perilunate dislocation; Mayflield's classification; scapholunate advanced collapse wrist; Gilula's lines; Terry-Thomas sign
Objective: Studies in literature on skin of patients with massive weight loss are limited and somehow conflicting in their results. The aim of this study was to quantitatively assess the skin change after massive weight loss. Method: This study was performed on 30 patients from whom skin biopsies were taken from the skin excised during operations, divided into 3 main groups. The first included patients who were undergoing cosmetic contouring procedures without history of massive weight loss. The second included patients with morbid obesity, who were undergoing bariatric surgery. The third included patients with massive weight loss submitted to cosmetic contouring procedures after stable weight reduction for 6 months. Biopsies were taken from the skin for histological testing. Hematoxylin and Eosin, Mallory, and Aldehyde fuchsin Stains were used to assess the skin collagen and elastic fibers. For quantitative assessment, the Image Analyzer System (Leica Q 500 MC program) was employed. Tensile tests were applied to skin samples using (Instron 5500R) Universal testing machine to measure the skin tensile strength to determine the maximum stress (Burst strength) that skin can induce before damage. Results: Collagen was significantly thinner in massive weight loss group in both papillary and reticular dermis and significantly less dense in reticular dermis with damage to the elastic fiber network. Conclusion: The skin of the patients with massive weight loss is weak due to lower density and thickness of collagen fibers and damage to its elastic fibers.
image analyzer; collagen; massive weight loss; obesity; skin laxity
heterotopic ossification; implant calcification; breast implant; breast surgery complication; implant contracture
hematoma; carpal tunnel; palmar aponeurosis; atraumatic; warfarin
nodular; clear cell; poroid; hidradenoma; toe
zygoma; zygomatic arch fracture; coronoid impingement; trismus; facial trauma
Objective: Infantile hemangioma (IH) is a benign vascular tumor that gradually shrinks over several years. Involuting or involuted IHs usually retain their shape, however, and result in redundant skin or conspicuous scarring due to ulceration in the proliferating phase. We present a case series of 12 patients who underwent intralesional excision and primary closure for treatment of involuting or involuted IH. Methods: Twelve patients (5 boys, 7 girls) underwent our treatment method for involuting or involuted IH. A blinded assessor evaluated clinical result of each patient. Results: Surgical results were excellent in 4 patients, good in 6, and fair in 2. A small dog ear was prominent in 1 patient; nevertheless, all parents were satisfied with the results. Conclusions: Intralesional excision and primary closure for treatment of involuting or involuted IH is an easy and simple procedure that does not result in dog-ear formation or elongated residual scarring.
infantile hemangioma; intralesional excision; primary closure; scar; dog ear
hand bone tumor; enchondroma; digit; demineralized bone matrix; Maffucci syndrome
Lymphangioma; thumb angioma; lymphangioma thumb; lymphangioma hand; hand tumor
ulnar impaction; ulnar impaction syndrome; ulnar wrist pain; positive ulnar variance; subchondral sclerosis
pleomorphic adenoma; lacrimal sac tumor; eyebrow lesion; lacrimal sac adenoma; cutaneous sweat gland adenoma
Objective: The authors present the novel use of a new generation surgical ablative tool known as the WoundWand. Methods: A 66-year-old woman presented with 18% deep-dermal and full-thickness burns affecting the left side of her body including the total left upper limb, abdomen, and left thigh following lighting a cigarette in bed while on home oxygen therapy. She underwent tangential excision of burn using the WoundWand with immediate reconstruction using split skin grafts and topical negative pressure therapy. Results: We found that we were able to easily tangentially excise the hard eschar from delicate areas such as the hand and fingers using the WoundWand. Discussion: The authors conclude that the novel use of this device particularly in delicate areas such as dorsum of fingers and hand has some advantages over preexisting methods. Further clinical study may add to the surgical armamentarium of the burns surgeon.
