain how this allogenic fat tissue could have been tolerated by the patient's immune system. We particularly underline the immunomodulatory effect of mesenchymal stem cells, which are abundant in adipose tissues. This characteristic of fat tissue should be investigated further to assess its potential in treating autoimmune diseases or reducing the likelihood of allograft rejections.

The role of reactive oxygen species in mesenchymal stem cell adipogenic and osteogenic differentiation: a review

Mesenchymal stromal cells (MSCs) are promising candidates for tissue engineering and regenerative medicine. The multipotent stem cell component of MSC isolates is able to differentiate into derivatives of the mesodermal lineage including adipocytes, osteocytes, chondrocytes, and myocytes. Many common pathways have been described in the regulation of adipogenesis and osteogenesis. However, stimulation of osteogenesis appears to suppress adipogenesis and vice-versa. Increasing evidence implicates a tight regulation of these processes by reactive oxygen species (ROS). ROS are short-lived oxygen-containing molecules that display high chemical reactivity toward DNA, RNA, proteins, and lipids. Mitochondrial complexes I and III, and the NADPH oxidase isoform NOX4 are major sources of ROS production during MSC differentiation. ROS are thought to interact with several pathways that affect the transcription machinery required for MSC differentiation including the Wnt, Hedgehog, and FOXO signaling cascades. On the other hand, elevated levels of ROS, defined as oxidative stress, lead to arrest of the MSC cell cycle and apoptosis. Tightly regulated levels of ROS are therefore critical for MSC terminal differentiation, although the precise sources, localization, levels and the exact species of ROS implicated remain to be determined. This review provides a detailed overview of the influence of ROS on adipogenic and osteogenic differentiation in MSCs.

Autologous platelet-rich plasma: a biological supplement to enhance adipose-derived mesenchymal stem cell expansion

Currently the use of non-autologous cell culture media (e.g., animal-derived or allogeneic serum) for clinical applications of mesenchymal stem cells (MSCs) is criticized by regulatory agencies. Autologous platelet-rich plasma (PRP) is proposed as a safer alternative medium supplement for adipose-derived mesenchymal stem cells (AT-MSC) culture. To study its efficiency on cell proliferation, AT-MSCs were cultured for 10 days in media supplemented with different concentrations of autologous non-activated PRP (nPRP) or thrombin-activated PRP (tPRP) (1-60%). AT-MSC proliferation, cell phenotype, multipotency capacity, and chromosome stability were assessed and compared to AT-MSCs expanded in a classical medium supplemented with 10% of fetal bovine serum (FBS). Culture media supplemented with nPRP showed dose-dependent higher AT-MSC proliferation than did FBS or tPRP. Twenty percent nPRP was the most effective concentration to promote cell proliferation. This condition increased 13.9 times greater AT-MSC number in comparison to culture with FBS, without changing the AT-MSC phenotype, differentiation capacity, and chromosome status. We concluded that 20% autologous nPRP is a safe, efficient, and cost-effective supplement for AT-MSC expansion. It should be considered as an alternative to FBS or other nonautologous blood derivatives. It could serve as a potent substitute for the validation of future clinical protocols as it respects good manufacturing practices and regulatory agencies' standards.