Control of the skin scarring response

There comes a time when the understanding of the cutaneous healing process becomes essential due to the need for a precocious tissue repair to reduce the physical, social, and psychological morbidity. Advances in the knowledge on the control of interaction among cells, matrix and growth factors will provide more information on the Regenerative Medicine, an emerging area of research in medical bioengineering. However, considering the dynamism and complexity of the cutaneous healing response, it is fundamental to understand the control mechanism exerted by the interaction and synergism of both systems, cutaneous nervous and central nervous, via hypothalamus hypophysis-adrenal axis, a relevant subject, but hardly ever explored. The present study reviews the neuro-immune-endocrine physiology of the skin responsible for its multiple functions and the extreme disturbances of the healing process, like the excess and deficiency of the extracellular matrix deposition.Aproxima-se uma época na qual é fundamental a compreensão do processo cicatricial cutâneo frente à necessidade da restauração tecidual precoce, visando a diminuição das morbidades física, social e psicológica. O avanço no conhecimento acerca do controle das interações entre as células, a matriz e os fatores de crescimento dará maiores informações à Medicina Regenerativa, área de pesquisa emergente da bioengenharia médica. Entretanto, diante do dinamismo e complexidade da resposta cicatricial cutânea torna-se indispensável o entendimento do mecanismo de controle exercido pela interação e sinergismo do sistema nervoso cutâneo e o sistema nervoso central, via eixo hipotálamo-hipófise-adrenal, tema relevante, porém, pouco abordado. O presente estudo revisa a fisiologia neuro-imuno-endócrina da pele, responsável por suas múltiplas funções, e os distúrbios extremos do processocicatricial, como o excesso e deficiência de deposição da matriz extracelular.Universidade Federal de São Paulo (UNIFESP) Programa de Pós-Graduação em Cirurgia PlásticaUNIFESP, Programa de Pós-Graduação em Cirurgia PlásticaSciEL

Heteroenxerto de quelóide na bolsa jugal do hamster (Mesocricetus auratus)

PURPOSE: To study the integration of keloid heterograft in hamster (Mesocricetus auratus) cheek pouch. METHODS: The sample is formed by 18 male hamsters, heterogenic ones, aged between 10 and 14 weeks. Keloid fragments were obtained from keloid scars of the breast region of adult female mulatto patient. Each hamster received keloid fragments into both of its pouches, in a total of 36 grafted fragments. Animals were distributed into 6 groups for having their grafts assessed in the days 5, 12, 21, 42, 84, and 168. A macroscopic assessment is performed by comparing the pouch containing the grafted fragment, at each time point, with the same pouch in the immediate post surgical moment through a comparison of standardized photographs. Under microscope, the presence of blood vases is considered within the conjunctive tissue of the grafted fragment, as a criterion of its integration. Other events, as keratin secretion, the presence of cellular infiltrated, epithelium and keloid collagen fibers aspects are also analyzed. RESULTS: Macroscopy reveals intensive vascularization of the pouch up to 12 days from the transplantation and the presence of constant dark brown pigmentation on the grafted keloid fragments. In microscopy, the integration of keloid fragments is considered by the presence of blood capillary vases within conjunctive tissue. The presence of intensive cellular inflammatory type infiltrated up to 12 days is also observed, as well as the remaining of keloid epithelium up to 21 days, and the appearing of melanocytes from the day 42. CONCLUSION: Hamster cheek pouch represents, a priori, an experimental model for the investigation of keloid.OBJETIVO: Investigar a integração do transplante heterólogo de quelóide na bolsa jugal do hamster (Mesocricetus auratus). MÉTODOS: A amostragem consiste de 18 hamsters machos, heterogênicos, com 10 a 14 semanas de idade. Fragmentos de quelóide foram obtidos de cicatrizes queloidianas da região mamária de paciente adulta parda. Cada hamster foi enxertado em ambas as bolsas com fragmentos de quelóide, totalizando 36 fragmentos enxertados. Os animais foram distribuídos em 6 grupos para exame dos fragmentos enxertados, com 5, 12, 21, 42, 84 e 168 dias. Uma avaliação macroscópica é realizada comparando a bolsa contendo o fragmento enxertado em cada período com a mesma bolsa no pós-operatório imediato, mediante a comparação de fotografias padronizadas. À microscopia, considera-se a presença de vasos sangüíneos no tecido conjuntivo do fragmento enxertado como critério de integração do mesmo. Outros eventos, como secreção de queratina, presença de infiltrados celulares e aspecto do epitélio e das fibras colágenas do quelóide, também são observados. RESULTADOS: A macroscopia revela intensa vascularização na bolsa até 12 dias de enxertia, e a presença constante de pigmentação castanho-escura nos fragmentos de quelóide enxertados. Na microscopia constata-se a integração dos fragmentos de quelóide pela presença de capilares sangüíneos no tecido conjuntivo. Observa-se, também, a presença de intenso infiltrado celular do tipo inflamatório até 12 dias, a permanência do epitélio do quelóide até 21 dias, e o aparecimento de melanócitos a partir de 42 dias. CONCLUSÃO: A bolsa jugal do hamster representa, a priori, modelo experimental para investigação do quelóide.UNIFESP-EPM Post-Graduation ProgramUNIFESP-EPM Department of SurgerySão Paulo University (USP) Immunology DepartmentUNIFESP-EPM Department of Veterinary Medicine and ZootechnologyUNIFESP-EPM Post-Graduation Program of Plastic SurgeryUNIFESP, EPM, Post-Graduation ProgramUNIFESP, EPM Department of SurgeryUNIFESP, EPM Department of Veterinary Medicine and ZootechnologyUNIFESP, EPM Post-Graduation Program of Plastic SurgerySciEL

