Graft Bed Research Articles

Reconstruction after inappropriate lower limb open degloving injury management resulting in the necrotic wound: a case report

Background: Trauma with shear mechanisms, which are typically the result of after trauma regarding traffic incidents, is the primary cause of degloving injuries. The condition is typified by the avulsion of skin and subcutaneous tissue, resulting in a deficiency in coverage and, in extreme situations, the loss of the limb involved. Case Presentation: A 58-year-old male was struck by a car and sustained a direct blow to his right lower leg from a rubber tire. The patient was hospitalized and did primary wound closure. A week later, the patient sought a second opinion in a different hospital due to necrotic tissue formation in his lower limb due to previous primary closure disregarding tissue vitality through split-thickness skin excision (STSE). Conclusion: This case reported management of necrotic tissue and reconstruction defect closure by skin graft through surgical cleaning and debridement. After establishing a viable grafting bed, split-thickness skin grafts were applied as covering.

Direct anterior bone block grafting for treatment of bone defects and dysplasia of the coronoid process

The aim of the surgery was to treat an elbow instability caused by critical coronoid bone loss (CCBL), lateral ulnar collateral ligament (LUCL) insufficiency,and general hyperlaxity by performing adirect anterior coronoid bone graft (CBG) and LUCL reconstruction in the same setting. In cases with CCBL isolated ligament reconstruction harbors ahigh failure rate, necessitating supplementary bony procedures. The diagnosis of CCBL is confirmed through lateral radiographs and further quantified through computed tomography (CT) imaging. Objective assessment of instability is conducted with standardized arthroscopic tests. Performing an anterior approach for CBG offers distinct advantages, notably in terms of achieving precise positioning of plates and screws and providing access to the proximal radioulnar joint. Usual contraindications to surgery, coronoid bone loss less than 40%. The surgical procedure is thoroughly illustrated with avideo of the operation that can be accessed online: reconstruction of the LUCL with asemitendinosus allograft, harvesting of the graft from the iliac crest, exposure of the coronoid process with adirect anterior approach, freshening up of the graft bed. Temporary fixation of the graft with aKirschner wire. Assessment of joint congruency, stability and range of motion (ROM) prior to definitive fixation with a2.4 mm buttress plate and screws. Nonsteroidal anti-inflammatory drugs (NSAID) to prevent heterotopic ossification. Elbow mobilization in pronation from day1 with an overhead motion protocol. Removable splint for 4weeks, free mobilization at 6weeks, return to sport at 3months. Durable elbow stability was achieved along with free ROM and high patient satisfaction.

Modified Atlantoaxial Arthrodesis Technique for Atlantoaxial Instability via Intraarticular Autografting Using Structural Iliac Bone: Technical Nuances and Case Series

ObjectiveThe present study described a modified technique of atlantoaxial arthrodesis in patients with atlantoaxial instability (AAI) along with the postoperative clinical and radiological results. MethodsFive patients underwent this method for their AAI concurrent with C1 arch hypoplasia and/or the development of odontoid pannus causing myelopathy. After thorough exposure of the posterior surface of the C1-2 complex, the bilateral C2 nerve roots were sectioned to allow for easier access to the C1/2 facet joints. To prepare a suitable grafting bed, the C1/2 facet capsule was opened, then the articular cartilaginous and synovial tissues were thoroughly removed. After being properly fashioned to match the gap between the C1/2 facet joint spaces, the structural bone grafts from the iliac crest were directly inserted into the facet joint spaces. To alleviate cord compression caused by concomitant odontoid pannus and/or hypoplastic C1 arch, C1 laminectomy was necessitated in all cases. Subsequently, posterior screw-rod instrumental fixation was conducted. ResultsAll five patients underwent this procedure successfully. Clinical and radiological follow-up data of all patients indicated favorable relief of clinical symptoms and early rigid C1-2 stability. The sequelae of C2 nerve resection were not remarkable. No other neural or vascular damage associated with this technique was observed. ConclusionModified atlantoaxial arthrodesis via intraarticular autografting using the structural iliac bone combined with posterior instrumentation appears to be an efficient alternative treatment method for AAI patients with concurrent pathologies, even when the C1-2 posterior arches are unavailable for the grafting bed.

