REFERENCES
1.Coleman SR. Structural fat grafts: The ideal filler. Clin Plast Surg. 2001;28:111-119.
2.Shiffman MA, Mirafati S. Fat transfer techniques: The effects of harvest and transfer methods on adipocytes viability and review of the literature. Dermatol Surg. 2001;27:819-826.
3.Kurita M, Matsumoto D, Shigeruro T. Influences of centrifugation on cells and tissues in liposuction aspirate. Optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg. 2008;7: 211-228.
4.Carpenda CA, Ribiero MT. Percentage of grafts vs. injected volume in adipose autotransplants. Aesthetic Plastic Surg. 1994;18:17-19.
5.Zuk PA, Zhu M, Mizuno H, Huang J. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell. 2005;13:4279-4294.
6.Moseley TA, Zhu M, Hedrick MH. Adipose derived stem and progenitor cells as fillers in plastic and reconstructive surgery. Plast Reconstr Surg. 2006;118 (3 supplement):1215-1285.
7.Planat-Bernard V, Silvestre JS, Cousin B. Plasticity of human adipose lineage cells toward endothelial cells: physiological and therapeutic perspective. Circulation 2004;109:656-663.
8.Strawford A, Autelo F, Christianseu M. Adipose triglyceride turnover, cell proliferation in humans measured with 2 H2O. AmJ Physiol Endocrinol Metab. 2004;256:E 577-588.
9.Yoshimura K, Sato K, Aoi N, Cell assisted lipotransfer for cosmetic breast augmentation – supportive use of adipose derived stem-stromal cells. Aesthetic Plast Surg. 2008;32:48-55.
10.Yoshimura K, Sato K, Aoi N, Masakazu K. Cell assisted lipotransfer for facial lipoatrophy: efficacy of clinical use of adipose derived stem cells. Dermatol Surg. 2006;34:1178-1185.
11.Mojallal N. Improvement in skin quality after fat grafting: clinical observations and an animal study. Plast reconstruct Surg. 2009;124:765-774.
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ABOUT THE AUTHOR
Dr. Robert Bowen is an Internal Medicine and Pulmonary specialist, Board Certified in Cosmetic Laser Surgery by the American Board of Laser Surgery. He is a Fellow of the American Society of Laser Medicine and Surgery and has published research articles on laser medicine. Dr. Bowen is a Diplomate of the American Board of Anti-Aging Medicine and a graduate of the Aesthetic Medicine Fellowship.
Chapter 3
Innovations in the Treatment of Chronic Wounds
Robert E. Bowen, M.D., FCCP, FSLMS
Clinical Associate Professor, WVU-East
Medical Director, The Center for Positive Aging, Martinsburg, WV
ABSTRACT
Healing of wounds is a complex process that most often proceeds in an orchestrated fashion resulting in repair of the injured area. When this orchestration proceeds in a disordered fashion then the healing process may result in an over-expression of fibroblasts (resulting in a hypertrophic scar or keloid) or inability to form new tissue (chronic wound). Hypertrophic scars are commonly seen as sequelae of thermal injuries (burns) and chronic wounds are often seen in patients with arterial and venous insufficiency and diabetes.
Previous approaches to these problems have resulted only in marginal improvement in care. Newly developed innovations in wound care are discussed as are future directions for research.
INTRODUCTION
Thermal Injuries
Advances in the treatment of serious burns have been achieved by centralizing treatment in “burn units” where multiple specialties including surgery, infectious disease, and critical care medicine have contributed to improvement in survival. This has been achieved by more effective management of the hypermetabolic state, infection control and nutrition. As a result of increased survival from serious burns, more patients are left with the sequelae of the resultant cutaneous and psychological scars.
The fibroblastic reaction to a thermal injury includes increased levels of inflammatory cytokines including interleukin-4 (IL-4), which increases several weeks after injury and continues for several months. In this stage of disordered healing there is increased collagen formation and decreased collagenolysis resulting in the formation of a hypertrophic scar.
Lasers have been used in the treatment of these hypertrophic scars with varying degrees of success. The SOFT™ method was developed to address the issue of the heterogeneity of the thickness of such scars. With this approach each region of a scar is treated with a fractional ablative laser at a depth sufficient to penetrate the scar.1 This both reduces the volume of the scar tissue and creates channels that may allow resident and circulating stem cells to gain access to the scar and help normalize the structure of the tissue. Early case studies have established the credibility of this concept and further improvement of efficacy can be achieved by defining the optimal:
•Density of treatment to the area (pitch);
•Quantity of thermal effect (in addition to the ablative effect);
•Timing of the treatment in relation to the burn.2
Other areas of potential research include optimizing nutrition, low-level light therapy (LLT), and the use of growth factors (including platelet rich plasma) and adult mesenchymal stem cells to modify abnormal tissue generation.
Chronic Wounds
In 2007, 5.7 million patients were treated for chronic wounds at a direct cost of $20 billion.3 Failure of wounds to heal can result in aesthetic issues, pain, decreased mobility, amputation, and decreased quality of life.
Wound healing in diabetic patients is especially problematic. This is secondary to:
•Large and small vessel vascular disease resulting in decreased profusion;
•Neuropathy – diabetic patients are more likely to become injured (and re-injured);
•Dysfunction of white blood cells;
•Glycation – resulting in increased susceptibility to free radical injury.
The microbiology of chronic wounds is also problematic. These wounds are often populated by multiple organisms living in a “biofilm”. Bacteria coexisting in a biofilm are organized in a 3-dimensional structure, are able to react to the environment, to communicate, and to act in concert to overcome the limitations of nutrients, low oxygen tension, and host defenses.4,5
TREATMENT OF CHRONIC WOUNDS
Conventional Treatment
Conventional treatment of chronic wounds includes:
•Treating the underlying condition (revascularization, improving insulin receptor sensitivity);
•Avoiding re-injury (therapeutic footwear);
•Debridement (scalpel, curette, biological);
•Dressings impregnated with iodine or silver;
•Antibiotics
•Hyperbaric oxygen (HBO2).
The conventional wisdom regarding HBO2 is that it improves the physiologic state of hypoxic hypoperfused tissue. Recently,