Prevalência de úlcera por pressão em instituições de longa permanência para idosos em São Paulo

CONTEXT AND OBJECTIVE: The prevalence of pressure ulcers varies according to geographic region and population group, such as the institutionalized elderly. The aim of this study was to identify the prevalence of pressure ulcers among elderly people living in long-stay institutions. DESIGN AND SETTING: Cross-sectional study in six long-stay institutions for the elderly in São Paulo, Brazil. METHODS: Demographic and clinical data were collected in six long-stay institutions on two visits to each institution between May and August 2007, during which all elderly patients with pressure ulcers were evaluated. The Braden scale was used to identify the risk of developing pressure ulcers and the National Pressure Ulcer Advisory Panel (NPUAP) stages for classifying the pressure ulcers. Statistical analysis was performed using the chi-square test, Student's t-test and Fisher's exact test. RESULTS: There was no significant difference in the results between visits. The population was 181 elderly people in May and 184 in August: 23 had pressure ulcers in May (prevalence of 12.7%) and 17 in August (prevalence of 9.2%). The mean age at the two times was 84 years, and the average length of stay was 32 months. Pressure ulcers were found mainly in the sacral region (mean, 71.5%), and most commonly in stage II (mean, 41%). CONCLUSION: The prevalence of pressure ulcers was 10.95%. These data provide background information that may aid in developing protocols for applying best practices for prevention and treatment of pressure ulcers, consequently reducing the prevalence.CONTEXTO E OBJETIVO: A prevalência de úlcera por pressão (UP) varia de acordo com a região geográfica e grupo populacional, como idosos institucionalizados. O objetivo foi identificar a prevalência de UP em instituições de longa permanência para idosos (ILPI). TIPO DE ESTUDO E LOCAL: Estudo transversal em seis ILPI em São Paulo. MÉTODOS: A coleta de dados demográficos e clínicos foi realizada em seis ILPI durante duas visitas a cada instituição no período de maio a agosto de 2007, sendo avaliados todos os idosos com UP. Foi utilizada a Escala de Braden para identificar o risco de desenvolver UP e o National Pressure Ulcer Advisory Panel (NPUAP) para a classificação das UP. Foram realizados os testes: Exato de Fisher, Q-Quadrado e t-Student para análise estatística. RESULTADOS: Não houve significância estatística nos resultados encontrados. A população era de 181 idosos em maio e 184 em agosto, sendo 23 idosos com UP (prevalência de 12,7%) e 17 idosos com UP (prevalência de 9,2%) respectivamente. A média de idade nos dois períodos foi de 84 anos, e 32 meses de permanência nas Instituições. A região sacral foi a mais frequente com média de 71,5% e as úlceras no estágio II com média de 41%. CONCLUSÃO: A prevalência de UP foi de 10,95%. Estes dados fornecem informações de base que podem auxiliar no desenvolvimento de protocolos para a aplicação de melhores práticas na prevenção e tratamento de úlceras de pressão, consequentemente reduzindo a prevalência.Universidade Federal de São Paulo (UNIFESP) Division of Plastic SurgeryUniversidade Federal de São Paulo (UNIFESP) Division of Plastic Surgery Program on Plastic SurgeryUNIFESP, Division of Plastic SurgeryUNIFESP, Division of Plastic Surgery Program on Plastic SurgerySciEL

