A Study of Cadaveric Skin Graft Harvest and Usage: An Observational Prospective Pilot Study

Background Burn injuries pose a significant global public health challenge, causing substantial morbidity and mortality, particularly in low- and middle-income countries. Timely and effective wound coverage is critical in treating severe burns to prevent infection, reduce pain, and promote healing. Cadaveric skin grafts (allografts) have become essential in treating extensive burn wounds, serving as temporary biological dressings to prepare the wound bed for autografting. This study aims to comprehensively analyze the process of cadaveric skin graft harvest and usage in a tertiary care setting. It seeks to evaluate the procedures, challenges, and outcomes associated with cadaveric skin grafts, contributing to optimizing burn care practices and improving patient outcomes. Methods  This observational study was conducted at a tertiary care hospital and burns center with a skin bank, involving 44 cadaveric skin graft harvests and 27 applications between July 1, 2011, and June 30, 2013. The study focused on prospective donors and recipients needing cadaveric skin grafts. Inclusion criteria for donors included consent from the next of kin and the absence of infections or septicemia, while exclusion criteria included prolonged post-mortem intervals and medico-legal cases. The procedures adhered to the Euro Skin Bank protocols, encompassing retrieval, processing, storage, and usage. Data were analyzed using Epi-Info version 7.2.1 software, employing descriptive statistics for categorical variables. Ethical clearance was obtained from the university ethical committee, with mandatory written informed consent for skin donation. Results Out of 519 deaths in the tertiary care hospital, significant barriers to skin donation included septicemia, skin changes, late reporting, young age, medico-legal issues, and positive viral markers. Notably, 114 (21.97%) of next of kin refused consent. Cadaveric skin was harvested in five (11.36%) cases, with potential donors identified in 78 (15.02%) of deaths. Donors were predominantly older males, with efficient procurement processes ensuring timely harvests. The tertiary burns center facilitated 39 (88.63%) cases of cadaveric skin harvests with a skin bank, either at the donor's home or other hospitals notified to the burns center. Cadaveric skin grafts were applied in 27 cases, primarily for burns, with high graft uptake observed over 10 days. Non-healing ulcers showed 100% graft uptake. The survival rate among burn patients was 20 (74%), with deaths mainly due to sepsis and multi-organ failure. Significant barriers to obtaining consent included a lack of awareness, superstitions, social stigmas, and religious objections. Conclusion  The study highlights the critical role of cadaveric skin in managing extensive wounds, particularly burns. Despite challenges in obtaining consent and limited donor availability, cadaveric skin grafts effectively prepared wound beds for autografting, contributing to improved patient outcomes. Increasing community awareness and addressing superstitions and social stigmas are essential for improving donation rates.

Regulatory frameworks in plastic and cosmetic surgery: a comparative scoping review across Australia, United Kingdom, and Italy

Background

The regulatory landscape for plastic and cosmetic surgery across the country plays a crucial role in shaping the practices within its premises, ensuring patient safety, and maintaining ethical standards in the medical community. This review examines the distinct regulatory frameworks that govern Australia, United Kingdom (UK), and Italy practices, focusing on the nuances that influence the professional accountability and safety measures in place.

Methods

A comprehensive scoping review was conducted, exploring the legal and regulatory frameworks governing plastic and reconstructive surgery in Australia, the UK, and Italy. Databases such as PubMed, Scopus, and Google Scholar were searched for relevant studies from infinity to May 2024, which were then analyzed to compare regulatory practices, qualification requirements, and their implications on patient safety and professional accountability.

Results

Each country presents a unique set of regulations that reflect their individual medical, legal, and cultural contexts. In Australia, the Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia impose stringent criteria for differentiating between "cosmetic surgeons" and "plastic surgeons". The UK's approach, governed by the General Medical Council (GMC), emphasizes ethical conduct, informed consent, and transparent advertising. Italy's regulatory framework varies slightly with a specific focus on the qualifications and titles of practitioners.

Conclusions

The study underscores the importance of stringent regulations in plastic and cosmetic surgery, advocating for enhanced regulatory measures and comprehensive education on the qualifications of practitioners. It is imperative that these standards are maintained and adapted as necessary to protect patients in the rapidly evolving landscape of cosmetic and plastic surgery across the different regions.

