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el plasma rico en plaquetas auto¿logo<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; el tratamiento con ox&#237;geno hiperb&#225;rico<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">19</span></a>&#44; la terapia electromagn&#233;tica<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">20</span></a> y la terapia de presi&#243;n negativa<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">21</span></a>&#46; Respecto al tratamiento quir&#250;rgico las opciones disponibles incluyen la cirug&#237;a del sistema venoso<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">3&#44;22&#8211;25</span></a> y el uso de injertos cut&#225;neos<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">1</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Injertos de piel en &#250;lceras cr&#243;nicas</span><p id="par0010" class="elsevierStylePara elsevierViewall">Los injertos de piel se pueden clasificar en autoinjertos&#44; aloinjertos o xenoinjertos&#46; Los injertos tambi&#233;n pueden clasificarse en aquellos que est&#225;n constituidos por fragmentos de piel&#44; por capas de c&#233;lulas cultivadas en el laboratorio o por ap&#243;sitos que incorporan c&#233;lulas de la piel<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">1&#44;26</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Los autoinjertos se obtienen del mismo paciente&#46; Se han utilizado injertos tipo pellizco <span class="elsevierStyleItalic">&#40;pinch grafts&#41;</span>&#44; injertos obtenidos con <span class="elsevierStyleItalic">punch &#40;punch grafts&#41;</span><a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">27&#8211;29</span></a>&#44; injertos de piel de espesor parcial&#44; injertos de piel de grosor total e injertos elaborados a partir del cultivo de c&#233;lulas del propio paciente en un laboratorio&#44; como por ejemplo los injertos de queratinocitos cultivados&#46; Los aloinjertos se obtienen de piel o c&#233;lulas de otra persona&#44; cultivadas y preparadas en el laboratorio &#40;queratinocitos cultivados&#44; fibroblastos epid&#233;rmicos cultivados&#41;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">30&#44;31</span></a>&#46; Los xenoinjertos se obtienen de un animal&#44; siendo el m&#225;s frecuente el cerdo&#44; por su similitud con la piel humana&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En algunos estudios se han referido porcentajes de curaci&#243;n tras la realizaci&#243;n de los injertos cut&#225;neos del 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">3&#44;32&#44;33</span></a>&#46; Debido a la facilidad de acceso&#44; la zona donante de los injertos siempre ha sido el muslo&#44; la nalga o la espalda<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Sin embargo&#44; el concepto tradicional de injertos de piel gl&#250;tea o abdominal en el tratamiento de las &#250;lceras cr&#243;nicas se ha visto modificado en los &#250;ltimos a&#241;os gracias a la publicaci&#243;n de m&#250;ltiples estudios que avalan la conexi&#243;n existente entre el fol&#237;culo piloso&#44; las c&#233;lulas madre y la curaci&#243;n de las heridas<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">34&#8211;44</span></a>&#46; Como consecuencia&#44; nuevos trabajos han utilizado el injerto de fol&#237;culo piloso obtenido de cuero cabelludo como una nueva opci&#243;n de tratamiento dentro del arsenal terap&#233;utico de las &#250;lceras cr&#243;nicas<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">45&#8211;47</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Por otro lado&#44; la zona donante del injerto ideal debe reunir adem&#225;s una serie de propiedades como son un cuidado postoperatorio sencillo&#44; un bajo riesgo de infecci&#243;n&#44; una cicatrizaci&#243;n de la herida r&#225;pida y una m&#237;nima cicatriz residual&#46; La localizaci&#243;n que cumple todas estas caracter&#237;sticas es el cuero cabelludo<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">48</span></a>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funci&#243;n del fol&#237;culo piloso en la curaci&#243;n de las heridas</span><p id="par0030" class="elsevierStylePara elsevierViewall">Es un hecho demostrado que las zonas de piel con pelo cicatrizan m&#225;s r&#225;pidamente que la piel glabra<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">49&#8211;51</span></a>&#46; Por ejemplo&#44; zonas de piel que han recibido radioterapia<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">52</span></a> en las que se han destruido las estructuras anexiales como