Evaluation of the Bone Union Occurring Subsequent to C1-2 Fusion Combined With C1 Laminectomy for the Surgical Treatment of Retro-Odontoid Pseudotumor.

Introduction Surgical treatments for retro-odontoid pseudotumors (ROPs) include C1 laminectomies and C1-2 and occipitocervical (OC) fusions. When a C1 laminectomy is combined with a C1-2 fusion, concerns arise regarding an increased risk of pseudarthrosis due to decreased bone grafting space. Extension of the fusion area to the OC region may be considered to ensure an adequate bone graft bed. However, this procedure is associated with a risk of complications. Thus, in this study, we investigated the bone fusion and clinical outcomes of C1-2 fusion combined with a C1 laminectomy. Methods Between January 2017 and December 2022, seven patients with ROPs who had undergone C1-2 fusion combined with a C1 laminectomy were included in the study. All patients were followed up for >1 year. Bone fusion was evaluated by computed tomography (CT) at one year postoperatively, while implant failure was assessed by radiography at the final follow-up. Clinical evaluations included preoperative and one-year postoperative Japanese Orthopaedic Association (JOA) scores and recovery rates. Results This study included five male and two female patients, with an average age of 71.9 years. The average follow-up duration was 3.3 years. The primary anchor choices included the C1 lateral mass screw and the C2 pedicle screw. In one case, the transarticular screw was utilized unilaterally, and in another case, a lamina screw was utilized unilaterally. One year postoperatively, CT revealed bone fusion in three of the seven patients. Fusion occurred at the lateral and median atlantoaxial joints in two cases and one case, respectively. Screw loosening was observed in one case. None of the patients required reoperations. The average JOA recovery rate was 34.6%. Conclusion This surgical technique is useful for stabilizing and decompressing the C1-2 region while preserving mobility at the OC joint. However, further long-term follow-up studies are required.

Myeloid-derived suppressor cells promote allograft survival by suppressing regulatory T cell dysfunction in high-risk corneal transplantation

Highly inflamed and neovascularized corneal graft beds are known as high-risk (HR) environments for transplant survival. One of the primary factors leading to this rejection is reduction in the suppressive function of regulatory T cells (Treg). Our results show that myeloid-derived suppressor cells (MDSC) counteract interleukin-6–mediated Treg dysfunction by expressing interleukin-10. Additionally, MDSC maintain forkhead box P3 stability and their ability to suppress IFN-γ+ Th1 cells. Administering MDSC to HR corneal transplant recipients demonstrates prolonged graft survival via promotion of Treg while concurrently suppressing IFN-γ+ Th1 cells. Moreover, MDSC-mediated donor-specific immune tolerance leads to long-term corneal graft survival as evidenced by the higher survival rate or delayed survival of a second-party C57BL/7 (B6) graft compared to those of third-party C3H grafts observed in contralateral low-risk or HR corneal transplantation of BALB/c recipient mice, respectively. Our study provides compelling preliminary evidence demonstrating the effectiveness of MDSC in preventing Treg dysfunction, significantly improving graft survival in HR corneal transplantation, and showing promising potential for immune tolerance induction.