The action of CGRP and SP on cultured skin fibroblasts

Calcitonin gene-related peptide (CGRP) is the most abundant neuropeptide in the skin, followed by substance P (SP), vasoactive intestinal peptide (VIP), and other neuropeptides in smaller amounts. the proliferative effect of neuropeptides on fibroblasts may affect wound healing and may be associated with hyperproliferative skin and mesenchymal disorders. Understanding the neuropeptidergic action on fibroblasts may provide relevant information to a deeper comprehension of the healing process. This study reviews the action of the main neuropeptides, CGRP and SP, on cultured human skin fibroblasts.A systematic literature search was conducted on Medline and Web of Science databases on December 21, 2013.A total of 74 articles were retrieved using the proposed search strategies and 3 were found in the references section of the selected articles. Thirteen of the retrieved articles studied the action of CGRP and SP on cultured human skin fibroblasts, 12 of which related to SP and 1 related to both CGRP and SP.Only one study was retrieved about the action of both CGRP and SP on cultured human skin fibroblasts. Further studies are necessary to investigate CGRP on skin fibroblasts and its role in the fibroplasia phase of wound healing.Universidade Federal de São Paulo Unifesp, Dept Surg, Plast Surg Div, Postgrad Program Translat Surg, BR-04024002 São Paulo, BrazilUniv Estadual Santa Cruz, Dept Agr & Environm Sci, BR-45662900 Ilheus, BA, BrazilUniv Estadual Santa Cruz, Dept Biol Sci, BR-45662900 Ilheus, BA, BrazilUniversidade Federal de São Paulo Unifesp, Dept Surg, Plast Surg Div, Postgrad Program Translat Surg, BR-04024002 São Paulo, BrazilWeb of Scienc

Image analysis software versus direct anthropometry for breast measurements

PURPOSE:To compare breast measurements performed using the software packages ImageTool(r), AutoCAD(r) and Adobe Photoshop(r) with direct anthropometric measurements.METHODS:Points were marked on the breasts and arms of 40 volunteer women aged between 18 and 60 years. When connecting the points, seven linear segments and one angular measurement on each half of the body, and one medial segment common to both body halves were defined. The volunteers were photographed in a standardized manner. Photogrammetric measurements were performed by three independent observers using the three software packages and compared to direct anthropometric measurements made with calipers and a protractor.RESULTS:Measurements obtained with AutoCAD(r) were the most reproducible and those made with ImageTool(r) were the most similar to direct anthropometry, while measurements with Adobe Photoshop(r) showed the largest differences. Except for angular measurements, significant differences were found between measurements of line segments made using the three software packages and those obtained by direct anthropometry.CONCLUSION:AutoCAD(r) provided the highest precision and intermediate accuracy; ImageTool(r) had the highest accuracy and lowest precision; and Adobe Photoshop(r) showed intermediate precision and the worst accuracy among the three software packages.Federal University of São PauloUniversidade Federal de São Paulo (UNIFESP) Department of SurgeryUNIFESPUNIFESP, Department of SurgeryUNIFESPSciEL