los fol&#237;culos pilosos o las gl&#225;ndulas ecrinas<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">53</span></a> cicatrizan con mucha dificultad&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La demostraci&#243;n m&#225;s importante realizada hasta la fecha de que los fol&#237;culos pilosos desempe&#241;an un papel central en la curaci&#243;n de la heridas sigue siendo el trabajo publicado por Bishop en 1945&#46; Este investigador realiz&#243; heridas cut&#225;neas a diferentes profundidades en su propio brazo y biopsias secuenciales&#44; con el fin de estudiar meticulosamente el proceso de curaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">49</span></a>&#46; Observ&#243; que la curaci&#243;n de la piel comienza no solo a partir de los bordes de la herida&#44; sino alrededor de los fol&#237;culos remanentes&#46; Demostr&#243; tambi&#233;n que no solo la reepitelizaci&#243;n&#44; sino tambi&#233;n el tejido de granulaci&#243;n regenerado se comienza a formar a partir del tejido conjuntivo perifolicular&#44; otorgando al fol&#237;culo piloso un papel clave en el inicio del proceso de curaci&#243;n de las heridas<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">49</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Okuda en 1939 realiz&#243; estudios histol&#243;gicos sobre biopsias tomadas en diferentes momentos evolutivos tras la realizaci&#243;n de injertos de pelo&#44; describiendo la proliferaci&#243;n de c&#233;lulas de tejido conectivo proveniente de los fol&#237;culos pilosos implantados en el seno del tejido conectivo de la zona receptora<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">54</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tambi&#233;n se conoce que el fol&#237;culo piloso representa el principal reservorio de c&#233;lulas madre cut&#225;neas<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">55&#8211;57</span></a>&#46; As&#237;&#44; en respuesta a una herida cut&#225;nea&#44; c&#233;lulas madre epiteliales localizadas en la zona bulge del fol&#237;culo proliferan y emigran a la superficie contribuyendo a la reepitelizaci&#243;n de la nueva epidermis<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">50</span></a>&#46; De igual modo&#44; las c&#233;lulas madre mesenquimales localizadas en la vaina perifolicular <span class="elsevierStyleItalic">&#40;dermal sheath&#41;</span> contribuyen a la regeneraci&#243;n del tejido d&#233;rmico<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">58&#8211;60</span></a>&#46; El cuero cabelludo&#44; por su gran densidad de fol&#237;culos pilosos en fase an&#225;gena&#44; y por la consiguiente gran densidad de c&#233;lulas madre epiteliales y mesenquimales&#44; ser&#237;a te&#243;ricamente la zona donante ideal para trasplantar fol&#237;culos&#44; con el objetivo de estimular la curaci&#243;n de heridas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Existen numerosos casos cl&#237;nicos publicados que respaldan la contribuci&#243;n del fol&#237;culo piloso en la curaci&#243;n de las heridas<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">35&#44;38&#44;39&#44;59&#44;61&#44;62</span></a>&#46; La mayor parte son casos cl&#237;nicos aislados de pacientes con quemaduras o heridas quir&#250;rgicas tratadas con una combinaci&#243;n de ap&#243;sitos de dermis artificial m&#225;s trasplante de fol&#237;culos pilosos<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">63&#8211;65</span></a>&#46; Navsaria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">64</span></a> publicaron el caso de un paciente con una quemadura extensa y profunda en el cuero cabelludo&#44; en el que consiguieron una cicatrizaci&#243;n completa de la herida mediante un trasplante de fol&#237;culos pilosos sobre una dermis artificial &#40;Integra<span class="elsevierStyleSup">&#174;</span>&#44; Integra LifeSciences Corporation&#44; Plainsboro&#44; N&#46;J&#46;&#41;&#46; De forma similar Narushima et al&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">63</span></a> publicaron los casos de 2 pacientes con defectos quir&#250;rgicos en el cuero cabelludo que fueron cubiertos con dermis artificial &#40;PELNAC&#44; Smith &#38; Nephew KK&#44; Japan&#41; para posteriormente realizar el trasplante de unidades foliculares sobre ella&#44; con el fin de obtener crecimiento de cabello y con ello un resultado m&#225;s est&#233;tico&#46; Zakine et al&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">65</span></a> publicaron una serie de 15 pacientes con quemaduras agudas de tercer grado que fueron tratadas con injertos de dermis de cuero