Improvement in Early Scar Maturation by Nanofat Infiltration: Histological and Spectrophotometric Preliminary Results From a Split Scar-Controlled, Randomized, Double-Blinded Clinical Trial

Background

The regenerative properties of stromal vascular fraction (SVF) in wound healing and scar formation are a subject of increasing clinical interest.

Objectives

Although preclinical studies have confirmed the angiogenetic, proliferative, and antifibrotic properties of SVF, there is limited clinical evidence from randomized controlled clinical trials.

Methods

Twelve patients who underwent abdominoplasty were included in this clinical study. Nanofat was mechanically obtained intraoperatively and infiltrated intradermally in the sutured surgical wound, randomly assigned to either the left or the right side. The abdominal scar was evaluated with the Patient and Observer Scar Assessment Scale, whereas erythema and pigmentation were measured with a reflectance spectrophotometry device (Mexameter, Courage + Khazaka electronic GmbH, Köln,Germany). Histological analysis and electron scan microscopy of tissue biopsies were performed at 8 months.

Results

The treated side of the scar showed significantly less erythema at 3- and 6-month follow-ups, but this difference reduced after 12 months. Patients reported better scar scores at the 6-month follow-up with a significantly better color at the treated side. Observers reported better overall scar scores at the treated side at 3-, 6-, and 12-month follow-ups, with better vascularization, pigmentation, and thickness. There was no statistically significant difference in terms of histological analysis between the 2 groups. There was no difference in the occurrence of adverse events between both sides.

Conclusions

Infiltration of nanofat exhibited promising results in surgical scar maturation characterized by less erythema and better texture. More clinical trials with a larger sample size are warranted to better elucidate the possible benefits of SVF on surgical scar formation.

Level of Evidence 5

Long-Term Functional and Radiological Results in Tonkin Type 3B Thumb Hypoplasia Treated With Nonvascularized Toe Phalanx Transfer as an Alternative to Pollicization

PURPOSE

Parents of children with hypoplastic thumbs often reject the option of pollicization for various reasons and enquire about alternate choices. Our study aimed to assess the outcome in children who underwent nonvascularized toe phalanx transfer for Tonkin type 3B thumb hypoplasia and compare it with a similar cohort of children treated with pollicization.

METHODS

At an average follow-up of 7 years for toe phalanx transfer and 6 years of pollicization, five children from each group were tested for thumb length, stability of the first carpometacarpal (CMC) joint, mobility, opposition, and donor-site morbidity. Parents were asked to report improvements in function and appearance. All cases were Tonkin type 3B thumb hypoplasia.

RESULTS

The CMC joint was found to be stable in all children, and the Kapandji score was 6 in 3 children and 5 in 2 children with toe phalanx transfer compared to 9 in all children with pollicization. The average palmar abduction was 24°, and the average radial abduction was 36° in the toe phalanx transfer group compared to 40° and 45°, respectively, in children with pollicization. The average thumb length was 50.8% of the index finger's proximal phalanx in the toe phalanx group compared to 60 % in the pollicization group. The mean visual analog scale scores for the thumb's function and appearance were 6.8 and 6.4, respectively, compared to 9.2 and 8.8, respectively, in the pollicization group. No resorption was noted in the donor phalanx at a mean follow-up of 7 years with no donor-site morbidity other than mild shortening of the toes.

CONCLUSIONS

We noted increased palmar abduction and radial abduction in the pollicization group. No resorption was noted in the donor toe phalanx at the longest follow-up of 9 years. Toe phalanx can be considered an alternative for those children in whom a five-finger hand is a priority.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Comprehensive Mapping and Dynamic Monitoring of the Temporal Branch of the Facial Nerve in Complex Cranial Reconstruction Surgery and Revision Cranioplasty