Suppression of Neovascularization by Topical and Subconjunctival Bevacizumab After High-Risk Corneal Transplantation

To assess the effectiveness of topical and subconjunctival bevacizumab in suppressing vascularization in graft and host bed after high-risk corneal transplantation. Secondary analysis of prospective, randomized, double-blind, placebo-controlled multicentric clinical trial. The study includes patients aged > 18 years who underwent high-risk penetrating keratoplasty, which was defined as corneal vascularization in ≥ 1 quadrants of the corneal graft and host bed, excluding the limbus. Patients were randomized to treatment and control groups. The patients in the treatment group received subconjunctival injection of bevacizumab (2.5 mg/0.1 ml) on the day of the procedure, followed by topical bevacizumab (10 mg/ml) 4 times per day for 4 weeks. The patients in control group received injection of vehicle (0.9% sodium chloride) on the day of procedure, followed by topical vehicle (carboxymethylcellulose sodium 1%) 4 times a day for 4 weeks. Vessel and invasion area of vessels in the corneal graft and host beds. This study included 56 eyes of 56 patients who underwent high-risk corneal transplantation, with equal numbers in the bevacizumab and vehicle (control) treatment groups. The mean age of patients who received bevacizumab was 61.2 ± 15.9 years, and the mean age of those treated with vehicle was 60.0 ± 16.1 years. The vessel area at baseline was comparable in the bevacizumab (16.72% ± 3.19%) and control groups (15.48% ± 3.12%; P= 0.72). Similarly, the invasion areas were also similar in the treatment (35.60% ± 2.47%) and control (34.23% ± 2.64%; P= 0.9) groups at baseline. The reduction in vessel area was significantly higher in the bevacizumab-treated group (83.7%) over a period of 52 weeks compared with the control group (61.5%; P < 0.0001). In the bevacizumab-treated group, invasion area was reduced by 75.8% as compared with 46.5% in the control group. The vessel area was similar at 52 weeks postprocedure in cases of first (3.54% ± 1.21%) and repeat (3.80% ± 0.40%) corneal transplantation in patients who received bevacizumab treatment. In the vehicle-treated patients, the vessel area was significantly higher in repeat (9.76% ± 0.32%) compared with first (8.06% ± 1.02%; P < 0.0001) penetrating keratoplasty. In the bevacizumab treatment group, invasion areas at week 52 were comparable in first (11.70% ± 3.38%) and repeat (11.64% ± 1.74%) procedures, whereas invasion area was significantly higher in repeat (27.87% ± 2.57%) as compared with first (24.11% ± 2.17%) penetrating keratoplasty in vehicle-treated patients. In patients undergoing vascularized high-risk corneal transplantation, bevacizumab is efficacious in reducing vascularization of corneal graft and host bed, thereby reducing the risk of corneal graft rejection in vascularized host beds. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Direct Anterior Bone Block Grafting for Coronoid Bone Loss and Dysplasia

Background: Critical coronoid bone loss (CCBL) can be the key factor of elbow instability, making bony reconstruction essential. Coronoid bone grafting (CBG) is challenging, with a paucity of descriptions in the literature. We present direct anterior CBG in a patient with instability, CCBL (&gt;40%), lateral ulnar collateral ligament (LUCL) insufficiency, and ligamentous laxity who underwent LUCL reconstruction in the same setting. Indications: Isolated ligament reconstruction has a high failure rate in cases with CCBL and therefore requires additional bone grafting. The diagnosis of CCBL is made with lateral radiographs and further quantified by computed tomography imaging. Instability can be best assessed objectively during arthroscopy with a switching stick. CBG performed with an anterior approach facilitates direct access with advantages for plate and screw positioning and access to the proximal radio-ulnar joint. Technique Description: First, LUCL reconstruction was performed. After harvesting of the graft from the iliac crest, the coronoid was exposed with a direct anterior approach. The incision starts centrally medial to the biceps tendon (BT) in the flexion crease extending distally (9 cm). Ligation of multiple vessels (leash of Henry) is required. The deep dissection is continued between the bicipital aponeurosis and BT. Blunt and flat Langenbeck-type retractors are used with care, laterally (BT/radial nerve) and medially (aponeurosis/median nerve). The brachialis muscle is exposed and longitudinally split in line with its fibers, gaining access to the capsule. Harmful retraction on either side of the split has to be avoided. The capsule is incised as a Z-plasty, the coronoid exposed from the joint in the distal direction prior to freshening up the graft bed. The graft is held in place with a wire joystick, sculpted, and temporarily fixed. Joint congruency, stability, and a range of motion (ROM) are checked prior to definitive fixation with a 2.4-mm buttress plate and screws. Results: The coronoid process height was successfully reconstructed from &lt;60% to 100% with durable elbow stability (&gt;1 year), free ROM, and high patient satisfaction. Conclusion: CBG can be standardized and facilitated with a direct anterior approach as a key element for successful elbow stabilization in the setting of CCBL. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Outcomes of Cortical Bone Fenestration Performed on the Denuded Frontal Bone to Induce Granulation Tissue Growth: A Case Study