Keloid and hypertrophic scar distribution according to Fitzpatrick skin phototypes

BACKGROUND: Keloid and hypertrophic scars have a common physiopathogenic origin and are defined as fibroproliferative scars. Fibroproliferative scars are frequent in individuals with darker skin. However, mixing of races renders it difficult to group patients with different skin tones according to morphological and static classifications (white for Caucasians; brown for individuals of Spanish descent (Hispanic/Latino); yellow for individuals of East Asian descent; and black for individuals of African descent) according to their response to sun exposure. It is known that when individuals whose ethnic origin is in colder countries move to tropical countries, they show a higher incidence of these types of scars, which mainly affect parts of the body that are more exposed to the sun. A correlation between fibroproliferative scars and Fitzpatrick phototype, a dynamic classification based on the skin's response to sun exposure, would contribute to an understanding of the pathophysiology of these scars. The aim of this study is to investigate the distribution of fibroproliferative scars according to Fitzpatrick phototypes. METHODS: We classified patients' fibroproliferative scars according to the Muir classification as Long-Term Evolution (keloid scars), Short-Term Evolution (hypertrophic scars), and Intermediate Group (mixed scars), while their skin types were grouped according to the Fitzpatrick classification. RESULTS: Fitzpatrick phototype III and mixed scars were predominant among the patients analyzed (p = 0.001). A correlation (p = 0.025) was observed between fibroproliferative scars and Fitzpatrick phototypes; the higher the phototype, the higher the tendency to develop keloid and mixed scar tissue. CONCLUSIONS: Fitzpatrick skin phototypes proved to be an efficient method to study keloid and hypertrophic scars.INTRODUÇÃO: Queloide e cicatriz hipertrófica são cicatrizes patológicas com natureza fisiopatogênica comum, denominadas, em conjunto, cicatrizes fibroproliferativas. São mais frequentes em indivíduos de pele mais escura. Contudo, a atual miscigenação dificulta o enquadramento dos pacientes com variadas tonalidades de pele em classificações morfológicas e estáticas (branco ou caucasoide, mulato, pardo, hispânico ou latino, amarelo ou oriental ou mongoloide e negro ou negroide), e diferentes quanto à exposição solar. Sabe-se que pessoas oriundas de países de clima temperado ou frio quando residem em países tropicais aumentam a incidência dessas cicatrizes, principalmente nas áreas de maior exposição solar. Uma relação entre as cicatrizes fibroproliferativas e os fototipos de Fitzpatrick, classificação dinâmica baseada no relato do paciente quanto a sua resposta cutânea após a exposição solar, poderia contribuir para a compreensão da fisiopatologia dessas cicatrizes. Este estudo teve como objetivo investigar a distribuição das cicatrizes fibroproliferativas segundo os fototipos de Fitzpatrick. MÉTODO: Foram avaliados 146 pacientes provenientes do Ambulatório da Disciplina de Cirurgia Plástica da Universidade Federal de São Paulo (UNIFESP) (UNIFESP, São Paulo, SP, Brasil), portadores de qualquer tipo de cicatriz fibroproliferativa, em um ou mais locais do corpo. As cicatrizes fibroproliferativas dos pacientes foram classificadas de acordo com os critérios de Muir em cicatriz tipo queloide (Long-term Evolution, LTE), cicatriz tipo hipertrófica (Short-term Evolution, STE) e cicatriz tipo mista (Intermediate Group, IG), e os tipos de pele foram classificados segundo os fototipos de Fitzpatrick. RESULTADOS: O fototipo Fitzpatrick III e a cicatriz mista foram mais frequentes entre os pacientes avaliados (P = 0,001). Houve associação (P = 0,025) entre as cicatrizes fibroproliferativas e os fototipos de Fitzpatrick, ou seja, quanto maior o fototipo maior a tendência de desenvolvimento de cicatrizes dos tipos queloide e mista. CONCLUSÕES: Os fototipos de pele segundo Fitzpatrick mostraram-se válidos como critério a ser utilizado em estudos de queloide e cicatriz hipertrófica.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL