La lipostructure dans les séquelles de brûlures faciales

Scarring and Skin Fibrosis Reversal with Regenerative Surgery and Stem Cell Therapy

Skin scarring and fibrosis affect millions of people worldwide, representing a serious clinical problem causing physical and psychological challenges for patients. Stem cell therapy and regenerative surgery represent a new area of treatment focused on promoting the body's natural ability to repair damaged tissue. Adipose-derived stem cells (ASCs) represent an optimal choice for practical regenerative medicine due to their abundance, autologous tissue origin, non-immunogenicity, and ease of access with minimal morbidity for patients. This review of the literature explores the current body of evidence around the use of ASCs-based regenerative strategies for the treatment of scarring and skin fibrosis, exploring the different surgical approaches and their application in multiple fibrotic skin conditions. Human, animal, and in vitro studies demonstrate that ASCs present potentialities in modifying scar tissue and fibrosis by suppressing extracellular matrix (ECM) synthesis and promoting the degradation of their constituents. Through softening skin fibrosis, function and overall quality of life may be considerably enhanced in different patient cohorts presenting with scar-related symptoms. The use of stem cell therapies for skin scar repair and regeneration represents a paradigm shift, offering potential alternative therapeutic avenues for fibrosis, a condition that currently lacks a cure.

Autologous Fat Transfer for Scar Prevention and Remodeling: A Randomized, Blinded, Placebo-controlled Trial

Autologous fat transfer—also referred to as fat grafting—has been reported to provide beneficial effects to overlying scar and skin. Despite procedural frequency, there is a paucity of high-level evidence guiding the surgeon in technique, patient selection, and efficacy.

Autologous fat transfer to treat fibrosis and scar-related conditions: A systematic review and meta-analysis

BACKGROUND

Autologous fat transfer (AFT), also known as lipofilling, has been demonstrated to be more than just a filler. Through both mechanical dissection and local tissue remodelling mediated by stem cells, it is thought to improve scar quality, function and even pain. This paper aims to investigate the evidence regarding its safety and effectiveness for treating fibrosis and scar-related conditions.

METHODS

A literature search was performed in PubMed, Embase and the Cochrane Library to identify relevant studies. Extensive data extraction and standardization allowed conducting a meta-analysis.

RESULTS

Forty-five studies (3033 patients) provided sufficient data for meta-analysis. The AFT treatment resulted in significant increase in satisfaction scores of both patient and surgeon (p  =  0.001). Furthermore, a significant overall scar improvement was also found in the evaluation using the Patient and Observer Scar Assessment Scale, with the most notable effect in the scar stiffness (p<0.001) and pliability (p  =  0.004). In patients with severe pain, AFT resulted in a significant pain reduction of 3.7 points on the Visual Analogue Scale (p<0.001). Last, but not the least, the evidence suggests a significant recovery of radiotherapy-induced tissue damage (p  =  0.003) and function (p  =  0.012). On average, 1.4 procedures were required to achieve the desired result. Minor complications occurred in 4.8% of the procedures.

CONCLUSIONS

AFT is a promising treatment for fibrosis and scar-related conditions. Future research should focus on determining the long-term effects of AFT on fibrosis, pain and function. In addition, it would be crucial to quantify the mechanical and regenerative properties of fat as well as the effect of added supplements or stem cells.

Human Adipocyte Conditioned Medium Promotes In Vitro Fibroblast Conversion to Myofibroblasts

Adipocytes and adipose tissue derived cells have been investigated for their potential to contribute to the wound healing process. However, the details of how these cells interact with other essential cell types, such as myofibroblasts/fibroblasts, remain unclear. Using a novel in-vitro 3D human adipocyte/pre-adipocyte spheroid model, we investigated whether adipocytes and their precursors (pre-adipocytes) secrete factors that affect human dermal fibroblast behavior. We found that both adipocyte and pre-adipocyte conditioned medium induced the migration of fibroblasts, but only adipocyte conditioned medium induced fibroblast differentiation into a highly contractile, collagen producing myofibroblast phenotype. Furthermore, adipocyte mediated myofibroblast induction occurred through a TGF-β independent mechanism. Our findings contribute to a better understanding on the involvement of adipose tissue in wound healing, and may help to uncover and develop fat-related wound healing treatments.

Histological Evaluation of the Skin After Fat Grafting: A Blinded, Randomized, Controlled Clinical Study

BACKGROUND

Autologous fat graft is often employed to treat body contour defects. There is currently increased interest in the regenerative properties of fat grafting.

OBJECTIVES

The authors evaluated the histological changes of fat grafting in a blinded randomized controlled trial of staged fat grafting-abdominoplasty.

METHODS

Ten women between 24 and 55 years of age with a body mass index <30 kg/m2 and previous cesarean scar were submitted to fat grafting followed by staged abdominoplasty. The C-section scar served as a landmark for standardization of fat grafting site and control. One side of the abdomen was fat grafted and the other was left intact (control). At the time of abdominoplasty, 4 months later, a full-thickness skin sample from each hemi abdomen (fat-grafted area and control) was collected and sent to histological analysis.

RESULTS

All of the fat-grafted samples showed extracellular lipids and signs of fat graft viability, whereas no such changes occurred in the control group. There were no statistically significant differences in fat-grafted vs control samples regarding skin inflammatory infiltrate (P = 0.582), dermis thickness (P = 0.973), vascular density (P = 0.326), and amount of elastic fibers (P = 1).

CONCLUSIONS

The histological evaluation of women's abdominoplasty surgical site skin after 4 months of fat grafting showed signs of fat graft in 100% of the grafted sides but no change in skin inflammatory infiltrate, dermis thickness, vascularity density, or elastic fiber quantity.

Fat Grafting for Treatment of Facial Burns and Burn Scars

This article presents the authors' experience with the use of fat grafting via the Coleman technique, for the adjuvant treatment of facial burn wounds and their sequelae. It demonstrates the regenerative effects of fat injected under the wound and/or the scar as well as of fat delivered to the debrided surface of the wound and to the surface of the scar after laser treatment or microneedling.

Efficacy and Safety of Autologous Fat Transfer in Facial Reconstructive Surgery: A Systematic Review and Meta-analysis

Importance

The use of autologous fat transfer (AFT) or lipofilling for correcting contour deformities is seen as one of the major breakthroughs in reconstructive plastic surgery. Its applications in facial reconstructive surgery have been of particular interest owing to the prospect of achieving autologous reconstruction by a minimally invasive approach. However, its unpredictability and variable degree of resorption have limited its utility and much skepticism still exists regarding its efficacy. Furthermore, more than 2 decades of clinical research have produced a highly fragmented body of evidence that has not been able to provide definite answers.

Objective

To investigate the safety and efficacy of AFT in facial reconstruction through a systematic review and meta-analysis.

Data Sources

A literature search was performed in PubMed, Embase, and the Cochrane Library from inception to October 11, 2017.

Study Selection

All published studies investigating the efficacy and safety of AFT in facial reconstructive surgery.

Data Extraction and Synthesis

Two independent reviewers performed data extraction systematically, adhering to the PRISMA guidelines. Summary measures were pooled in a random-effects model meta-analysis.

Main Outcomes and Measures

The patient and surgeon satisfaction, graft survival, number of AFT sessions, and the incidence of AFT-related complications were the main outcomes of interest in this meta-analysis.

Results

This systematic review resulted in the inclusion 52 relevant studies consisting of 1568 unique patients. These included 4 randomized clinical trials, 11 cohort studies, and 37 case series. The overall follow-up averaged 1.3 years after AFT. Meta-analysis revealed a very high overall patient satisfaction rate of 91.1% (95% CI, 85.1%-94.8%) and overall surgeon satisfaction rate of 88.6% (95% CI, 83.4%-92.4%). The number of AFT sessions required to achieve the desired result was 1.5 (95% CI, 1.3-1.7) and 50% to 60% of the injected volume was retained at 1 year. Only 4.8% (95% CI, 3.3%-6.9%) of procedures resulted in clinical complications.

