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Chlorhexidine is known to be a potent antiseptic with evidence of a beneficial role in burn care. Nevertheless, several in vitro studies have reported cytotoxicity on cultured cells, while in vivo and clinical data seem to show more controversial results. In the frame of this work, we aimed to evaluate the use of chlorhexidine in burn units worldwide be sending a survey to professionals of the field. We associated survey results to those perspectives reported in the literature to update recommendations for the use of chlorhexidine in specific protocols for burn management. The survey results showed that there is no clear consensus on the use of chlorhexidine regarding the concentrations, the type of excipient and the cleansing after application. Literature searches showed evidence that the skin of premature infants appears to be more sensitive to chlorhexidine that adult skin, with more reported cases of adverse effects. It was also determined that aqueous formulations of chlorhexidine do not appear to be necessarily less efficient than with alcohol as an excipient, and that lower concentrations are as efficient as higher concentrations. In view of this study, we have adjusted our protocols for the use of aqueous formulations at low concentrations and investigated further the role of washing after application in order to standardize the indication of chlorhexidine and minimize the probability of adverse effects., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.

Background: We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure., Methods: We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases)., Results: Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05)., Conclusion: The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure., (© 2019 Wiley Periodicals, Inc.)

Background: Abdominoperineal resection (APR) following radiotherapy is associated with a high rate of perineal wound complications. The anterolateral thigh (ALT) flap, combined with the vastus lateralis (VL) muscle, can cover complex perineal and pelvic anteroposterior defects. This is used for the first time transabdominally through the pelvis and the perineum (TAPP) in the infero-posterior directions; this technique has been described and illustrated in this study., Methods: Among over 90 patients who underwent perineal reconstruction between May 2004 and June 2011, six patients presented high-grade tumours invading perineum, pelvis and sacrum, thereby resulting in a continuous anteroposterior defect. ALT + VL TAPP reconstructions were performed after extended APR and, subsequently, sacrectomy. Patients were examined retrospectively to determine demographics, operative time, complications (general and flap-related), time to complete healing and length of hospital stay. Long-term flap coverage, flap volume stability and functional and aesthetic outcomes were assessed., Results: Mean operating time of the reconstruction was 290 min. No deaths occurred. One patient presented partial flap necrosis. Another patient presented a novel wound dehiscence after flap healing, due to secondary skin dissemination of the primary tumour. Following volumetric flap analysis on serial post-operative CT scans, no significant flap atrophy was observed. All flaps fully covered the defects. No late complications such as fistulas or perineal hernias occurred. Donor-site recovery was uneventful with no functional deficits., Conclusions: The use of the ALT + VL flap transabdominally is an innovative method to reconstruct exceptionally complex perineal and pelvic defects extending up to the lower back. This flap guarantees superior bulk, obliterating all pelvic dead space, with the fascia lata (FL) supporting the pelvic floor., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Engineering of fetal tissue has a high potential for the treatment of acute and chronic wounds of the skin in humans as these cells have high expansion capacity under simple culture conditions and one organ donation can produce Master Cell Banks which can fabricate over 900 million biological bandages (9 x 12cm). In a Phase 1 clinical safety study, cases are presented for the treatment of therapy resistant leg ulcers. All eight patients, representing 13 ulcers, tolerated multiple treatments with fetal biological bandages showing no negative secondary effects and repair processes similar to that seen in 3rd degree burns. Differential gene profiling using Affymetrix gene chips (analyzing 12,500 genes) were accomplished on these banked fetal dermal skin cells compared to banked dermal skin cells of an aged donor in order to point to potential indicators of wound healing. Families of genes involved in cell adhesion and extracellular matrix, cell cycle, cellular signaling, development and immune response show significant differences in regulation between banked fetal and those from banked old skin cells: with approximately 47.0% of genes over-expressed in fetal fibroblasts. It is perhaps these differences which contribute to efficient tissue repair seen in the clinic with fetal cell therapy.

Wound care made great progress during last years related to several factors. The first is an awakening of the importance of wounds. The progress made in the comprehension of the physiopathology of wounds led to innovations in all stages of this complex process which is the wound healing. Autologus platelet concentrate producing growth factors are in use to stimulate the first phase of the healing. The second phase which is the phase of proliferation and secretion is currently better managed with new categories of bandages which are true local treatments. The nutrition became one of the pillars of wound treatments especially among old patients. The reconstructive surgery took great steps since the physiology and the vascular anatomy of the skin and soft tissues are better known. Finally the bio-engineering has entered the treatment of the wound there is more than 20 years ago and methods have improved and become more reliable.

