New strategies in regenerative medicine and surgery and their application to orthopedic surgery field: The bio-active composite therapies (BACTs)

Regenerative Medicine and Surgery is a rapidly expanding branch of translational research in tissue engineering, cellular and molecular biology. To date, the methods to improve cell intake, survival and isolation need to comply with a complex and still unclear regulatory frame, becoming everyday more restrictive and often limiting effectiveness and outcome of the therapeutic choices. Thus, the author developed a novel regenerative strategy, based on the synergic action of several bio-active components, called the Bio-Active Composite Therapies (BACTs) to improve grafted cells intake and survival in total compliance with the legal and ethical limits of the current regulatory frame. The rationale at the origin of this new technology is based on the evidence that cells need supportive substrate to survive in vitro and this observation, applying the concept of translational medicine, is true also in vivo. Many different sources have been used in the past for MSCs, molecules and growth factors (GF) isolation and extraction, but the Adipose Tissue and its Stromal Vascular Fraction (SVF) definitely remains the most valuable, abundant, safe and reliable. Bio-Active Composite Mixtures (BACMs) are tailor-made injectable “cocktails” containing several bio-active components to support cells survival and induce a strong regenerative response in vivo by stimulating the recipient site to act as an in-situ real Bioreactor. In this article, the author analyze the main causes of cell’s death and the strategies for preventing it, and outline all the technical steps for preparing the main components of BACMs and the different mixing modalities to obtain the most efficient regenerative action on different clinical and pathological conditions in several surgical specialties. Orthopedic Surgery is definitely the one that most can benefit of these new therapeutic strategies. The final part of this work is anticipating the logical and sequential evolution toward other fundamental technical steps for further supporting and enhancing the most efficient regenerative activity.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

Background Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. Methods In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. Summary Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. Conclusion We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Teaching Microsurgical Breast Reconstruction—A Retrospective Cohort Study

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, ”no-training group”), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery (“passive training”); by the trainee, and a senior surgeon was supervising (“active training”); or by the trainee without a senior surgeon (“after training”). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

Free Medial Femoral Condyle Flap for Reconstruction of Scaphoid Nonunion: A Systematic Review

Background The free medial femoral condyle (MFC) bone flap is an attractive option for reconstruction of scaphoid nonunion utilizing vascularized bone to augment bony healing, especially in cases of failed prior treatment or osteonecrosis. This review aims to determine the role and reliability of the free MFC flap for treatment of scaphoid nonunion. Methods A search of electronic databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles examining free MFC bone flaps for treatment of scaphoid nonunion were included for analysis. Outcomes of interest included flap failure, postoperative union rate, time to union, carpal indices, functional outcomes, and complications. Results Twelve articles met the inclusion criteria. A total of 262 patients underwent free MFC flaps for treatment of scaphoid nonunion. The most common site of nonunion was the proximal pole of the scaphoid with 47% of patients receiving prior attempts at operative management. Overall bony union rate was 93.4% with a mean time to union of 15.6 weeks. There were no flap failures reported. Improvements in carpal indices including scapholunate (p < 0.0004), radiolunate (p < 0.004), lateral interscaphoid angles (p < 0.035), and revised carpal ratio height (p < 0.024) were seen postoperatively. Visual analog scale improved postoperatively from 6.5 to 2.3 (p < 0.015). Postoperative complications were observed in 69 cases (26.3%), with 27 patients (10.3%) requiring further operative intervention. However, no major donor or recipient site morbidity was appreciated. Conclusion MFC flaps provide a highly versatile and reliable option for reconstruction of scaphoid nonunion with excellent bony union rates and acceptable complication rates. The present literature suggests that MFC reconstruction of scaphoid nonunion restores radiocarpal anatomy and improves wrist function without causing significant donor or recipient site morbidity.

Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis

Background Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. Methods We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. Results A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. Conclusion These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.

Role of Bone Grafts in Implant Surgery: A Review

Introduction of dental implants and more concern in patients about esthetics after loss of natural teeth increases the demand of bone grafts. Various types of bone grafts as allografts, xenografts and autografts are used all with their own pros and cons. Bone grafts are more likely to succeed when the conditions at the recipient site are favourable and certain requirements are fulfilled. This review explores the use of various bone grafts in implant dentistry.

Long-Term Outcome of Autotransplantation of a Complete Root Formed a Mandibular Third Molar

Autogenous tooth transplantation is a procedure to reposition an autogenous tooth to another extraction area or surgically created recipient site. The autotransplantation procedures have been documented well in the literature, and the survival rate of the transplanted teeth was reported to be more than 90% after ten years. Therefore, autotransplantation might have been overlooked as a treatment option. The purpose of this case report is to evaluate the long-term (29-year) success and periodontal stability of the tooth autotransplantation from the mandibular third molar to the second molar. A 24-year old female presented to a clinic with a large caries lesion with periapical radiolucnecy on to tooth #18. The tooth was extracted with the site and treated with autogenous tooth transplantation from #17 with a complete root form. Endodontic treatment was completed 3 months post autotransplantation; the final prosthesis was placed 6 months postoperatively. The patient has shown excellent oral hygiene care and high compliance with the regular maintenance recall program. The transplanted tooth has been still functioning without any symptoms. Radiographic and clinical examinations revealed stable periodontal and endodontic conditions over the 29 years after the procedure. This case report showed the long-term success of autotransplantation of the mandibular third molar with a closed root apex to the second molar site. Autotransplantation can be an option when an adequate donor site is available to reconstruct the occlusion after the tooth extraction.

Surgical management of RT2 gingival recession using sub epithelial connective tissue graft and coronally advanced flap: A case report

Apical migration of the gingival fiber attachment and marginal gingiva leads to gingival recession and can be caused due to many factors such as faulty tooth brushing, masochistic habits, periodontal disease etc. This causes dentinal hypersensitivity, aesthetic problems, root caries, cervical abrasion, and difficulty in maintaining oral hygiene and often possess a challenging situation for the clinician to deliver best care to the patients. This case reports about the use of SCTG along with coronally advanced flap. To report a case of RT2 recession, older term – Millers Class II recession which showed promising result when root coverage procedure was done using sub-epithelial connective tissue and coronally advancing the flap. A 62-year-old male patient was referred to the Department of Periodontology, with a chief complaint of hypersensitivity and downward shifting of gum in upper front left teeth region which was progressive in nature with no obvious medical history.After achieving profound anaesthesia over the concerned region the recipient site was prepared. After which the donor tissue was retrieved from the palatal area using trap door method and placed over the recipient site. No root biomodification agents were used. The graft was stabilised using interrupted suture and then criss-cross suturing was done, and non-eugenol periodontal dressing was given. The follow up results showed good outcome with predictable root coverage achieved using Sub-epithelial Connective Tissue Graft (SCTG) and coronally advanced flap in the canine region which is often the most difficult one to achieve complete root coverage because of canine prominence. SCTG can be used successfully along with coronally advanced flap and clinicians must opt for such treatment modalities for patients benefit.