Open wounds with denuded bone may pose a challenge for surgeons if primary closure or flap surgery is not feasible. In such cases, cortical bone fenestration (CBF) has been employed as a preconditioning procedure to induce granulation tissue growth and provide a suitable bed for skin grafting or secondary intention healing. Our clinical study aimed to assess the outcomes of CBF performed on open wounds involving the denuded frontal bone. We treated a patient with multiple open wounds involving the denuded frontal bone using secondary intention healing in conjunction with CBF procedures and evaluated the outcomes of the fenestrated bones as well as the wound healing process at regular intervals. Granulation tissue did not develop on the fenestrated bones throughout the healing process. However, the frontal wounds healed well without complications at 16 weeks after CBF through the centripetal migration of granulation tissue from the wound margins and simultaneous epithelialization. Our results suggest that CBF procedures that do not adequately expose the diploic space fail to induce granulation tissue growth and may not be needed to treat open wounds with less than 5 cm of denuded skull bone.

Subcutaneous angiogenesis induced by transdermal delivery of gel-in-oil nanogel dispersion

Subcutaneous transplantation aims to enhance the growth and functionality of transplanted cells for therapeutic outcomes in tissue engineering. However, the limited subcutaneous vascular network poses a challenge. Conventional methods involve co-transplantation with endothelial cells or angiogenic scaffold implantation, but they have drawbacks like tissue inflammation, compromised endothelial cell functionality, and the risk of repeated scaffold transplantation. Effective techniques are needed to overcome these challenges. This study explores the potential of G/O-NGD, a gel-in-oil nanogel dispersion, as a transdermal carrier of proliferative factors to promote angiogenesis in subcutaneous graft beds before cell transplantation. We observed robust subcutaneous angiogenesis by delivering varying amounts of bFGF using the G/O-NGD emulsion. Quantitative analysis of several parameters confirmed the efficacy of this method for building a subcutaneous vascular network. G/O-NGD is a biodegradable material that facilitates localized transdermal delivery of bFGF while maintaining its activity. The findings of this study have significant implications in both medical and industrial fields.

The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series

Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47±13.5 years, and the body mass index mean was 31±4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89±1.76 and the time to first revision mean was 15.89±14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48±8.66 months. A mean of 6.77±5.35cm was gained after the Integra® revision (4.92±4.1cm before versus 12.54±3.07cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34±4.65cm. Overall, the depth gain mean was 7.48±5.77cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.

Outcomes of Apert Syndrome Hand Reconstruction With Tilapia Skin: A Prospective Study.

Tilapia skin has already been used in various medical scenarios, but there are no studies showing the use of tilapia skin for hand reconstruction in Apert syndrome. The objective of this study is to determine whether the use of tilapia skin during graft bed preparation for children with Apert syndrome can shorten wound reepithelialization intervals, reduce the number of dressing changes, and decrease patient discomfort. This is a prospective study on consecutive patients with Apert syndrome who underwent hand reconstruction at our Hospital. Patients were divided into 2 groups: (1) a control group consisting of patients who underwent conventional digit separation hand reconstruction surgery (2) an experimental group consisting of patients who underwent similar digit separation hand reconstruction surgery that commenced with the placement of a thin layer of tilapia skin at the raw commissures during a first operation, which was subsequently replaced by an autologous skin graft during a second operation staged 10 days postoperatively. Pain assessment was performed using the Visual Analog Scale. The number of dressing changes was also assessed. A T test compared the total number of dressings changes and pain data. Experimental group patients (n = 8) required an average of 9.4 days of daily dressing changes, and control group patients (n = 5) required an average of 20.8 days of daily dressing changes ( P < 0.05) and tended to experience significantly less pain when compared with patients in the control group ( P = 0.079). Tilapia skin can shorten wound reepithelialization intervals by reducing the total number of dressing changes.