Background: After major burns, patients can develop nutritional deficiencies including trace element (TE) deficiencies. Various complications, such as infections and delayed wound healing, influence the clinical course of such patients., Objectives: We aimed to investigate the effects of large, intravenous doses of TE supplements on circulating and cutaneous TE tissue concentrations, on antioxidant status, and on clinical outcome after major burns., Design: This was a prospective, randomized, placebo-controlled trial in 21 patients aged 35 +/- 11 y (x +/- SD) with burns on 45 +/- 21% of their body surface area. Intravenous copper, selenium, and zinc (TE group) or vehicle (V group) was given with a saline solution for 14-21 d. Blood and urine samples were collected until day 20, and skin biopsy specimens were collected on days 3, 10, and 20., Results: The age of the patients and the severity of their burns did not differ significantly between the groups. Plasma TE concentrations were significantly higher in the TE group. In burned areas, skin contents of both selenium (P=0.05) and zinc (P=0.04) increased significantly by day 20. Plasma and tissue antioxidant status was improved by supplementation. The number of infections in the first 30 d was significantly lower in the TE group (P=0.015), with a median number of 2 versus 4 infections per patient in the TE and V groups, respectively, as a result of a reduction in pulmonary infections (P=0.03). Wound healing was improved in the TE group, with lower requirements for regrafting (P=0.02)., Conclusions: TE supplementation was associated with higher circulating plasma and skin tissue contents of selenium and zinc and improved antioxidant status. These changes were associated with improved clinical outcome, including fewer pulmonary infections and better wound healing.

Lower limb skin defects are very common and can result from a wide range of aetiologies. Split thickness skin graft (STSG) is a widely used method to address these problems. The role of postoperative dressing is primary as it permits one to apply a uniform pressure over the grafted area and promote adherence. Focusing on lower limb reconstruction, our clinical study compares the application of V.A.C. (Vacuum Assisted Closure) Therapy vs. conventional dressing in the immediate postoperative period following skin grafting. We included in the study all patients who received skin grafts on the leg region between January 2015 and December 2018, despite the aetiology of the defect. Only reconstructions with complete preoperative and postoperative follow-up data were included in the study. Patients were divided into two groups depending on if they received a traditional compressive dressing or a VAC dressing in the immediate postoperative period. We could retain 92 patients, 23 in the No VAC group and 69 in the VAC group. The patients included in the VAC group showed a statistically significant higher rate of graft take together with a lower immobilisation time (p < 0.05). Moreover, a lower rate of postoperative infection was recorded in the VAC group. This study represents the largest in the literature to report in detail surgical outcomes comparing the use of VAC therapy vs. conventional dressing after STSG in the postoperative management of lower limb reconstruction using skin grafts. VAC therapy was used to secure the grafts in the leg region, increasing the early graft take rate while at the same time improving patient mobilisation. [ABSTRACT FROM AUTHOR]

Background: Burnpatients characteristically have increased energy, glucose, and protein requirements. Glutamine supplementation is strongly recommended during early‐phase treatment and is associated with improved immunity, wound healing, and reduced mortality. This study evaluated if early burn exudative losses might contribute to higher supplementation needs. Methods: Patients admitted to the burn intensive care unit (ICU) had exudate collection from tight bandages applied to arms or legs during the first week (exudate aliquot twice daily). Seven amino acids (alanine, arginine, cystEine, glutamine, leucine, lysine, and methionine) were quantified by liquid chromatography–mass spectrometry. Descriptive analysis of all results is provided as median and interquartile range or in value ranges. Results: Eleven patients aged 19–77 years, presenting with burns on 18%–70% of the body surface, with a median simplified acute physiology score II of 33 (range, 16–56) were included during the study period. The highest amino acid losses were observed during the first 3 days with an important interpatient and intrapatient variability. Glutamine and alanine losses were highest, followed by leucine and lysine in all patients; amino acid exudate concentrations were in the range of normal plasma concentrations and were stable over time. Total glutamine losses were correlated to the burned surface (r2 = 0.552, P =.012), but not to enteral glutamine supplements. Conclusions: The study shows significant exudative losses during early‐stage burn recovery and particularly for glutamine and alanine. Glutamine loss generally decreased with wound closure, the subsequent decline of exudation, and the evolving size of burn surfaces. [ABSTRACT FROM AUTHOR]

