1. Our Experience Oxygen-Ozone-lipofilling Madeyski and colleagues.

2. Trophic lesions of the legs: their treatment with the Madeyski Local Chamber. Madeyski P. With the collaboration of G. Amato (ozone therapy) And the collaboration of A. Corezzola (lipofilling) Sileno e Anna Nursing Home, Rizzola. S. Dona di Piave Rizzola 2015

3. Types of ULCERS 1) Venous stasis ulcers 2) Arterial ulcers 3) Traumatic ulcers 4) Collagenopathy ulcers 5) Diabetic ulcers Rizzola 2015

4. Pathophysiology of ulcers transcutaneous oximetry has shown that at a vascular lesion, the pO2 reaches values ​​ of up to 5-10 mm Hg. This value is incompatible with living cells and impedes the proliferation and activity of leukocytes, which require pO2 values ​​ of 30-40 mm Hg: from which the danger of infection arises. Rizzola 2015

5. Pathophysiology of ulcers The synthesis of collagen by fibroblasts too cannot be separated from oxygen, and an immature and unstable collagen forms, with inevitable healing problems. Rizzola 2015

6. Pathophysiology of ulcers We should aim for: a)An optimal supply of oxygen, b)Complete wound cleansing, c)A cellular stimulation, d)Good blood perfusion. Rizzola 2015.

7. TREATMENTS proposed. 1) Medical treatments 2) Surgical treatments 3)Hyperbaric chamber treatment 4)Topical oxygen therapy 5)Oxygen-ozone therapy 6)Lipofilling Rizzola 2015

8. Hyperbaric oxygenation therapy Hyperbaric oxygen therapy is a systemic therapy based on the respiration of O2 at high pressure. THE ULTIMATE PURPOSE IS TO BRING O 2 IN AMOUNTS THAT ARE ADAPTED TO THE METABOLIC NEEDS OF THE TISSUES. Rizzola 2015

9. AdvantagesDisadvantages Increase in disolved O2 Bactericidal action Anti-edema action Healing action -Not tolerated by many patients. - Cardiac, vestibular and psychological problems etc. - Limited number of centres. - Problems with transport. - Higher costs Rizzola 2015 Hyperbaric Chamber

10. AdvantagesDisadvantages High oxygen concentration at the lesion Minor or no increase in oxygen dissolved in the plasma NO LOCAL OR SYSTEMIC CONTRAINDICATIONS The Madeyski Normobaric Chamber Rizzola 2015

11. Total-body chamber Local chamber The oxygen concentration reaches 22% The oxygen concentration reaches 95% Dissolved oxygen in the blood equal to 6 ml % Dissolved oxygen in the blood equal to 2% DIFFERENCES BETWEEN THE "TOTAL BODY" CHAMBER AND THE LOCAL CHAMBER. Rizzola 2015

12. DIFFERENCES BETWEEN THE "TOTAL BODY" CHAMBER AND THE LOCAL CHAMBER. Basically, thetotal body chamber acts due to an increase in dissolved oxygen whilst the local chamber acts due to a raised concentration of oxygen being achieve at trophic lesions. Rizzola 2015

13. Characteristics and benefits 1) Localised therapy 2) Appreciated by patients and the healthcare team 3) Easy to use 4) No local or systemic contraindications 5) Small and easy to carry 6) Possible domiciliary use 8) Low cost to operate and maintain 10) Documented efficacy Rizzola 2015 The Madeyski chamber

14. Personal cases 2014 204 patients sub-divided as follows: 1) 127 venous stasis ulcers, 2) 35 arterial ulcers, 3) 15 traumatic ulcers, 4) 3 collagenopathic ulcers, 5) 22 diabetic ulcers, 6) 2 chemotherapy ulcers, 7) 33 patients with skin grafts. Rizzola 2015

15. Methodology Patients underwent daily sessions of an hour and occasionally underwent two sessions a day. The number of sessions varied from case to case, but was never lower than thirty. The pressure within the chamber was maintained slightly above 760 mm of Hg and the humidity between 60 and 80% Rizzola 2015

16. Results 1) Reduction in secretions and wound cleansing. 2) Improvement of subjective symptoms (pain, burning, itching). 1) Early appearance of good tissue granulation. 2) Reduction in the diameter of lesions until their complete closure in 70% of cases. 5) Favourable effect on attachment in subsequent grafts in 20% of patients. 6) Zero result in 20% of cases. Rizzola 2015