Feasibility of intra-operative image guidance in burn excision surgery with multispectral imaging and deep learning

BackgroundExposing a healthy wound bed for skin grafting is an important step during burn surgery to ensure graft take and maintain good functional outcomes. Currently, the removal of non-viable tissue in the burn wound bed during excision is determined by expert clinician judgment. Using a porcine model of tangential burn excision, we investigated the effectiveness of an intraoperative multispectral imaging device combined with artificial intelligence to aid clinician judgment for the excision of non-viable tissue. MethodsMultispectral imaging data was obtained from serial tangential excisions of thermal burn injuries and used to train a deep learning algorithm to identify the presence and location of non-viable tissue in the wound bed. Following algorithm development, we studied the ability of two surgeons to estimate wound bed viability, both unaided and aided by the imaging device. ResultsThe deep learning algorithm was 87% accurate in identifying the viability of a burn wound bed. When paired with the surgeons, this device significantly improved their abilities to determine the viability of the wound bed by 25% (p = 0.03). Each time a surgeon changed their decision after seeing the AI model output, it was always a change from an incorrect decision to excise more tissue to a correct decision to stop excision. ConclusionThis study provides insight into the feasibility of image-guided burn excision, its effect on surgeon decision making, and suggests further investigation of a real-time imaging system for burn surgery could reduce over-excision of burn wounds.

Use of MatriDerm® (skin substitute) and split skin graft in one stage in wound healing of exposed tibia without periosteum in two patients

Reporting two cases one of two centimetres breadth and the other of four centimetres breadth exposed tibia bone devoid of periosteum due to post debridement involving periosteum elevator to remove infective tissue which was successfully covered by a simple procedure with MatriDerm® and split skin graft in a single stage. Tibia bone was not drilled to sprout granulation tissue from bone marrow to create a granulated vascularised bed for second-stage skin grafting. It avoided local flap or microsurgical free flap surgery for small exposed bone devoid of periosteum. Both cases had a pleasing aesthetic outlook after a few months of follow-up. Difficult to find instances of more than two centimetres of exposed tibia devoid of periosteum covered successfully in a single stage by this procedure.

Paper 54: Long Term Clinical and Radiological Review of Matrix-Induced Autologous Chondrocyte Implantation