Conclusions and Relevance

To our knowledge, this study provides the first overview of the current knowledge about AFT in facial reconstructive surgery. Our results confirm that AFT is an effective technique for treating soft-tissue deformities in the head and neck, with low rate of minor complications.

Level of Evidence

NA.

Combined Non-Ablative Laser and Microfat Grafting for Burn Scar Treatment

BACKGROUND

Burn scar treatment persists as an unsolved problem, involving thousands of affected patients disfigured for life.

OBJECTIVES

We sought to present our experience with the use of combined treatments for patients with burn scars.

METHODS

This was a case series report of the senior author's experience during 8 years utilizing the combined treatments of Fraxel Restore (fractional laser) and microfat graft injection for 288 patients with burn scars.

RESULTS

Laser treatment reduced scar intensity and attenuated skin irregularities and hyperpigmentation. All patients demonstrated marked improvement of skin texture and an increase in scar softness after 3 sessions of microfat grafting. However, the degree of improvement varied between patients and was related to the severity of the scar and the type of tissue. Overall, a 40% to 80% improvement was noted in our patients. All patients and their families expressed satisfaction with the results.

CONCLUSIONS

The combined treatment of Fraxel and microfat grafting is an effective technique for improving the appearance of a hypertrophic scar or keloid on burn patients. Fat tissue stem cells may have helped to repair the damaged skin.

LEVEL OF EVIDENCE: 4

Burn injury: Challenges and advances in burn wound healing, infection, pain and scarring

Severe burn injuries are the most traumatic and physically debilitating injuries affecting nearly every organ system and leading to significant morbidity and mortality. Early burn wound excision and skin grafting are common clinical practices that have significantly improved the outcomes for severe burn injured patients by reducing mortality rate and days of hospital stay. However, slow wound healing, infection, pain, and hypertrophic scarring continue to remain a major challenge in burn research and management. In the present article, we review and discuss issues in the current treatment of burn injuries; the advances and novel strategies developed in the past decade that have improved burn management; and also, pioneer ideas and studies in burn research which aims to enhance burn wound care with a focus on burn wound infection, pain management, treatments for scarring and skin tissue engineering.

A promising tool for surgical lipotransfer: a constant pressure and quantity injection device in facial fat grafting

BACKGROUND

The purpose of this study was to preliminarily assess a constant pressure and quantity fat granule injection device for minimal invasive properties in clinic.

METHODS

A retrospective controlled study was carried out, from October 2013 to January 2015, on 76 female healthy patients aged between 26 and 53 years at the General Hospital of Lanzhou Military Command, China. To achieve small volume, high thrust, and precision requirements of facial fat grafting, an integrated handheld controller and motor design was adopted, reducing the volume and weight of the fat transplantation injection device. The 76 patients underwent 90 procedures each side of the face; each patient was treated with the aforementioned device on the face's left side, while a conventional hand-push injection device was used on the right side as control. The outcome was assessed on pre- and postoperative images, with 6-24 months follow-up.

RESULTS

The current device consistently allowed deposition of fat threads at about 55 μL/cm after cannula withdrawal; the volume of fat injected could be precisely adjusted to 0.04 mL/s. This device had the advantages of small-volume injection and convenient operation. The patients exhibited a good, stable shape and a smooth contour line in both sides. The long term satisfaction was higher for the left side than for the right one. Nodules and unevenness occurred only on the right side. Ecchymosis occurred significantly less frequent on the left side than the right one. Intraoperative pain was significantly lower for the left side than the right one.

CONCLUSIONS

This device offered superior control compared with the conventional one and constitutes a promising tool for surgeons practicing lipotransfer.