burn; eschar; full thickness; tangential excision; WoundWand
aneurysm; ligation; temporal artery; trauma; surgery
cheek reconstruction; forehead flap; cheek defects; forehead blood supply; forehead esthetic unit
Objective: Previous abdominal wall surgery is viewed as a contraindication to abdominal free tissue transfer. We present two patients who underwent multiple abdominal liposuction procedures, followed by successful free deep inferior epigastric artery perforator flap. We review the literature pertaining to reliability of abdominal free flaps in those with previous abdominal surgery. Methods: Review of case notes and radiological investigations of two patients, and a PubMed search using the terms “DIEP”, “deep inferior epigastric”, “TRAM”, “transverse rectus abdominis”, “perforator” and “laparotomy”, “abdominal wall”, “liposuction”, “liposculpture”, “fat graft”, “pfannenstiel”, with subsequent appraisal of relevant papers by the first and second authors. Results: Patient 1 had 3 episodes of liposuction from the abdomen for fat grafting to a reconstructed breast. Subsequent revision reconstruction of the same breast with DIEP flap was preceded by CT angiography, which demonstrated normal perforator anatomy. The reconstruction healed well with no ischaemic complications. Patient 2 had 5 liposuction procedures from the abdomen to graft fat to a wide local excision defect. Recurrence of cancer led to mastectomy and immediate reconstruction with free DIEP flap. Preoperative MR angiography demonstrated a large perforator right of the umbilicus, with which the intraoperative findings were consistent. The patient had an uneventful recovery and good healing with no fat necrosis or wound dehiscence. Conclusions: We demonstrate that DIEP flaps can safely be raised without perfusion-related complications following multiple liposuction procedures to the abdomen. The safe interval between procedures is difficult to quantify, but we demonstrate successful free flap after 16 months.
liposuction; DIEP; free flap; breast reconstruction; angiography
Objective: The immune response to an inflammatory stimulus is balanced and orchestrated by stimulatory and inhibitory factors. After a thermal trauma, this balance is disturbed and an excessive immune reaction with increased production and release of proinflammatory cytokines results. The nicotine-stimulated anti-inflammatory reflex offsets this. The goal of this study was to verify that transdermal administration of nicotine downregulates proinflammatory cytokine release after burn trauma. Methods: A 30% total body surface area full-thickness rat burn model was used in Sprague Dawley rats (n = 35, male). The experimental animals were divided into a control group, a burn trauma group, a burn trauma group with additional nicotine treatment, and a sham + nicotine group with 5 experimental animals per group. The last 2 groups received a transdermal nicotine administration of 1.75 mg. The concentrations of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6 were determined in homogenates of hearts, livers, and spleens 12 or 24 hours after burn trauma. Results: Experimental burn trauma resulted in a significant increase in cytokine levels in hearts, livers, and spleens. Nicotine treatment led to a decrease of the effect of the burn trauma with significantly lower concentrations of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6 compared to the trauma group. Conclusions: This study confirms in a standardized burn model that stimulation of the nicotinic acetylcholine receptor is involved in the regulation of effectory molecules of the immune response. Looking at the results of our study, further experiments designed to explore and evaluate the potency and mechanisms of the immunomodulating effects of this receptor system are warranted.
burn trauma; nicotine; inflammatory reflex; neuroimmunology; cytokines
Objective: Drawtex's ability to remove pathogens and associated virulence factors has been demonstrated in vitro. A model of burn wound infection was used to characterize the in vivo impact of this dressing on infection and wound healing. Methods: Paired burn wounds were created on the dorsum of Sprague Dawley rats and were inoculated with methicillin-resistant Staphylococcus aureus (MRSA). Animals were divided into 2 groups, half with wounds that received experimental dressing and the remaining half with control dressing-treated wounds. Dressings remained in place through 3, 6, 9, or 14 days after injury, and methicillin-resistant S aureus and virulence factors were quantified. Laser Doppler imaging was used to examine wound perfusion, and local host immune response was assessed through the quantification of mRNA expression. Results: By day 3, less methicillin-resistant S aureus was measured in wounds treated with experimental-dressing compared to control-dressing wounds. Quantities remained lower in the experimental group through day 14 (P < .001). More methicillin-resistant S aureus was quantified in the experimental dressing itself than in control dressing at all time points (P < .05). Experimental dressing-treated wounds contained less toxic shock syndrome toxin 1 and Panton-Valentine leukocidin than controls (P < .01) on days 6, 9, and 14. Induction of toll-like receptor 2, NOD-like receptor family, pyrin domain containing 3, and interleukin 6 was significantly lower in experimental-dressing treated wounds than in controls on days 6 and 9 (P < .05). Conclusions: The hydroconductive dressing provided a significant reduction in pathogen and virulence factors compared to a control dressing. As a result of clearance of virulence factors from the wound bed, a requisite alteration in host innate immune response was observed.