Objectives: Long-term outcomes following matrix-induced autologous chondrocyte implantation (MACI) are required to better demonstrate later-stage clinical outcomes, patient satisfaction and longevity of repair tissue. This prospective study sought to present the long-term (minimum 10 year) clinical and radiological outcomes of the largest prospectively assessed MACI dataset yet to be reported and compare outcomes in patients undergoing tibiofemoral (TF) versus patellofemoral (PF) MACI. Methods: Between September 2002 and December 2012, 204 patients that underwent MACI were prospectively registered into a research program and assessed pre-surgery and at 2, 5 and 10 years. Of these, 168 patients (182 grafts) were available for clinical review at a minimum 10 years (range 10 to 16 years), of which 151 also underwent MRI. Included in the 182 MACI grafts with minimum 10-year review were: 83 medial femoral condyle (MFC), 32 lateral femoral condyle (LFC), 35 trochlea and 32 patella. Clinically, patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the 36-item Short Form Health Surveys (SF-36), a visual analogue scale for pain frequency (VAS-F) and severity (VAS-S), satisfaction and peak isokinetic knee extensor and flexor strength. Limb symmetry indices (LSIs) were calculated for strength measures. Grafts were scored on MRI via the magnetic resonance observation of cartilage repair tissue (MOCART) system, with a focus on tissue infill and an overall MRI graft composite score. Results: All PROMs significantly improved (p&lt;0.0001) over the pre- and post-operative period to 2-years post-surgery (Figure 1), with no statistical change (p&gt;0.05) from 2-years to final 10-year follow-up. While the peak isokinetic knee extensor LSI improved significantly over time (p=0.016), at final follow up the mean LSI for peak isokinetic knee flexor and extensor strength was 99.1% and 92.8%, respectively. At final follow-up, 93% of patients were satisfied with MACI to provide knee pain relief, 77% were satisfied with their ability to participate in sports and 89% were satisfied overall. A statistically significant decline was observed from 5 years post-surgery to final follow-up in the MOCART variable of subchondral lamina (p=0.002), while a non-statistical decline was observed in tissue infill (p=0.066) and the overall MRI composite score (p=0.072) (Figure 2), with the MRI-based progression of one patient over the period demonstrated in Figure 3. Of the 151 grafts reviewed via MRI at 10 years or beyond, 14 (9.3%) had failed as defined by graft de-lamination or a graft bed devoid of any repair tissue. Furthermore, of the 36 patients (out of the prospectively recruited 204) that were not available for longer term review, 7 had already proceeded to total knee arthroplasty (TKA) and 1 patient had undergone secondary MACI at the same MFC site due to earlier graft failure. Therefore, a total of 22 patients (10.8%) had essentially failed at or before the final review time. At final follow-up, patients that underwent MACI in the TF (versus PF) joint reported significantly better KOOS sub-scale scores for Pain (p=0.013, TF mean 86.5, PF mean 80.1), Sport (p&lt;0.001, TF mean 71.5, PF mean 60.5) and Quality of Life (p=0.010, TF mean 65.8, PF mean 58.7), as well as a greater knee extensor strength LSI (p=0.002, TF mean 96.0%, PF mean 85.8%). While the TF group demonstrated better 10-year MOCART scores for tissue infill (p=0.027, TF mean 3.2, PF mean 2.9), there were no other differences in MRI-based scores including the overall MRI composite score (p=0.481, TF mean 3.0, PF mean 3.1). Conclusions: This study reports the largest prospective series of patients with long-term review, demonstrating good clinical scores, levels of patient satisfaction and graft survivorship beyond 10 years. Patients undergoing TF (versus PF) MACI reported better long-term clinical outcomes, despite largely similar MRI-based outcomes.

Stair-Step Incision for Composite Grafts in Nasal Reconstruction.

Composite grafts are excellent options for treating external nasal deformities because they provide support and include the skin, which improves the delicate anatomy of the nose. However, they are constrained by size limits since the grafts rely on blood flow to the nasal bed. This is a critical issue when the recipient sites have scarring or degenerative diseases. A novel stair-step incision was made to produce a graft bed with a blood supply and to maximize the use of nonvascularized composite grafts. Instead of making a full-thickness defect through the skin envelope and lining, we placed individual incisions and connected them via a subcutaneous dissection. By dividing the defect into 2 layers, the graft bed was produced and the risk of fistula was reduced. From 2009 to 2020, we satisfactorily conducted 3 cases of nasal reconstruction with a stair-step incision followed by a composite tissue graft. One patient was a girl, and 2 were men. Their ages ranged from 11 to 44 years. The largest graft was 24 × 24mm in size. No complications were observed. The stair-step incision method for nasal reconstruction can eliminate the limitations of composite grafts and maximize improvements through a simple procedure. This makes composite grafts safer in cases with poor vascularity, enables larger composite grafts to survive, and lowers the risk of fistula formation by avoiding full-thickness defects.