Modern trends in lipomodeling

Lipomodeling is the process of relocating autologous fat to change the shape, volume, consistency, and profile of tissues, with the aim of reconstructing, rejuvenating, and regenerating body features. There have been several important advancements in lipomodeling procedures during the last thirty years. Four clinical steps are important for the success of engraftment: fat harvesting, fat processing, fat reinjection, and preconditioning of the recipient site. With the discovery of adipose derived stem cells and dedifferentiated cells, fat cells become a major tool of regenerative medicine. This article reviews recent trends in lipomodeling trying to understand most of the issues in this field.

[Reconstruction of proximal nasal defect after deep carcinological resection. Interest to combine titane mesh with fat grafting]

INTRODUCTION

The mucosal cylindroma or adenoid cystic carcinoma is the second sinonasal non-epithelial malignant tumor frequency argument. Due to the achievement of the nasal mucosa and a late diagnosis reconstructions are often complex. We report the case of a mucous cylindroma recurrence of nasal septum requiring a wide and deep excision of the root of the nose with nasal reconstruction.

CASE REPORT

A patient aged 66 years whose history resection two years ago with a mucous adenoid cystic carcinoma of the right side of the nasal septum, had a local recurrence T2NOM0 imposing a wide excision with amputation nasal septum own bones of nose, the anterior portion of the triangular cartilages. The reconstruction was carried out in three areas: a musculocutaneous forehead flap to the mucosal level, a titanium plate to the bone plane, nasal native skin to skin level. Histological examination confirmed the existence of a recurrence cylindroma infiltrating the bone. The surgical margins were however in sano. Adjuvant radiotherapy to 60Gy dose of the surgical area was indicated after surgery. The consequences of surgery and radiotherapy were simple. However local changes to show a progressive refinement of the nasal skin due to irradiation leading to a small titanium plate exposure revision surgery with coverage by a glabellar flap associated with a time of lipomodeling unexposed areas have improved and trophism of soft tissue. Two further lipomodeling sessions have yielded a good quality and stable skin. From an oncological point of view, no recurrence was detected with a decline of 10 years. Aesthetic and functional point of view the results were highly satisfactory.

DISCUSSION

Oncologic resections subtotal nasal pyramid are complex, we will see the benefits and disadvantages of the different techniques used in the different stages.

CONCLUSION

This case report illustrates the difficulties of reconstruction after wide excision of mucosal lesions root of the nose carrying the mucous plan and nasal bones. It stresses the importance of bone reconstruction titanium plate and innovative element, the efficiency of fat transfer to restore the quality and trophicity soft tissue. Fat transfer in addition to reconstructions by titanium plates and splints may thus expand the indications of these types of techniques in complex facial and cranial reconstructions.

The Use of Autologous Fat Grafting for Treatment of Scar Tissue and Scar-Related Conditions: A Systematic Review

BACKGROUND

Scar tissue can cause cosmetic impairments, functional limitations, pain, and itch. It may also cause emotional, social, and behavioral problems, especially when it is located in exposed areas. To date, no gold standard exists for the treatment of scar tissue. Autologous fat grafting has been introduced as a promising treatment option for scar tissue-related symptoms. However, the scientific evidence for its effectiveness remains unclear. This systematic review aims to evaluate the available evidence regarding the effectiveness of autologous fat grafting for the treatment of scar tissue and scar-related conditions.

METHODS

A systematic literature review was performed using MEDLINE, Cochrane Library, EMBASE, and Web of Science. No language restrictions were imposed.

RESULTS

Twenty-six clinical articles were included, reporting on 905 patients in total. Meta-analysis was not performed because of the heterogeneous methodology demonstrated among the articles. Main outcome measures were scar appearance and skin characteristics, restoration of volume and/or (three-dimensional) contour, itch, and pain. All publications report a beneficial effect of autologous fat grafting on scar tissue. There is statistical significant improvement of the scar appearance, skin characteristics, and pain. Itch and restoration of volume and three-dimensional contour also improved.