cabelludo&#44; mostrando la eficacia de este tipo de injertos en la cicatrizaci&#243;n&#44; as&#237; como la excelente capacidad regeneradora de las zonas donantes de cuero cabelludo&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Trasplante de fol&#237;culos pilosos mediante injertos <span class="elsevierStyleItalic">punch</span> en &#250;lceras cr&#243;nicas recalcitrantes&#58; su aplicaci&#243;n en la pr&#225;ctica cl&#237;nica</span><p id="par0055" class="elsevierStylePara elsevierViewall">En cuanto al trasplante de injertos tipo <span class="elsevierStyleItalic">punch</span> de fol&#237;culos pilosos en las &#250;lceras cr&#243;nicas en las piernas&#44; el primer trabajo para estudiar su viabilidad y seguridad cl&#237;nica en pacientes fue publicado por Jim&#233;nez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">45</span></a> en 2012&#46; Fueron tratados 10 pacientes con &#250;lceras cr&#243;nicas recalcitrantes &#40;10&#44;5 a&#241;os de duraci&#243;n media&#41; en los miembros inferiores de etiolog&#237;a venosa&#44; mixta y por presi&#243;n&#44; con un tama&#241;o medio de 36&#44;8 cm<span class="elsevierStyleSup">2</span>&#46; En cada &#250;lcera se asign&#243; aleatoriamente un &#225;rea experimental y un &#225;rea control&#44; ambas de 4 cm<span class="elsevierStyleSup">2</span>&#46; Ambos grupos recibieron los mismos cuidados de la &#250;lcera &#40;limpieza y ap&#243;sitos vaselinados&#41;&#44; mientras solo en el &#225;rea experimental se implantaron los injertos <span class="elsevierStyleItalic">punch</span> de cuero cabelludo conteniendo fol&#237;culos pilosos terminales&#46; A modo similar a como se realiza el trasplante quir&#250;rgico en la alopecia androgen&#233;tica&#44; se extrajeron <span class="elsevierStyleItalic">punches</span> de 2<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro de la zona occipital del cuero cabelludo&#44; los cuales fueron trasplantados de forma inmediata en el seno de la &#250;lcera del propio paciente&#46; Tras 18 semanas de seguimiento se observ&#243; una reducci&#243;n del &#225;rea experimental del 27&#44;1&#37; comparada con el 6&#44;5&#37; en el &#225;rea control &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;046&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Los signos cl&#237;nicos tambi&#233;n mejoraron en 7 de los 10 pacientes&#44; con aparici&#243;n de tejido de granulaci&#243;n&#44; reactivaci&#243;n del borde de la herida y disminuci&#243;n del exudado&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Tras este ensayo cl&#237;nico piloto&#44; nuestro grupo de trabajo realiz&#243; otro estudio cl&#237;nico en &#250;lceras venosas cr&#243;nicas comparando <span class="elsevierStyleItalic">punches</span> de piel del cuero cabelludo con fol&#237;culos terminales versus <span class="elsevierStyleItalic">punches</span> de piel de zonas sin pelo terminal visible<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">66</span></a>&#46; Se incluyeron un total de 12 pacientes con &#250;lceras cr&#243;nicas venosas en los miembros inferiores durante 18 semanas&#44; con un tama&#241;o medio inicial de 23&#44;34 cm<span class="elsevierStyleSup">2</span> y un tiempo de evoluci&#243;n medio de 6&#44;04 a&#241;os&#46; En cada paciente se trat&#243; una sola &#250;lcera que fue dividida en 2 partes de igual superficie&#44; una mitad que recibir&#237;a los injertos <span class="elsevierStyleItalic">punch</span> de cuero cabelludo y la otra mitad los injertos <span class="elsevierStyleItalic">punch</span> de piel sin pelo &#40;de la regi&#243;n abdominal&#41;&#46; Al finalizar el estudio el porcentaje de reducci&#243;n del &#225;rea de la &#250;lcera que se trasplant&#243; con <span class="elsevierStyleItalic">punches</span> de cuero cabelludo fue de un 75&#44;15&#37;&#44; mientras en el grupo trasplantado con <span class="elsevierStyleItalic">punches</span> sin pelo visible fue de un 33&#44;7&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">66</span></a>&#46; La conclusi&#243;n de este estudio fue la demostraci&#243;n de que los injertos <span class="elsevierStyleItalic">punch</span> de fol&#237;culos pilosos de cuero cabelludo estimulan en mayor grado la curaci&#243;n de la &#250;lcera que los injertos <span class="elsevierStyleItalic">punch</span> de piel sin pelo&#44; con lo cual se confirma esta t&#233;cnica de trasplante de fol&#237;culos pilosos como una alternativa terap&#233;utica eficaz en las &#250;lceras venosas cr&#243;nicas que no curan con tratamiento convencional&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Una