New approaches to improving corneal transplant survival in a pre‐clinical model

AbstractCornea transplantation has been a target for mesenchymal stromal cell (MSC) therapy for several years with a number of publications highlighting the therapeutic potential and mechanism of action of these cells. It is widely known that MSC possess potent anti‐inflammatory capabilities and are able to modulate the activity of a wide array of immune cells including T cells, B cells, dendritic cells and macrophages. This modulation occurs through both cell–cell contact and the paracrine release of soluble factors such as nitric oxide and prostaglandin E2.High risk cornea transplant recipients suffer from a much higher rate of rejection than the average patient. Factors which place patients at high risk of rejection include corneal ulcers, bullous keratopathy or a failed previous graft. These conditions frequently lead to increased blood and lymphatic vessel infiltration to the recipient graft bed and/or some pre‐existing high immunological risk. As outcomes for lower risk cornea transplant recipients, such as those who require a transplant as a result of keratoconus, improves the field is shifting its focus to improve outcomes for more complex cases.In this presentation, I will discuss the therapeutic potential of MSC to promote corneal transplant survival in both low‐ and high‐risk pre‐clinical models and its pathway to potential clinical translation.Funding received for this work.This work was supported by Science Foundation Ireland (12/IA/1624), by a grant from the European Commission [FP7 Collaborative Health Project VISICORT (grant number 602470), www.visicort.eu], by infrastructural funds from the European Regional Development Fund and by the European Union's Horizon 2020 research and innovation programme under grant agreement no. 814439.Keywords: corneal transplantation, high risk, mesenchymal stromal cells, immunomodulation, regulatory cells, tolerance.

Basic fibroblast growth factor-impregnated collagen gelatin sponge completes formation of dermis-like tissue within 2 weeks: Aprospective cohort study.

IntroductionThis study included patients who underwent full-thickness skin reconstruction using a two-stage procedure comprising basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) implantation and autologous skin grafting, and the take rate of skin grafts was compared between groups of patients who underwent autologous skin grafting after a waiting period of <2 weeks or ≥2 weeks.MethodsAn acute, full-thickness skin defect was treated with thorough debridement of contaminated/necrotic tissue, followed by washing with saline and hemostasis with electrocautery. Then, an FGF-CGS was fixed to the skin defect wound using non-absorbable sutures, and after confirming regeneration of sufficient dermis-like tissue, the second-stage autologous skin grafting was performed for wound closure. Patients were divided into two groups according to the waiting period before the second operation, namely, <2 weeks (early group) and ≥2 weeks (late group), and the take rate of skin grafts was compared.ResultsWe enrolled and treated 25 cases (18 men, 7 women; mean age: 49 [range 2–86] years). The mean take rate of skin grafts was 93% (range 80%–100%) in the early group and 92% (range 65%–100%) in the late group, with no significant difference between the two groups. There was a significant difference between the groups in mean time to complete healing: 25.2 ± 9.7 days in the early group vs 44.7 ± 27 days in the late group (p < 0.05).ConclusionOur data suggest that bFGF-CGF can form dermis-like granulation tissue with sufficient quality as a graft bed for skin transplantation within 2 weeks.

Enzymatic debridement: past, present, and future

Introduction Early surgical debridement of the deep second and third-degree burns is still the standard of care (SOC) to prepare the wound bed for skin grafting. However, this technique has some drawbacks that explain the growing interest in enzymatic debridement as an alternative. In this article, we provide a historic overview as well as the current state-of-the-art and future prospective of this type of non-surgical debridement. Materials and methods A narrative review of the available literature was conducted using a systematic search. Results A total of 32 articles were included. The only enzyme mixture still used nowadays for burn eschar removal is bromelain-based. There is increasing evidence that this type of enzymatic debridement is a powerful tool to selectively remove the eschar in deep burns, thereby reducing the need for autologous skin grafting compared to surgical SOC. Moreover, off-label use of enzymatic debridement with NexoBrid® (facial, pediatric, and >15%TBSA burns) has proven to be effective and safe. Conclusion There is increasing evidence that bedside administered NexoBrid®, preferably under regional anesthesia, is a powerful tool for selective burn eschar removal. However, the clinical wound bed evaluation post-NexoBrid® procedure in relation to the optimal treatment decision—conservative treatment vs. surgery—is not yet completely elucidated. More high-quality prospective clinical trials are necessary to compare enzymatic debridement of objectively confirmed deep burns with the current standard treatment and assess the effectiveness of the eschar removal, the need for surgery, the healing time of such wounds, and the long-term scar quality.

