Juan P. Barret

Up-to-date approach to manage keloids and hypertrophic scars: A useful guide

Keloids and hypertrophic scars occur anywhere from 30 to 90% of patients, and are characterized by pathologically excessive dermal fibrosis and aberrant wound healing. Both entities have different clinical and histochemical characteristics, and unfortunately still represent a great challenge for clinicians due to lack of efficacious treatments. Current advances in molecular biology and genetics reveal new preventive and therapeutical options which represent a hope to manage this highly prevalent, chronic and disabling problem, with long-term beneficial outcomes and improvement of quality of life. While we wait for these translational clinical products to be marketed, however, it is imperative to know the basics of the currently existing wide array of strategies to deal with excessive scars: from the classical corticotherapy, to the most recent botulinum toxin and lasers. The main aim of this review paper is to offer a useful up-to-date guideline to prevent and treat keloids and hypertrophic scars.

Chemical burns: Pathophysiology and treatment

Chemical burns continue to pose a variety of dilemmas to the clinician managing such cases. Assessment of burn depth is often difficult and the decision whether to excise the wound early is not always clear-cut. In this updated review, common agents are classified and the basic principles of management and specific recommendations are examined. The complications arising from exposure to these chemicals and the supportive measures needed during treatment are also described.

Extracorporeal shock waves, a new non-surgical method to treat severe burns.

UNLABELLED Extracorporeal shock wave treatment (ESWT) increases perfusion in ischaemic tissues, stimulates growth factors, decreases inflammation and accelerates wound healing. It is a safe technique classically used in urology and orthopaedic surgery with success, but there is still limited literature regarding its use in the management of burns. PURPOSE The aim of this study is to analyse the effect of ESWT on deep partial/full thickness burns in patients attended at our emergency burn unit. MATERIALS AND METHODS We performed two ESWT sessions in 15 patients with <5% TBSA (total body surface area) deep partial/full thickness burns, on the third and fifth day after injury; prior to each session, we used laser Doppler imaging (LDI). RESULTS Of all treated burns, 80% healed uneventfully prior to 3 weeks; as many as 15% required surgical debridement and grafting and 5% developed hypertrophic scarring. After one ESW session, burns had a significant increase in perfusion, objectivated by the LDI images. CONCLUSIONS Extracorporeal shock wave therapy emerges as a new non-invasive, feasible, safe and cost-effective method in deep partial/full thickness burns. It may decrease the need of surgery and therefore the morbidity of the patient. There is a strong need for more studies to establish the optimal timing and dosage of treatment.

New molecular medicine-based scar management strategies

Keloids and hypertrophic scars are prevalent disabling conditions with still suboptimal treatments. Basic science and molecular-based medicine research have contributed to unravel new bench-to-bedside scar therapies and to dissect the complex signalling pathways involved. Peptides such as the transforming growth factor beta (TGF-β) superfamily, with Smads, Ski, SnoN, Fussels, endoglin, DS-Sily, Cav-1p, AZX100, thymosin-β4 and other related molecules may emerge as targets to prevent and treat keloids and hypertrophic scars. The aim of this review is to describe the basic complexity of these new molecular scar management strategies and point out new fibrosis research lines.

Maximizing Results for Lipofilling in Facial Reconstruction

Lipostructure (also known as structural fat grafts, lipofilling, or fat grafting) has become a technique with a good reputation and reproducible results. The application of this technology in patients undergoing reconstruction is a novel surgical alternative. Obtaining good results in this patient population is very difficult, but the application of small fat grafts with a strict Coleman technique produces long-term cosmetic effects. Adult-derived stem cells have been pointed out as important effectors of this regenerative technology, and future research should focus in this direction.

Full Face Transplantation Organization, Development, and Results—The Barcelona Experience: A Case Report

The initial experience in facial composite tissue allotransplantation has demonstrated that it is surgically feasible, safe, and reproducible. A robust team approach is necessary to warrant successful outcomes. We designed a specific face organ donation that limits facial donation requests followed by synchronous in situ dissection with the internal organs that has proved to be efficient and safe for face and solid organ procurement and transplantation. The first human full face transplantation in our institution was performed on March 27, 2010. The holistic team approach of donation and procurement proved to be effective and reproducible; the recipient showed excellent outcomes at 12 months.