Facial nerve (FN) injury is a significant risk during complex cranial reconstruction surgeries, especially in revision cases where normal anatomy is distorted. The authors introduce a technique to mitigate FN injury, including preoperative FN mapping, intraoperative FN mapping, and continuous FN monitoring. Preoperative mapping uses a handheld ball-tip stimulator to elicit compound muscle action potentials (CMAP) in the frontalis muscle. Needle electrodes are placed above the orbital margin to record responses, starting at the stylomastoid foramen and extending until the entire temporal branch is mapped. Intraoperatively, continuous mapping is achieved using an electrified insulated suction device, allowing dynamic mapping during soft tissue dissection. Continuous monitoring involves placing stimulation electrodes near the stylomastoid foramen and recording CMAP responses from the frontalis and orbicularis oculi/orbicularis oris muscles. The authors tested this technique in 5 patients. The authors successfully mapped the temporal branch of the FN with isolated frontalis CMAP recordings in all patients. Intraoperative FN mapping and continuous monitoring were successfully performed in all cases. Two patients experienced complete cessation of FN CMAPs, which resumed upon loosening the tension on the myocutaneous flap held by fishhooks. One patient showed a 39% decrement in frontalis CMAP that did not recover. Despite these issues, all patients had intact FN function postoperatively and at follow-up. Our technique shows promise in mitigating FN injury during complex cranial reconstruction and cranioplasty revision surgery. Further research with a larger cohort is needed to confirm efficacy and statistical significance.

Clean-label alternatives for food preservation: An emerging trend

Consumer demand for natural or 'clean-label' food ingredients has risen over the past 50 years and continues growing. Consumers have become more aware of their health and, therefore, insist on transparency in the list of ingredients. Preservatives are the most crucial food additives, ensuring food safety and security. Despite tremendous technological advancements, food preservation remains a significant challenge worldwide, primarily because most are synthetic and non-biodegradable. As a result, the food industry is placing more value on microbiota and other natural sources for bio-preservation, leading to the substitution of conventional processing and chemical preservatives with natural alternatives to ensure 'clean-label.' General Standard for Food Additives (GSFA) includes some of these 'clean-label' options in its list of additives. However, they are very rarely capable of replacing a synthetic preservative on a 'one-for-one' basis, putting pressure on researchers to decipher newer, cleaner, and more economical alternatives. Academic and scientific research has led to the discovery of several plant, animal, and microbial metabolites that may function as effective bio-preservatives. However, most have not yet been put in the market or are under trial. Hence, the present review aims to summarise such relevant and potential metabolites with bio-preservative properties comprehensively. This article will help readers comprehend recent innovations in the 'clean-label' era, provide informed choices to consumers, and improve the business of regulatory approvals.

Madelung disease with postoperative priapism and multiple venous thromboses: case report and literature review

Madelung disease is an uncommon metabolic disorder of uncertain pathogenesis, distinguished by the symmetric accumulation of nonencapsulated adipose tissue within the subcutaneous layer of the neck, abdomen, thighs, and other anatomical regions. This condition has been tightly connected with comorbidities including diabetes, dyslipidemia, hyperuricemia, hypothyroidism, and adrenal dysfunction, as well as sensory, motor, and autonomic polyneuropathy. The prevalence of Madelung disease is conspicuously higher in Mediterranean and Eastern European, with a distinct scarcity within the Asian population. Surgical interventions involving lipectomy and liposuction represent the foremost and most efficacious treatment approach. Herein, we present a case encompassing type II Madelung disease featuring bilateral thighs adipose tissue accumulation. The patient exhibited unexplained priapism alongside multiple venous thrombosis during four surgical interventions. The infrequent manifestation of postoperative hypercoagulability in patients of Madelung disease merits broad attention, owing to the potentiality for extensive venous thrombosis and consequential severe outcomes such as pulmonary embolism or cerebral infarction arising from thrombus dislodgment. Building upon this clinical scenario, we systematically documented the clinical manifestations and disease progression in this patient, meticulously analyzed the causes of complications, and proposed targeted preventive measures. Additionally, we conducted a comprehensive review of the relevant literature to summarize the clinical and epidemiological features of Madelung disease and to elucidate its mechanisms. This study will provide a valuable reference for future clinical treatments and mitigate perioperative complications of Madelung disease.