A Sandwich-Like Oral Mucosa Graft-Conjunctiva In Situ-Dermis-Fat Graft for Reconstruction of the Anophthalmic Socket with Ocular Infection History.

IntroductionA novel technique of using a sandwich-like structure, namely, an oral mucosa graft (OMG)–conjunctiva in situ–dermis-fat graft (DFG) (OMG-C-DFG), to reconstruct a contracted and low-capacity anophthalmic socket for a patient with ocular infection history was evaluated.MethodsThis was retrospective case study of four patients (cases) who underwent anophthalmic socket reconstruction surgery in which the OMG-C-DFG technique was applied. The procedures were performed in the Department of Ophthalmology at the Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine (Shanghai, China). Postoperative cosmetic appearance, graft outcome, the ability to wear an ocular prosthesis, and postoperative complications were evaluated.ResultsThe median (± standard deviation) age of patients was 41.5 ± 22.1 (range 10–60) years. All patients suffered from contracted and low-capacity anophthalmic sockets. Three patients had a history of orbital implant infection and one patient had a history of enucleation due to exogenous endophthalmitis after globe rupture. The DFG and OMG were harvested from the abdominal region and lower lip, respectively. All four patients achieved a good postoperative appearance, with dermal surfaces appearing pink and smooth, the orbital areas showing good fullness, the ocular prosthesis showing good wearability, and no narrowing of the sockets. There was no lipid secretion, fat lysate outflow, or infection in the graft bed. There were only small amounts of scars and no infection of the donor site.ConclusionThe sandwich-like structure can be effectively used to reconstruct the contracted and low-capacity anophthalmic socket with a history of orbital infection in one stage.

Platelet-rich plasma and bone morphogenetic protein: bucomaxillofacial and bone regeneration

Introduction: Science has evolved at an accelerated pace in the last decades, due to the need to know more and more the human being and the environment that surrounds them. In the search for this knowledge, aiming to improve the quality of life and the treatment of diseases previously considered incurable, research, especially in the field of biotechnology, has transformed the day-to-day health professionals. The application of this biotechnology related to growth factors can be exemplified in the use of platelet-rich plasma (PRP), gel capable of modulating and accelerating some repair processes. Objective: The objective of this work was to review the concepts related to growth factors, as well as in relation to platelet-rich plasma as an adjuvant in bone regeneration therapies. Methods: The present study followed a systematic review model, following the rules of systematic review – PRISMA. This study focuses on the treatment of bone regeneration through platelet-rich plasma and morphogenetic protein (BMP). To this end, a survey was conducted in scientific articles in the databases PubMed, Medline, Scielo, Lilacs, and e-books. The Cochrane Instrument was used to assess the risk of bias of the included studies, and GRADE was used to classify the quality of articles to the type of study and scientific evidence. Results and Conclusion: Therefore, the use of PRP, which would accelerate the rate of bone formation, with bone morphogenetic proteins (BMPs), recombinant or autogenous, should be quite important and elucidative. The development of new research, seeking to use all known technology, will always be the best way for a short future to recognize what should be incorporated into the daily routine of medical and dental clinics, differing from what, for various reasons, whether it was just a marketing procedure or something. The greatest advantage of the use of platelet-rich plasma is its ability to accelerate the process of bone regeneration by increasing the number of growth factors present in human platelets. On the other hand, it is observed that one of its major disadvantages is the low life expectancy of these platelets in the recipient or graft bed. However, it is also known that the PRP technique would only accelerate a process of bone regeneration that normally already occurs and this process follows its path until the formation of the mature bone.