Background: Wound healing involves complex mechanisms, which, if properly chaperoned, can enhance patient recovery. The abilities of platelets and keratinocytes may be harnessed in order to stimulate wound healing through the formation of platelet clots, the release of several growth factors and cytokines, and cell proliferation. The aim of the study was to test whether autologous keratinocyte suspensions in platelet concentrate would improve wound healing. The study was conducted at the Lausanne University Hospital, Switzerland in 45 patients, randomized to three different topical treatment groups: standard treatment serving as control, autologous platelet concentrate (PC) and keratinocytes suspended in autologous platelet concentrate (PC + K). Split thickness skin graft donor sites were chosen on the anterolateral thighs of patients undergoing plastic surgery for a variety of defects. Wound healing was assessed by the duration and quality of the healing process. Pain intensity was evaluated at day five. Results: Healing time was reduced from 13.9 ± 0.5 days (mean ± SEM) in the control group to 7.2 ± 0.2 days in the PC group (P < 0.01). An addition of keratinocytes in suspension further reduced the healing time to 5.7 ± 0.2 days. Pain was reduced in both the PC and PC + K groups. Data showed a statistically detectable advantage of using PC + K over PC alone (P < 0.01). Conclusion: The results demonstrate the positive contribution of autologous platelets combined with keratinocytes in stimulating wound healing and reducing pain. This strikingly simple approach could have a significant impact on patient care, especially critically burned victims for whom time is of the essence. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Chronic low-limb ulcers and pressure ulcers are a serious and costly issue. Malnutrition is a risk factor. Searching for intervention strategies in elderly patients referred for surgical closure of their ulcers, the trial aimed at investigating the micronutrient status, determining the food intake of such patients, and the role of oral liquid supplements. Methods: Observational cohort study in 9 patients, starting 5 days prior to surgery until day 10 after surgery. Variables: body mass index (BMI), food intake assessed using standardized meals (energy target 25 kcal/kg/day). Oral liquid supplements were provided between meals. Laboratory: blood count, plasma proteins, antioxidant status, vitamins, Fe, Se, and Zn. Results: The patients were aged 71±10 y (mean±SD), with a BMI of 23.3±3.3. Baseline blood samples showed anemia and strong inflammation in 4 patients: albumin, retinol, and selenium were low; iron and zinc were very low. Food intake was largely variable and covered only about 76% (31-95%) of energy requirements. Breakfast provided 225±110, lunch 570±215, and dinner 405±150 kcal. Supplements were willingly consumed covering 35±12% of energy target. While vitamin supply was adequate, selenium and zinc requirements were not met. Conclusions: Most patients with chronic skin ulcers suffered micronutrient status alterations, and borderline malnutrition. Meals did not cover energy requirements, while oral supplements covered basic micronutrient requirements and compensated for insufficient oral energy and protein intakes, justifying their use in hospitalized elderly patients. [Copyright &y& Elsevier]

Cultured fibroblast progenitor cells (FPC) have been studied in Swiss translational regenerative medicine for over two decades, wherein clinical experience was gathered for safely managing burns and refractory cutaneous ulcers. Inherent FPC advantages include high robustness, optimal adaptability to industrial manufacture, and potential for effective repair stimulation of wounded tissues. Major technical bottlenecks in cell therapy development comprise sustainability, stability, and logistics of biological material sources. Herein, we report stringently optimized and up-scaled processing (i.e., cell biobanking and stabilization by lyophilization) of dermal FPCs, with the objective of addressing potential cell source sustainability and stability issues with regard to active substance manufacturing in cutaneous regenerative medicine. Firstly, multi-tiered FPC banking was optimized in terms of overall quality and efficiency by benchmarking key reagents (e.g., medium supplement source, dissociation reagent), consumables (e.g., culture vessels), and technical specifications. Therein, fetal bovine serum batch identity and culture vessel surface were confirmed, among other parameters, to largely impact harvest cell yields. Secondly, FPC stabilization by lyophilization was undertaken and shown to maintain critical functions for devitalized cells in vitro, potentially enabling high logistical gains. Overall, this study provides the technical basis for the elaboration of next-generation off-the-shelf topical regenerative medicine therapeutic products for wound healing and post-burn care. [ABSTRACT FROM AUTHOR]