The Role of Botulinum Toxin A Neuromodulator in the Management of Synkinesis in Facial Palsy

Facial palsy describes the denervation of the facial nerve leading to difficulty in facial animation and expression. Facial synkinesis is the result of complex pathological nerve regeneration following damage to the facial nerve axons. Synkinesis in facial palsy can be managed using facial neuromuscular rehabilitation, botulinum toxin neuromodulators, and surgical treatment options. Botulinum toxin A can be used as an adjunct to other treatment options to manage synkinesis. This article will explore the role of botulinum toxin A in the management of synkinesis in facial palsy including the clinical assessment, injection location (muscles targeted), dosages, treatment interval, and long-term results. It will also include surgical management options.

An Innovative Methodology: The Submental Island Flap Offers Enhanced Soft Tissue Coverage to the Vascularized Iliac Crest Flap

The vascularized iliac crest flap has garnered widespread acclaim within the field of mandibular reconstruction attributable to its sufficient bone mass and congruent curved morphology. However, when the precise orientation of the iliac crest is imperative during mandibular reconstruction and there exists an accompanying defect within the oral soft tissue, the indispensability of an additional flap to facilitate concurrent defect repair becomes evident. In such instances, the submental island flap emerges as an exemplary candidate.

Integrating Psychological Insights into Aesthetic Medicine: A Cross-Generational Analysis of Patient Archetypes (IMPACT Study)

BACKGROUND

Aesthetic medicine has evolved significantly, accommodating diverse demographics and motivations influenced by societal shifts and technological advancements. The IMPACT (integrative multigenerational psychological analysis for cosmetic treatment) study refines patient archetypes, integrating psychological theories to tailor treatments, especially for younger demographics and LGBTQIA + communities.

METHODS

This cross-sectional study utilized a comprehensive, validated survey with a Cronbach's alpha of 0.89 and a Content Validity Index (CVI) of 0.92, distributed across a globally diverse, generationally stratified sample. Techniques like regression analysis, ANOVA, Bayesian modelling, and factor analysis were employed to analyse the data, focusing on developing nuanced patient archetypes.

RESULTS

Among 5645 participants, 5340 complete responses highlighted significant generational differences in aesthetic preferences. Millennials showed a strong preference for non-invasive procedures (β = 0.65, p < 0.001). ANOVA results confirmed significant variances across generations [F (3, 5118) = 157.6, p < 0.001], with post-hoc analyses delineating specific inter-group differences. Bayesian modelling provided insights into the probability of non-invasive preferences among younger cohorts at over 92% certainty. Factor analysis revealed key dimensions such as 'Generational Influence' and 'Technological Adoption,' which helped in defining archetypes including Dynamic Self-Identity, Digital Native, Stability Seeker, Classic Conservatism, and Holistic Health, collectively explaining up to 78% of the variance in responses.

CONCLUSION

The IMPACT study underscores the influence of generational identity and digital exposure on aesthetic preferences, advocating for personalized, archetype-based treatment approaches. This aligns with enhancing patient satisfaction and treatment outcomes, promoting an adaptive aesthetic medicine practice that meets the evolving needs of modern patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparative analysis of volumetric changes between resection volume of oral tongue cancer and post operative volume of radial forearm flaps

OBJECTIVES

This study investigates the relationship between the total volume of oral tongue cancer pre-operatively and the RFFF volume post-operatively.

MATERIALS AND METHODS

A total of 52 DICOM imaging datasets (CT or MRI) of 26 patients were included in this study. The volume of the desired structure was quantified using semi-automatic segmentation using the software ITK-SNAP. All extracted measurements were validated by two further clinicians at separate instances.

RESULTS

The variation of MeanVolTu can be predicted by MeanVolFlap moderately reliable with 59.1% confidence (R-Qua: 0.591). ANOVA Testing to represent how well the regression line fits the data, resulted in the overall regression model being statistically significant in predicting the MeanVolTu (p < 0.001). The flap volume may be predicted using the following algorithm: MeanVolFlap0 = 3241,633 + 1, 322 * MeanVolTu.

