Chronic ulcers are characterized by loss of substance without a normal tendency towards spontaneous healing. The Wound Bed Preparation Guideline advises that after diagnosis, the expert should correct the biological state of the ulcer micro-environment based on TIME principles (Tissue, Infection, Moisture balance, Epidermal). There are many ways to treat such ulcers, for example through use of advanced dressings, negative pressure, surgical toilets, dermal substitutes, autologous skin grafting, and free or local flaps. In vitro and in vivo pre-clinical models hold widely acknowledged potential yet complex limitations. Tissue bioengineering could be an ideal approach to foster innovative strategies in wound healing. Our observational study reports on an in vitro and in vivo evaluation of a bio-functionalized scaffold composed of platelet-rich plasma (PRP) and hyaluronic acid (HA) used in 182 patients affected by chronic ulcers (diabetic and vascular), comparing the results with a control group of 182 patients treated with traditional dressings (HA alone). After 30 days the patients who had undergone the combined treatment (PRP + HA), showed 96.8% ± 1.5% re-epithelialization, as compared to 78.4% ± 4.4% in the control group (HA only). Within 80 days, they had 98.4% ± 1.3% re-epithelialization as compared to 87.8% ± 4.1% in the control group (HA only; p < 0.05). No local recurrence was observed during the follow-up period. PRP + HA treatment showed stronger regenerative potential in terms of epidermal proliferation and dermal renewal compared with HA alone.

The use of Dermal Regeneration Template (DRT) can be a valid alternative for scalp reconstruction, especially in elderly patients where a rapid procedure with an acceptable aesthetic and reliable functional outcome is required. We reviewed the surgical outcome of 20 patients, 14 (70%) males and 6 (30%) females, who underwent application of DRT for scalp reconstruction for small defects (group A: mean defect size of 12.51 cm²) and for large defects (group B: mean defect size of 28.7 cm²) after wide excision of scalp neoplasm (basal cell carcinoma and squamous cell carcinoma). In group A, the excisions were performed to the galeal layer avoiding pericranium, and in group B the excisions were performed including pericranium layer with subsequent coverage of the exposed bone with local pericranial flap. In both the groups (A and B) after the excision of the tumor, the wound bed was covered with Dermal Regeneration Template. In 3 weeks we observed the complete healing of the wound bed by secondary intention with acceptable cosmetic results and stable scars. Scalp reconstruction using a DRT is a valid coverage technique for minor and major scalp defects and it can be conducted with good results in elderly patients with multiple comorbidities.

Introduction: Therapeutic angiogenesis by autologous-peripheral blood mononuclear cells (A-PBMNC) implantation has been shown to be a safe and effective treatment for critical limb ischemia (CLI). We herein report our investigation of the long-term efficacy of implantation of A-PBMNC produced by selective filtration to treat patients with CLI, for which surgical bypass and/or percutaneous transluminal angioplasty are not possible. Materials and Methods: This is a prospective, and not a randomized, study based on a treated group who did not respond to conventional therapy ( n =43) when implanted with A-PBMNC cells versus a historically matched control group. Patients of both groups were suffering from CLI Fontaine scale IV with chronic ulcers and various accompanying conditions (diabetes, heart disease, kidney failure, etc.). Treated patients were implanted with 12 mL of A-PBMNC, 0.2–0.3 mL for each bolus, collected by selective filtration from 120 mL of peripheral blood in the ischemic area of the limbs. Patients were not mobilized by granulocyte colony-stimulating factor, and the A-PBMNC treatment was repeated for a maximum of three times. Results: The A-PBMNC-treated group showed a statistically significant improvement of limb rescue of 95.3% versus 52.2% of the control group ( p <0.001), and the result had been maintained for 2 years. The A-PBMNC group also showed reduction in pain at rest, increased maximum walking distance, and healing of the wound, which led to an overall improvement in the quality of life. Post-treatment radiological studies showed an improvement of vascularization with the formation of new collateral and by histological findings. Within 2 years of follow-up, none of the patients whom we treated showed any major or systemic adverse effects. Conclusion: The local injection of A-PBMNC showed striking early and long-term effects together with a favorable safety profile, significantly decreasing the risk of amputation. Our results are comparable with published data obtained by injection of bone marrow mononuclear cells, but with a lot less invasive approach. Moreover the intraoperative selective filtration system we used is fast, safe, not operator dependent, and easy to use in a sterile operating theatre. This system aims to produce fresh A-PBMNC as a valuable treatment option, particularly for those difficult patients who cannot undergo revascularization.