Face allotransplantation and burns: a review.

Burns may represent one of the main indications for face allotransplantation. Severely disfigured faces featuring a devastating appearance and great functional impairments are not only seen as burn sequelae but also occur as a result of other traumatic injuries, oncological surgical resections, benign tumors (eg, neurofibromatosis), and major congenital malformations. To date, 20 human face composite tissue allotransplants have been performed with success. Despite the initial scepticism about its applicability, due mainly to ethical and technical reasons, the previous worldwide cases and their associated positive outcomes, including acceptable immunosuppressive regimens, excellent aesthetic and functional results, and good psychological acceptance by the recipient, enable the conclusion that face composite tissue allotransplantation has become another therapeutic strategy in the reconstructive surgical armamentarium, which bears special consideration when dealing with severely disfigured burned patients. The aim of this review is to describe the basics of face composite tissue allotransplantation and give an overview of some of the cases performed until now, with special attention paid to debating the pros and cons of its applicability in burn patients.

Management of flap venous congestion: The role of heparin local subcutaneous injection

OBJECTIVE The study aimed to propose an alternative salvage technique based on local subcutaneous injection of low molecular-weight heparin (LMWH) for the management of venous congested pedicle and free flaps in which venous outflow could not be surgically restored. METHODS A retrospective review of all patients who received the proposed protocol at a single centre was performed. RESULTS Fifteen patients were treated (six free flaps and nine regional flaps). The LMWH protocol was applied for a mean of 11 days (10-14 days). Thirteen patients required transfusions with a mean number of 5 U (0-12 U) of packed red blood cells (PRBCs) transfused per patient. All flaps were successfully salvaged (seven totally and eight partially). There were two associated complications: one patient developed a recipient-site haematoma and another patient suffered a syncope episode, related to anaemia. CONCLUSIONS Local subcutaneous injection of LMWH was proven to be an effective alternative in improving flap venous congestion. The main advantages of this procedure are availability, easy application and local limited action. However, the associated morbidity should be balanced against the risk of flap loss and a judicious application is mandatory.

LeFort I osteotomy and secondary procedures in full-face transplant patients

Composite tissue allotransplantion has been the latest addition to reconstructive plastic surgery of limbs and faces. These techniques have opened up a new paradigm in reconstruction. However, plastic surgeons will have to face a new patient population that receives the application of vascularised tissue allografts and immunosuppression. Secondary surgery may be necessary in this population, especially in the transplanted tissues, to improve aesthetics and function following the transplant, although little is known regarding the exact clinical protocol to be followed and the feasibility of standard plastic surgery techniques on transplanted tissues. We present our experience of a LeFort I osteotomy, limited ritidectomy and blepharoplasty in a full-face transplant recipient.

Surgical, ethical, and psychosocial considerations in human head transplantation

Transplanting a head and brain is perhaps the final frontier of organ transplantation. The goal of body-to-head transplantation (BHT) is to sustain the life of individuals who suffer from terminal disease, but whose head and brain are healthy. Ideally BHT could provide a lifesaving treatment for several conditions where none currently exists. BHT is no ordinary experiment, to transfer a head to another body involves extraordinarily complex medical challenges as well as ethical and existential dilemmas that were previously confined to the imagination of writers of fiction. The possibility of replacing an incurably ill body with a healthy one tests not only our surgical limits, but also the social and psychological boundaries of physical life and alters what we recognize life to be. The purpose of this target article, the complementary manuscript focused on immunological issues in BHT, and the accompanying Commentaries by scholars and practitioners in medicine, immunology, and bioethics is to review major surgical and psychosocial-ethical and immunological considerations surrounding body-to-head transplantation. We hope that together these ideas will provide readers with a comprehensive overview of the possibilities and challenges associated with BHT and initiate professional discussion and debate through which this new frontier in medicine is considered and approached.