CONCLUSION

The results of this study show positive correlation between tumor volume and flap volume, highlighting the significance of efficient flap planning with increasing tumor volume. A larger extraction volume of the radial forearm free flap from the donor site compromises the forearm more, thus increasing the probability of post-operative complications.

CLINICAL RELEVANCE

Radial forearm free flap design in accordance with its corresponding 3D tumor volume.

Surgical Repair of Obstetric Brachial Plexus Injuries: A Case Series and Discussion of the Current Literature

OBJECTIVE

To assess factors which may influence surgical success following brachial plexus reconstruction for obstetric brachial plexus injury (OBPI).

METHODS

We retrospectively reviewed the charts of 27 consecutive patients who underwent brachial plexus reconstruction following OBPI by a single pediatric neurosurgeon, 22 of which had adequate follow-up be included in analysis. Data on preoperative function, intraoperative findings, and postoperative outcomes were collected. Mallet grades for abduction, external rotation, and hand-to-mouth were used as a measure of upper trunk function.

RESULTS

All patients undergoing brachial plexus reconstruction (n = 27) were found to have some degree of upper-trunk injury intra-operatively. Of the 22 patients with adequate follow-up to be included in the analysis, 17 had some degree of improvement in Mallet grade postoperatively. Prior to surgery, 95% (21/22) of patients had an abduction Mallet grade of 1, compared to 23% (5/22) at the time of maximum improvement (P < 0.001). These values were 100% (20/20) to 35% (5/14) (P < 0.001), and 95% (21/22) to 27% (6/22) (P < 0.001) for external rotation and hand-to-mouth, respectively. The average time to maximum Mallet grade was 583 days (standard deviation 356 days). Age at time of surgery and time to maximum recovery were not found to be correlated.

CONCLUSIONS

Brachial plexus reconstruction is an effective treatment modality for patients without spontaneous recovery of upper extremity function following OBPI, although identifying the optimal age-range for surgery remains elusive. Patients with intraoperative findings consistent with a more severe injury may be less likely to benefit from surgery.

Fabrication of Mupirocin-Loaded PEGylated Chitosan Nanoparticulate Films for Enhanced Wound Healing

Chitosan-based biomaterials are being investigated for their unique properties that support skin regeneration and wound healing. This study focused on the preparation and characterization of a mupirocin (Mup)-loaded PEGylated chitosan (CS-PEG) nanoparticulate film (NF) [CBNF]. The CBNF was characterized using FTIR spectroscopy and SEM analysis. The results demonstrated that CBNF was successfully incorporated into the composites, as shown by functional group modification through FTIR analysis. Additionally, the SEM micrograph revealed the deposition of nanoparticles (<200 nm) on the surface of transparent CBNF. The film has higher water absorption (≥1700%) and moderate water retention ability within 6 h. Furthermore, histological findings showed significant development, with re-epithelialization and granulation of tissues after 19 days, indicating the healing efficiency of CNBF. These results suggest that drug-loaded films could be an effective carrier and delivery agent for Mup-like anti-inflammatory drugs.

A Scoping Review on Complications in Modern Hair Transplantation: More than Just Splitting Hairs

BACKGROUND

Hair restoration surgery (HRS) is a commonly performed elective procedure but to date lacks a review of the full scope of complications.

OBJECTIVES

To provide a comprehensive overview of observed complications associated with follicular unit extraction (FUE) and follicular unit transplantation (FUT).

ELIGIBILITY CRITERIA

Randomized control trials, cohort studies, case series, and case reports published in 1985 or later on adults (age>18). Nontraumatic or autoimmune etiologies of alopecia were excluded as procedure indications.

SOURCES OF EVIDENCE

PubMed, EMBASE, Cochrane databases (last search December 31, 2022).

CHARTING METHODS

Data-charting and extraction were independently performed with two reviewers using Covidence.