posible explicaci&#243;n te&#243;rica de la mejor curaci&#243;n de las &#250;lceras introduciendo fol&#237;culos terminales ser&#237;a el mayor aporte de c&#233;lulas madre&#44; con gran capacidad proliferativa&#44; tanto epiteliales y mesenquimales&#44; contenidas en los fol&#237;culos terminales en an&#225;geno &#40;aproximadamente el 85&#37; de los fol&#237;culos en el cuero cabelludo se encuentran en an&#225;geno<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">67</span></a>&#41;&#46; De todos los tipos de injertos descritos anteriormente &#40;<span class="elsevierStyleItalic">pinch</span>&#44; <span class="elsevierStyleItalic">punch</span>&#44; laminares&#41;&#44; el m&#225;s adecuado para este fin ser&#237;a el injerto tipo <span class="elsevierStyleItalic">punch</span> de cuero cabelludo&#44; ya que de esta manera se conseguir&#237;a trasplantar el fol&#237;culo piloso completo&#44; aportando c&#233;lulas del <span class="elsevierStyleItalic">dermal sheath</span> de la porci&#243;n inferior del fol&#237;culo&#44; cuya capacidad de diferenciaci&#243;n a miofibroblastos ayudar&#237;a a crear un nuevo tejido de granulaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">59&#44;68</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A partir de estos trabajos han comenzado a publicarse otros estudios cl&#237;nicos similares de trasplante de fol&#237;culos pilosos en heridas cut&#225;neas con buenos resultados<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">47&#44;69</span></a>&#46; Liu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">47</span></a> realizaron un estudio con un total de 14 pacientes en los que trasplantaron unidades foliculares en &#250;lceras quir&#250;rgicas o traum&#225;ticas que no respond&#237;an al trasplante tradicional de injertos de piel&#44; observando una reepitelizaci&#243;n completa en todos los casos&#46; Sin embargo&#44; en este estudio no existi&#243; grupo control ni fue un estudio aleatorizado&#44; por lo que resulta dif&#237;cil comparar resultados&#46; Fox et al&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">69</span></a> presentaron un paciente con una &#250;lcera venosa cr&#243;nica de la pierna resistente a tratamiento conservador en la que trasplantaron <span class="elsevierStyleItalic">punches</span> de cuero cabelludo con fol&#237;culos pilosos terminales en una zona&#44; e injertos de <span class="elsevierStyleItalic">punch</span> sin pelo terminal en otra zona de igual superficie&#46; Se observ&#243; una reducci&#243;n del &#225;rea total de la &#250;lcera del 56&#37; y del 73&#37; a las 4 y 6 semanas del trasplante respectivamente&#44; sobre todo a expensas de la zona que recibi&#243; los injertos <span class="elsevierStyleItalic">punch</span> de cuero cabelludo&#46; Yang et al&#46; compararon los resultados obtenidos en 40 pacientes con &#250;lceras cr&#243;nicas tratados con trasplantes de fol&#237;culo piloso o con injertos de piel de espesor parcial&#44; observando no solo que los injertos de fol&#237;culos pilosos estimulan la curaci&#243;n de las &#250;lceras&#44; sino que las cicatrices de los casos trasplantados con fol&#237;culos pilosos eran de una mejor calidad &#40;piel menos contra&#237;da y m&#225;s el&#225;stica&#41; y ten&#237;an mejor aspecto est&#233;tico que las cicatrices de los casos trasplantados con injertos de piel parcial<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">70</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">T&#233;cnica quir&#250;rgica utilizada en el trasplante de fol&#237;culos pilosos en &#250;lceras cr&#243;nicas</span><p id="par0075" class="elsevierStylePara elsevierViewall">La t&#233;cnica quir&#250;rgica no precisa ser realizada en quir&#243;fano est&#233;ril&#44; siendo un procedimiento m&#237;nimamente invasivo&#44; seguro y de bajo coste&#44; especialmente cuando lo comparamos con las t&#233;cnicas de cirug&#237;a pl&#225;stica convencional o de ingenier&#237;a tisular &#40;figu&#46; 3&#41;&#46; En primer lugar&#44; tras rasurar y anestesiar la zona donante&#44; se extraen los injertos con un <span class="elsevierStyleItalic">punch</span> circular de biopsia de di&#225;metro aproximado de 2<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#44; aunque el tama&#241;o puede variar a juicio del cirujano&#46; El motivo de utilizar estos <span class="elsevierStyleItalic">punches</span> tan peque&#241;os es que las heridas remanentes curan en 5-6 d&#237;as por segunda intenci&#243;n&#44; sin necesidad de dar puntos de sutura y dejando solo una cicatriz puntiforme totalmente inapreciable e