17. Oxygen-Ozone therapy Up to now, we have had a positive experience with the local chamber with oxygen There are also a large number of case histories that demonstrate the effectiveness of oxygen-ozone administered via a bag. Rizzola 2015

18. The future…. Is it possible to combine the two methods, to exploit the benefits of both?  Local chamber with oxygen-ozone Rizzola 2015

19. Effects of localised ozone At high concentrations (70-80 gamma/ml) disinfection and cleansing of the lesions. At low concentrations (range 10-2/ cc) a healing and stimulating effect on the tissues. Rizzola 2015

20. Treatment Protocol No.5, weekly sessions Duration of session 60 minutes. 1 or 2 sessions per day. At the end of the session, aspiration of the gaseous mixture. Duration of treatment varies, depending on the progress of the lesions. Rizzola 2015

21. Treatment Protocol No.5, weekly sessions Surgical cleansing of the lesions. Humidification of the lesions with physiological water Introducing the limb into the chamber. Airtight closure of the chamber and production of the vacuum. Filling the chamber with the gas at variable concentrations. Rizzola 2015

22. Conclusions It appears we can say that using the local chamber with ozone improves the results obtained with oxygen alone or with the bag technique. This improvement involves both the percentage success rate as well as healing speed. Rizzola 2015

23. Conclusions (hypotheses) The greater effectiveness of the chamber with ozone could either be due to an intrinsic effect of ozone, or the control of important parameters such as humidity and pressure on tissues, resulting in a potentiation of the actions of the gas. Rizzola 2015

24. Conclusions (problems) Using the chamber with ozone poses a few problems however: The hermetic sealing of the chamber The time needed to create the vacuum The time needed to aspirate the gas The need for an ozone generator Rizzola 2015

25. Conclusions (problems) Using the chamber with ozone poses a few problems however: Higher costs Problematic domiciliary use Creation of suitable centres Rizzola 2015

26. Personal case histories 2004 141 patients divided as follows: 1) 87 venous stasis ulcers, 2) 10 arterial ulcers, 3) 5 traumatic ulcers, 4) 3 collagenopathic ulcers, 5) 22 diabetic ulcers, 6) 1 chemotherapy ulcers, 7) 13 patients with skin grafts. Rizzola 2015

27. Regenerative Lipofilling Rizzola Nursing Home Experiences Dr. P. Madeyski (Surgeon) Dr. A. Corezzola (Plastic Surgeon) Rizzola 2015

28. Regenerative Lipofilling Limited case histories Recent 2014 Cases selected Indications not recorded Times performed Rizzola 2015

29. HISTORY 1893 German surgeon Gustav Neuber (1850-1932) used adipose tissue taken from an arm to transfer it to the orbital region 1912 The first injection of adipose tissue was performed by Eugene Hollander (1867- 1932) 1980 Pierre Fournier 1990 Sydney Coleman 2000 Bill Futrell demonstated that adipose tissue is the largest stem cell bank (ASCs: adipose derived stem cells) 2007 Gino Rigotti treated an ulcer with injections of adipose tissue, with full restoration to integrity. 2009 publication of fat injections for regenerative use, published by Sydney Coleman and Richard Mazzola, which highlighted the regenerative potential of fat for repairing lesions due to tissue damage or loss Rizzola 2015

30. Adipose stem cells ASCs (Adipose- Derived Stem Cells) Cells present in abundance in the adipose tissue Capable of regenerating tissues Easy to take samples (liposuction) Rizzola 2015

31. Technique Used WITHDRAW SAMPLES WITH A 10 CC LUER LOK SYRINGE CENTRIFUGE AT 3000 RPM FOR 3 MINUTES REMOVAL OF OILY AND AQUEOUS PORTIONS TRANSFER INTO INSULIN SYRINGES INJECTION INTO ULCER MARGINS AND BASES Rizzola 2015

32. Case histories 2014 24 patients 16 phlebostatic ulcers 8 arteriopathic ulcers Before topical oxygen therapy variable x time 10 with successive free graft 90% healing 100% graftattachment Rizzola 2015