RESULTS

Forty-three publications were included. Two large series reported the overall complication rate to be 1.2 and 4.7%. Common complications included bleeding requiring intervention (up to 8%), persistent numbness (up to 11%), infection (up to 11% with two reports of Kaposi varicelliform eruptions and one of mucormycosis), effluvium at donor and recipient sites (up to 4.1% and 6.5%, respectively). The most common donor-site complication was hypertrophic scarring/keloid formation after FUT (up to 15.1%). Complications at the recipient site, including crusting (up to 54.8%), frontal edema (up to 50%), and sterile folliculitis (up to 53.3%), tended to be poorly defined with a broad range of incidences.

CONCLUSION

Serious complications associated with HRS are rare in the hands of experienced providers. However, comprehensive discussions of risk must be had with prospective patients as any complication in the context of an elective procedure may be significant and psychologically devastating for the individual patient.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A case of BIA-ALCL in which postoperative chest wall recurrence was highly suspected: the third reported case of BIA-ALCL in Japan

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare malignancy. Many cases of BIA-ALCL are identified based on the presence of late-onset effusion and/or masses. Importantly, the United States Food and Drug Administration noted that in all cases diagnosed in patients with textured implants, the patients either had a history of mixed implantation of smooth and textured devices or no clinical history was supplied for review. In Japan, the first case of BIA-ALCL was reported in 2019, and we encountered the third case in Japan in December 2021. There have been a total of five cases of BIA-ALCL previously reported at Japanese academic conferences (Japan Oncoplastic Breast Surgery Society. http://jopbs.umin.jp/medical/index.html ), of which only the first case has been published. Unlike the first case, this patient had clinical features that were highly suggestive of the postoperative chest wall recurrence of breast cancer, with a mass and rash on the skin.

CASE PRESENTATION

The patient was a 45-year-old woman who had undergone breast reconstruction after breast cancer surgery of the right breast 8 years previously. The patient presented with a mass and skin rash inside the inframammary area, and we suspected a damaged silicone breast implant (SBI) or chest wall recurrence. We examined the mass by a core needle biopsy and made a pathological diagnosis of BIA-ALCL. Imaging findings suggested internal thoracic lymph node swelling and lymphoma infiltration beyond the capsule but no metastatic lesions (cStage III). After en bloc resection of the SBI and lymphoma, adjuvant systemic therapy was performed.

CONCLUSION

We encountered the third case of BIA-ALCL in Japan. This was a case with clinically advanced stage of disease; however, the BIA-ALCL was found to be in remission.

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review

OBJECTIVE

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes.

DESIGN

A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

SETTING

All study designs were included. Non-English articles were excluded.

PATIENTS AND PARTICIPANTS

Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula.

INTERVENTIONS

Free tissue transfer for a palatal fistula repair.

MAIN OUTCOMEE MEASURES

Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained.

RESULTS

Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies.

CONCLUSIONS

Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Topical Probiotic Hydrogels for Burn Wound Healing

Hydrogels have increasingly been used to enhance the effective healing of various wounds, including burn wounds. Similarly, the application of probiotics has recently been explored in wound healing and skin repairs. While probiotics have been consumed to provide therapeutic effects that aid with improving gut health, topical applications have been found to accelerate wound healing both in vitro and in vivo. For wounds that have complex healing mechanisms, such as burn wounds which depend on factors such as the depth of the burn, size of the afflicted area, and cause of the injury, probiotics with or without conventional therapeutic agents topically delivered via hydrogel technology are proven to be effective in the recovery of the damaged skin. This article aims to investigate the microorganisms present in the human skin microbiome and observe the effects of probiotics delivered by hydrogels on burn wound healing.

Lower Extremity Traumatic Wound Management: Relative Significance of Negative Pressure Wound Therapy in the Orthopedic Setting