invisible para el paciente &#40;<a class="elsevierStyleCrossRef" href="#fig0025">fig&#46; 5</a>&#41;&#44; lo que resulta importante desde el punto de vista est&#233;tico&#46; Las posibilidades de infecci&#243;n son muy reducidas al ser un tejido muy vascularizado&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Tras su extracci&#243;n&#44; los injertos son introducidos en un recipiente est&#233;ril con suero salino hasta su implantaci&#243;n&#44; que se lleva a cabo a los pocos minutos &#40;<a class="elsevierStyleCrossRef" href="#fig0030">fig&#46; 6</a>&#41;&#46; Con el fin de disminuir el dolor asociado a las infiltraciones del anest&#233;sico en la periferia de la &#250;lcera&#44; una hora antes del procedimiento se podr&#237;a aplicar una crema anest&#233;sica en oclusi&#243;n sobre la superficie de esta&#46; Los injertos <span class="elsevierStyleItalic">punch</span> se insertan en el interior del tejido de las &#250;lceras realizando una m&#237;nima incisi&#243;n de tama&#241;o acorde las dimensiones del injerto &#40;1&#44;5<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro por 3-4<span class="elsevierStyleHsp" style=""></span>mm de profundidad con un trocar de 14<span class="elsevierStyleHsp" style=""></span>G&#41;&#46; La inserci&#243;n del injerto se realiza&#44; una por una&#44; con pinzas de punta muy fina &#40;<span class="elsevierStyleItalic">jeweler forceps</span> o pinzas de joyero&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0035">fig&#46; 7</a>&#41;&#46; La densidad de injertos trasplantados al seno de las &#250;lceras es de aproximadamente 5 injertos&#47;cm<span class="elsevierStyleSup">2</span>&#44; al ser esta la densidad m&#237;nima que consideramos adecuada para garantizar la regeneraci&#243;n del tejido<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">45</span></a>&#44; aunque esta densidad puede variar seg&#250;n cada cirujano&#46; Tras finalizar el trasplante la &#250;lcera tratada se cubre durante 4 d&#237;as con un ap&#243;sito vaselinado y vendaje de compresi&#243;n terap&#233;utica&#46; Se recomienda al paciente reposo relativo durante 3-4 d&#237;as&#44; pero sin necesidad de inmovilizaci&#243;n&#46; En las primeras curas es importarte retirar los ap&#243;sitos de forma lenta&#44; y tras humedecerlos con suero fisiol&#243;gico durante unos minutos previamente con el fin de evitar las adherencias al tejido&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En los trabajos publicados por nuestro grupo hemos observado que aproximadamente a las 18 semanas tras el trasplante se observa la mayor estimulaci&#243;n de la cicatrizaci&#243;n de la &#250;lcera&#46; Finalmente resulta interesante destacar que&#44; a pesar de que los injertos implantados en las &#250;lceras contienen numerosos fol&#237;culos terminales&#44; los pelos que salen en las &#250;lceras una vez cicatrizadas son m&#225;s bien escasos en n&#250;mero &#40;<a class="elsevierStyleCrossRef" href="#fig0040">fig&#46; 8</a>&#41;&#46; Este hecho tambi&#233;n ha sido destacado por otros autores<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">47&#44;70</span></a>&#46; La explicaci&#243;n posible de este fen&#243;meno es que el microambiente de la &#250;lcera estimula las c&#233;lulas foliculares a diferenciarse m&#225;s en la direcci&#243;n de la curaci&#243;n de la herida y no tanto en la fabricaci&#243;n del tallo piloso&#46; Esta explicaci&#243;n concuerda con una sugerente teor&#237;a propuesta ya hace a&#241;os por Jahoda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">59</span></a>&#44; quienes plantearon que la prioridad evolutiva del fol&#237;culo piloso humano es la curaci&#243;n de las heridas cut&#225;neas y no la producci&#243;n del tallo piloso&#44; y que la maquinaria celular del fol&#237;culo piloso&#44; en funci&#243;n de factores microambientales de la piel&#44; debe tomar partido entre producir un tallo piloso o participar en la curaci&#243;n de las heridas&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="par0090" class="elsevierStylePara elsevierViewall">Los resultados obtenidos en nuestro estudio demuestran que el trasplante de injertos <span class="elsevierStyleItalic">punch</span> de fol&#237;culos pilosos de cuero cabelludo estimula m&#225;s la curaci&#243;n de las &#250;lceras venosas cr&#243;nicas que el trasplante de injertos <span class="elsevierStyleItalic">punch</span> de piel sin pelo&#46; El trasplante de fol&#237;culos pilosos parece ser una alternativa terap&#233;utica eficaz en las &#250;lceras venosas cr&#243;nicas que no curan con tratamiento convencional&#46; La realizaci&#243;n de futuros ensayos cl&#237;nicos ser&#225; necesaria para evaluar el perfil de paciente y las caracter&#237;sticas de las &#250;lceras que se pueden beneficiar en mayor medida de este tipo de injertos&#44; as&#237; como su uso en &#250;lceras cr&#243;nicas de otras etiolog&#237;as&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicto de intereses</span><p id="par0095" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Funci&#243;n del fol&#237;culo piloso en la curaci&#243;n de las heridas"