CONCLUSIONS

Autologous fat grafting is used to improve a variety of symptoms related to scar tissue. This systematic review suggests that autologous fat grafting provides beneficial effects with limited side effects. However, the level of evidence and methodological quality are quite low. Future randomized controlled trials with a methodologically strong design are necessary to confirm the effects of autologous fat grafting on scar tissue and scar-related conditions.

[Annular lipoatrophy of the ankles treated by fat grafting: Case report and review of the literature]

INTRODUCTION

Annular lipoatrophy of the ankles is a rare disease. Eleven cases are described in the literature.

CASE REPORT

We report the case of a 10-year-old girl having an annular lipoatrophy of the ankles. The clinical history begins with the appearance of inflammatory infiltrated nodules at the two legs, which have evolved in a few months to a circumferential lipoatrophy of the ankles. Laboratory studies showed a very high antistreptolysin O titer, concluding streptococcal origin of this hypodermitis. After two years of stable lesions, the patient received two sessions of fat injection.

RESULT/DISCUSSION

A satisfactory outcome of the adipocyte graft was observed with reconstitution of shapely legs, stable over time. Eleven cases described in the literature are found. It is a pediatric pathology seen predominantly in female children. The evolution towards lipoatrophy is systematic with or without treatment initiated at the inflammatory phase. We first discuss the management of aesthetic sequelae of this disease.

CONCLUSION

Fat grafting appears to be a good indication for the treatment of the cosmetic sequelae seen in annular lipoatrophy of the ankles.

Fat grafting for treatment of burns, burn scars, and other difficult wounds

This article presents the authors' 3-year experience with the use of fat grafting, via the Coleman technique, for the adjuvant treatment of burn wounds, venous ulcers, diabetic ulcers, and burn scars. It demonstrates the regenerative effects of fat injected under the scar, and of fat injected under the wound, in the periphery of the wound, and within a bone fracture line or space, and of fat deposited over the wound.

Stem cell application in acute burn care and reconstruction

Burn injuries have a consistently high rate of mortality and morbidity, principally due to sepsis and systemic inflammation. Furthermore, wound closure is often troubled by a limited supply of autologous skin graft availability. Researchers are now looking at augmenting alternative sources for tissues engineering, including stem cells in the bone marrow, fat and hair follicles. Many studies suggest that the ability of stem cells to augment the clinical care of thermally-injured patients shows great potential; however, while our understanding of stem-cell biology has expanded dramatically over the last two decades, significant insight is still required so the full potential of these cells can be safely harnessed and transferred to patient care. This article provides a commentary on the evidence supporting a role for stem-cell therapy in acute burn care and tissue reconstruction, with particular reference to those in the bone marrow, adipose tissue and hair follicle.

[Sequelae of hand burns]

INTRODUCTION

Hand burns are common. Aesthetic and functional consequences are mixed together.

ANATOMY

Palmar and dorsal skin are very different. Palmar skin is thick and strong, dedicated to the prehension. Dorsal skin is very thin, creating a mobility plan dedicated to the flexion of the fingers.

AESTHETIC SEQUELAE

They are rarely isolated. Proximal nail retractions can occur after nail burns, with matricial exposition. We remove the scar and a full skin graft is done in order to give a normal proximal nail skin shape.

FUNCTIONAL SEQUELAE

They are fingers and wrist retractions. We often use collagen substitute to cover soft tissue defect after scar excision. Commissure retractions are treated by trident plasty.

PARTICULAR CASES

Electrical burns: we expose the case of a thumb amputation after necrosis by electrical burn, secondary treated by index policization. Children burns: the bridles appear during the growth, so we must follow this patient for a long time.

CONCLUSION

Hand burns are frequent. Functional sequelae are often important: retractions, amputations. The orthopaedic treatment of these retractions is unspecific. We often use collagen substitute in our unit. The patient must be involved in his treatment, because it is very long and difficult.