infection; burn; wounds; dressings; virulence factors
Objective: Several devices exist today to assist the intraoperative determination of skin flap perfusion. Laser-Assisted Indocyanine Green Dye Angiography (LAICGA) has been shown to accurately predict mastectomy skin flap necrosis using quantitative perfusion values. The laser properties of the latest LAICGA device (SPY Elite) differ significantly from its predecessor system (SPY 2001), preventing direct translation of previous published data. The purpose of this study was to establish a mathematical relationship of perfusion values between these 2 devices. Methods: Breast reconstruction patients were prospectively enrolled into a clinical trial where skin flap evaluation and excision was based on quantitative SPY Q values previously established in the literature. Initial study patients underwent mastectomy skin flap evaluation using both SPY systems simultaneously. Absolute perfusion unit (APU) values at identical locations on the breast were then compared graphically. Results: 210 data points were identified on the same patients (n = 4) using both SPY systems. A linear relationship (y = 2.9883x + 12.726) was identified with a high level or correlation (R2 = 0.744). Previously published values using SPY 2001 (APU 3.7) provided a value of 23.8 APU on the SPY Elite. In addition, postoperative necrosis in these patients correlated to regions of skin identified with the SPY Elite with APU less than 23.8. Conclusion: Intraoperative comparison of LAICGA systems has provided direct correlation of perfusion values predictive of necrosis that were previously established in the literature. An APU value of 3.7 from the SPY 2001 correlates to a SPY Elite APU value of 23.8.
breast reconstruction; indocyanine green dye; mastectomy skin flap necrosis; quantitative perfusion values; SPY
Objective: Negative pressure wound therapy with instillation (NPWTi-d) combines NPWT with automated delivery and removal of topical wound treatment solutions. This porcine study compared genomic and proteomic responses of wounds treated with NPWTi-d with saline to wounds treated with NPWT in continuous and noncontinuous modes. Methods: Full-thickness porcine dorsal excisional wounds were treated with continuous NPWT, intermittent NPWT, dynamic NPWT, or NPWTi-d with saline (n = 10 wounds per group). On day 7, animals were euthanized and tissues collected. Real-time quantitative polymerase chain reaction arrays profiled expression of 84 genes including extracellular matrix remodeling factors, inflammatory cytokines and chemokines, and growth factors and major signaling molecules. Concentrations of proteins associated with angiogenesis, extracellular matrix components, and cellular energetics were analyzed via enzyme-linked immunosorbent assays. Results: Gene expression profiles for NPWTi-d with saline and continuous NPWT were similar. There were 5 upregulated and 18 downregulated genes overexpressed in NPWTi-d compared to NPWT wounds. Protein content was comparable in all treatment groups and similar to unwounded tissue. Conclusions: Previous preclinical studies have reported an increased rate of granulation tissue formation with NPWTi-d with saline compared to NPWT in continuous and noncontinuous modes. This evaluation of gene and protein expression suggests that the granulation tissue in these wounds has a similar quality. This first look at the differences in gene expression, particularly in genes related to remodeling, cell adhesion, inflammation, and growth factors, could help to clarify the observed differences in granulation rates.
genomics; proteomics; negative-pressure wound therapy; hypertonic saline solution; instillation
pectus excavatum; rib prosthesis; rib locking plates; modified ravitch technique; recurrent pectus excavatum
pyogenic granuloma; lower lip; surgery; cosmesis; female
Introduction: Reported infection rates in breast reconstruction with acellular dermal matrix (ADM) can exceed 31%. Prophylactic antibiotics remain controversial due to the absence of evidence-based literature. The purpose of this study was to examine published antibiotic regimens and their associated infection rates in this population. Methods: Systematic electronic searches were performed in PubMed, OVID, and the Cochrane databases for studies that reported on prophylactic antibiotic use and infection in patients undergoing ADM breast reconstruction. Two independent authors reviewed studies between 1970 and 2012 for inclusion and data extraction. Results: A total of 863 studies were identified and abstracts reviewed. A total of 24 articles were included, with 2148 patients and 3189 ADM reconstructions. Mean infection rates varied between 0% and 31.25%, with a combined average of 11.59%. When comparing antibiotic protocols of less than 24 hours and more than 24 hours, the average infection rate was 2.48% and 13.21%, respectively. Conclusion: The current literature lacks consensus on the necessary duration for postoperative antibiotic prophylaxis following breast reconstruction. The potential increased risk of infection associated with ADM remains controversial. Because of the lack of supportive evidence, we do not recommend prolonged postoperative antibiotics in ADM breast reconstruction.
Level of Evidence: Therapeutic level III evidence.
breast reconstruction; acellular dermal matrix; ADM; infection; antibiotics
radial tunnel syndrome; radial tunnel release; posterior interosseous nerve; peripheral nerve entrapment; lateral epicondylitis
epinephrine; amputation; necrosis; finger; lidocaine