Infections are among the most frequent and challenging events in diabetic foot ulcers (DFUs). Pathogenic bacteria growing in biofilms within host tissue are highly tolerant to environmental and chemical agents, including antibiotics. The present study was aimed at assessing the use of silver sulfadiazine (SSD) for wound healing and infection control in 16 patients with DFUs harboring biofilm-growing Staphylococcus aureus and Pseudomonas aeruginosa. All patients received a treatment based on a dressing protocol including disinfection, cleansing, application of SSD, and application of nonadherent gauze, followed by sterile gauze and tibio-breech bandage, in preparation for toilet surgery after 30 days of treatment. Clinical parameters were analyzed by the T.I.M.E. classification system. In addition, the activity of SSD against biofilm-growing S. aureus and P. aeruginosa isolates was assessed in vitro. A total of 16 patients with S. aureus and P. aeruginosa infected DFUs were included in the study. Clinical data showed a statistically significant (p < 0.002) improvement of patients’ DFUs after 30 days of treatment with SSD with significant amelioration of all the parameters analyzed. Notably, after 30 days of treatment, resolution of infection was observed in all DFUs. In vitro analysis showed that both S. aureus and P. aeruginosa isolates developed complex and highly structured biofilms. Antibiotic susceptibility profiles indicated that biofilm cultures were significantly (p ≤ 0.002) more tolerant to all tested antimicrobials than their planktonic counterparts. However, SSD was found to be effective against fully developed biofilms of both S. aureus and P. aeruginosa at concentrations below those normally used in clinical preparations (10 mg/mL). These results strongly suggest that the topical administration of SSD may represent an effective alternative to conventional antibiotics for the successful treatment of DFUs infected by biofilm-growing S. aureus and P. aeruginosa.

The healing of venous and arterial ulcers is slow, and in some cases, they may not heal at all. This study aims to demonstrate the clinical advantage of Nevelia^®, an innovative collagen dermal template substitute (DS) in venous and arterial chronic ulcers treatment. 35 patients affected by chronic vascular ulcers with a mean area of 35.1 ± 31.8 cm² were treated with DS followed by autologous dermal epidermal graft (DEG). Follow-up was performed at 7-14-21 and 28 days after DS implant and 7-14-21 and 28 days after DEG. At 28 days after DEG, the mean values of Manchester Scar Scale was of 1.8 ± 0.7 for skin color, 1.6 ± 0.7 for skin contour, 1.7 ± 0.7 for distortion, and 1.7 ± 0.7 for skin texture, whereas skin was matte in 27 patients (77%) and shiny in the remaining eight cases (23%). Histological findings correlate with the clinical result showing a regenerated skin with reactive epidermal hyperplasia and dermal granulation tissue after two weeks (T1), and after three weeks (T2) a re-epithelialization and a formed new tissue architecture analogue to normal skin physiology. These data suggest that Nevelia^® could be useful to treat chronic venous and arterial ulcers.

Context: Brow lifting is an essential element in the rejuvenation of the ageing face. Various surgical techniques have been described. Among these, the direct brow lifting is an easy and effective technique that is often neglected because the scar can remain visible. Thus, this approach is usually reserved for elderly patients and males, with thick bushy brows. Aims: The authors present their result from a series of fifty consecutive patients treated over 2 years with direct brow lift. The aim is to demonstrate when the hairline is high or temporal alopecia is present and whether this technique is the best in bald patients, when some surgical steps are carefully adhered to. In these cases, the scar is less visible, hidden in the brow and is a good solution in women too. Subjects and Methods: Between January 2011 and January 2013, fifty patients underwent direct brow lift surgery. All were men. In all the cases, brow lifting was undertaken together with an upper blepharoplasty. The amount of brow elevation produced was assessed by comparing the vertical distances between the superior eyebrow hairline and the inter-pupillary line, pre- and post-operatively. The result and the scar quality were assessed both by the patient and the surgeon. Statistical Analysis Used: The paired t-test. Results: The authors obtained statistically significant results in brow elevation in 98% of the patients after a 12-month follow-up. The main complication associated with this procedure was visibility of the scar in two patients. Conclusions: The direct brow lift technique in bald men and with a high anterior hairline provides excellent and long-lasting results.