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          "titulo" => "Trasplante de fol&#237;culos pilosos mediante injertos punch en &#250;lceras cr&#243;nicas recalcitrantes&#58; su aplicaci&#243;n en la pr&#225;ctica cl&#237;nica"
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          "titulo" => "T&#233;cnica quir&#250;rgica utilizada en el trasplante de fol&#237;culos pilosos en &#250;lceras cr&#243;nicas"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las &#250;lceras venosas cr&#243;nicas de los miembros inferiores representan un reto terap&#233;utico importante en la pr&#225;ctica cl&#237;nica diaria&#44; resultando primordial la b&#250;squeda de nuevas alternativas que mejoren la curaci&#243;n de estas heridas&#46; Pese al tratamiento habitual con compresi&#243;n&#44; desbridamiento y uso de ap&#243;sitos&#44; muchas &#250;lceras permanecen sin cicatrizar&#46; En estas &#250;lceras que no curan uno de los tratamientos m&#225;s empleados es el trasplante de injertos cut&#225;neos en sus diversas variantes&#58; <span class="elsevierStyleItalic">pinch grafts</span>&#44; <span class="elsevierStyleItalic">punch grafts</span>&#44; injertos de piel de espesor parcial&#44; injertos de piel de grosor total e injertos elaborados a partir de c&#233;lulas cultivadas en laboratorio&#46; En los &#250;ltimos a&#241;os numerosos estudios han destacado el importante papel del fol&#237;culo piloso en el proceso de cicatrizaci&#243;n de las heridas cut&#225;neas&#46; Trasladando a la pr&#225;ctica estos conocimientos se han utilizado fol&#237;culos pilosos del cuero cabelludo en injertos tipo <span class="elsevierStyleItalic">punch</span> que son trasplantados al lecho de las &#250;lceras cr&#243;nicas para estimular su curaci&#243;n&#46; Los resultados parecen ser mejores que el trasplante tradicional de injertos tipo <span class="elsevierStyleItalic">punch</span> sin pelo&#44; lo cual proporciona nuevas l&#237;neas de tratamiento para las &#250;lceras venosas cr&#243;nicas recalcitrantes&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chronic venous leg ulcers are a major therapeutic challenge in clinical practice&#44; and the search for new approaches to improve wound healing is essential&#46; Many ulcers do not heal with traditional treatment using compression&#44; debridement&#44; and dressings&#46; Skin-grafts variants&#44; such as pinch grafts&#44; punch grafts&#44; split- or full-thickness skin grafts&#44; and grafts derived from cells cultured in the laboratory&#44; are among the most widely used options in ulcers that do not heal&#46; In recent years&#44; numerous studies have brought to our attention the important role of the hair follicle in the healing process of cutaneous wounds&#46; Putting knowledge into practice&#44; hair follicles from the scalp have been used in punch-type grafts transplanted to the base of chronic ulcers to stimulate healing&#46; Results appear to be better than those with traditional hairless punch grafts&#44; opening new lines of treatment for recalcitrant chronic venous ulcers&#46;</p></span>"
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          "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#218;lcera venosa en la que se indican los 2 cuadrantes utilizados para el estudio&#46; El cuadrante superior correspondi&#243; al &#225;rea experimental que recibi&#243; los injertos <span class="elsevierStyleItalic">punch</span> de fol&#237;culos pilosos de cuero cabelludo &#40;&#225;rea experimental&#41; y el inferior fue el &#225;rea control que no recibi&#243; ning&#250;n trasplante &#40;&#225;rea control&#41;&#46;</p>"
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                      "titulo" => "Comparison of surgery and compression with compression alone in chronic venous ulceration &#40;ESCHAR study&#41;&#58; Randomised controlled trial"
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                      "titulo" => "Intermittent pneumatic compression for treating venous leg ulcers"
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