Diffusion and Perfusion: The Keys to Fat Grafting

Background: Fat grafting is now widely used in plastic surgery. Long-term graft retention can be unpredictable. Fat grafts must obtain oxygen via diffusion until neovascularization occurs, so oxygen delivery may be the overarching variable in graft retention. Methods: We studied the peer-reviewed literature to determine which aspects of a fat graft and the microenvironment surrounding a fat graft affect oxygen delivery and created 3 models relating distinct variables to oxygen delivery and graft retention. Results: Our models confirm that thin microribbons of fat maximize oxygen transport when injected into a large, compliant, well-vascularized recipient site. The “Microribbon Model” predicts that, in a typical human, fat injections larger than 0.16 cm in radius will have a region of central necrosis. Our “Fluid Accommodation Model” predicts that once grafted tissues approach a critical interstitial fluid pressure of 9 mm Hg, any additional fluid will drastically increase interstitial fluid pressure and reduce capillary perfusion and oxygen delivery. Our “External Volume Expansion Effect Model” predicts the effect of vascular changes induced by preoperative external volume expansion that allow for greater volumes of fat to be successfully grafted. Conclusions: These models confirm that initial fat grafting survival is limited by oxygen diffusion. Preoperative expansion increases oxygen diffusion capacity allowing for additional graft retention. These models provide a scientific framework for testing the current fat grafting theories

International lower limb collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures

Trauma remains a major cause of mortality and disability across the world1, with a higher burden in developing nations2. Open lower extremity injuries are devastating events from a physical3, mental health4, and socioeconomic5 standpoint. The potential sequelae, including risk of chronic infection and amputation, can lead to delayed recovery and major disability6. This international study aimed to describe global disparities, timely intervention, guideline-directed care, and economic aspects of open lower limb injuries

Autologous injectable dermis: a clinical and histological study.

BACKGROUND: : No perfect solution yet exists for dermal fillers. The authors hypothesized that autologous dermis can be processed in an operator-friendly manner and adopted in selected patients as a filler, following the principle of replacing "like with like." METHODS: : The authors designed a prototype "cutting chamber" to morsel dermis into an injectable form. Autologous injectable dermis grafting was performed in 16 patients who underwent lip or labionasal fold correction concomitant with abdominoplasty or cesarean scar correction; patient dermis was used for the donor graft. Furthermore, injectable dermis grafting was performed in the subcutaneous tissue of three patients undergoing multistage reconstructive procedures for obesity. The grafts were harvested and examined histologically at 3, 7, and 12 months. RESULTS: : Dermis processing and injection proved feasible with limited effort. All 16 patients presented good volume maintenance by 12 months. Two reported transient palpable firmness for the first 6 months, which subsequently resolved. Histological examination of processed and injected dermis showed volume maintenance over time, effective revascularization of the mass, and structural reorganization with collagen bundles and nested fibroblasts reminiscent of reticular dermis. A transient inflammatory reaction was observed, consistent with the expected healing events. CONCLUSIONS: : Use of autologous dermis as a filler substance for both aesthetic and reconstructive procedures appears to be a feasible option. It could be advised for patients requiring filler correction who undergo concomitant procedures involving excision of potential donor dermis

Negative pressure therapy potential enhancement with a biointeractive hyaluronan acid scaffold interface: case report.

Case Repor

Cutaneous manifestations of Scedosporium apiospermum in an immunosuppressed patient

Scedosporium apiospermum is a ubiquitous fungus of the soil and polluted water responsible for cutaneous and disseminated infection. It is identified as the common cause of mycetoma after trauma in immunocompetent patient and it is recognized as one of the medically important opportunistic fungi causing life-threatening infections in immunosuppressed patients. Cutaneous involvement lacks pathognomonic features that would make an early diagnosis possible. Presentations range from erythematous lesions, abscesses, nodules with purulent discharge to skin plaques, nodules, scaly, crusted surface, granulomatous lesions without signs of infection. A case of deep cutaneous mycosis mimicking a skin cancer is described. The patient was initially treated for an immunosuppressive therapy-related neoplasm. Afterwards the correct histopathological diagnosis was performed, and the patient underwent the proper long-term antifungal treatment. The review of 38 cases collected from the literature underlines the variability of clinical presentations of cutaneous Scedosporium apiospermum. Healthcare providers awareness of clinical aspects and presentation of Scedosporium apiospermum infections and the knowledge of the best treatment options would prevent treatment delay and can be life-saving in immunocompromised patients. The association of early surgical debridement and specific long-term antifungal therapy (based on intraoperative microbiological specimens) offers the best chance of healing, avoiding the risk of dissemination or local recurrence

Surgical anatomy of the axillary nerve and its implication in the transdeltoid approaches to the shoulder.

BACKGROUND: Traumatic and iatrogenic injuries of the axillary nerve (AN) are frequent in clinical practice; nevertheless, its anatomy and its relationships with the transdeltoid approaches to the shoulder are not well documented. MATERIALS AND METHODS: Anatomic study was performed on 16 shoulders of unembalmed cadavers. A proximal humeral internal locking system (PHILOS) plate was placed to simulate the osteosynthesis of a fracture of humeral surgical neck. The relationships between the plate and the nerve were evaluated. Selective dissection of all the nerve branches inside the deltoid muscle was performed. RESULTS: The mean distance between the point where the AN entered into the deltoid muscle and the humeral head was 5.0 cm, and it was 6.8 cm from the acromion. The mean distance between the origins of the anterior and posterior branches of the axillary nerve was 5.4 cm. The mean diameter of the AN was 0.57 cm, the anterior branch diameter was 0.40 cm, of posterior branch diameter was 0.33 cm, and the teres minor branch diameter was 0.24 cm. The application of the PHILOS plate demonstrated that in 100% of cases, the 2 distal holes of the plate of those dedicated to the humeral head coincided with the passage of AN. DISCUSSION: The different patterns of nerve branches inside the deltoid muscle show that the "safe zone" during transdeltoid approaches is the anterior region of the deltoid muscle for a maximum of 6.7 cm from the acromion. In addition, the insertion of the 2 distal screws of those dedicated to humeral head of the plate should be avoided