Significance: Lower extremity traumatic wounds are associated with numerous perioperative challenges. Their etiologies determine the characteristics and extent of the injury. The timing of subsequent surgical intervention and wound healing optimization after lower extremity trauma are integral to successful perioperative lower extremity wound management. Recent Advances: Managing trauma to the lower extremities uses a multidisciplinary surgical approach. The objective of this review is to summarize lower limb trauma assessment, advancements in lower extremity trauma management, and the clinical applications of advanced wound care in lower limb traumatic wounds. The advent of lower limb reconstruction and the development of advanced wound care modalities have helped to improve the management of these complex injuries. Critical Issues: The extensive involvement of bone, soft tissues, nerves, and blood vessels of severe lower extremity trauma wounds presents a challenge for clinicians in both the acute care setting and during patient rehabilitation. If not properly managed, these injuries may be subject to a decline in limb function and may possibly result in limb loss. To reveal developing limb-threatening conditions, serial examinations should be performed. Future Directions: The majority of lower limb traumatic wound will benefit from the perioperative administration of an appropriate negative pressure wound therapy (NPWT)-based system, which can help to promote granulation tissue and remove wound exudate before definitive closure and/or reconstruction. NPWT should be included as an important adjunct in the surgical management of lower limb traumatic wounds.

A multivariate analysis on characteristics of hand and wrist tumours: a multiethnic study

INTRODUCTION

Hand tumours are frequently encountered in clinical practice. However, large-scale epidemiological data of soft tissue tumours in the hand are infrequently published. Epidemiological data provide diagnostic cues to guide the workup and management of hand tumours. Assessing significant independent demographic factors and tumour characteristics associated with hand tumours is essential in health care.

METHODS

A retrospective review of patients who underwent excision of hand tumours in Singapore General Hospital between 2004 and 2015 was conducted. The data collected included age, gender, ethnicity, histological diagnosis, malignancy and location of tumour. Generalised linear latent and mixed models (GLLAMM) analyses were performed.

RESULTS

A total of 4476 tumours were identified from 4226 patients with a mean age of 51.3 (range 8-101) years and male to female ratio of 1 to 1.15. Most patients were Chinese (75%), followed by Malay (9%), Indian (8%) and others (8%). The most common hand tumours excised were ganglions (43%) (majority in the wrist), followed by giant cell tumours (9%) (commonly in the digits). Most soft tissue tumours were benign (97%), with only 3% of malignant cases. The GLLAMM analyses revealed further potential factors on the status of malignancy, tumour origin and tumour location.

CONCLUSION

Most soft tissue tumours in the hand and wrist are benign. This can guide workup and counselling of patients before the operation. While malignant tumours are uncommon, they have the potential for significant morbidity and mortality if not appropriately evaluated or treated. The application of GLLAMM analyses showed that age, ethnicity and gender were significant predictors of malignancy.

Photobiomodulation in Burn Wounds: A Systematic Review and Meta-Analysis of Clinical and Preclinical Studies

Objective: This systematic review and meta-analysis main goal was to evaluate the efficacy of photobiomodulation as burn wounds treatment. Methods: Systematic review of literature available in databases such as PubMed, Web of Science, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and gray literature in Google Scholar, Livivi, and Open Gray. SYRCLE's RoB tool was applied to determine methodological quality and risk of bias, and meta-analysis was performed using the software Review Manager. Results: Fifty-one studies, gathering more than three thousand animals were included in this systematic review, and four studies were selected to the meta-analysis due to their suitability. The results indicated that photobiomodulation was not effective to improve, statistical significantly, wound retraction (SMD = -0.22; 95% CI = -4.19, 3.75; p = 0.91; I2 = 92%) or collagen deposition (SMD = -0.02; 95% CI = -2.17, 2.13; p = 0.99; I2 = 78%). Conclusion: This meta-analysis suggests that photobiomodulation, applied in burn wounds, accordingly to the protocols presented by the selected studies, was not effective over analyzed outcomes. However, this conclusion could be further discussed and verified in more homogeneous animal models and human clinical trials.

Long-Term Complications of Aquafilling Injection after Male Breast Augmentation: A Case Report

(1) Background: Aquafilling, a filler initially designed for contouring the face, was developed in 2005 by the company Biomedica, Czech Republic. It is composed of 98% hydrophilic gel and 2% copolyamide. Since 2008 the use was expanded for augmentation of the breast and gluteal region. It is suitable as a nonsurgical method for patients who want discreet augmentation and would like to avoid undergoing an operation. This method promises long-term results lasting up to 10 years. However, according to the literature Aquafilling gel can cause long-term complications; (2) Methods: This case report presents a male patient who experienced severe complications following Aquafilling injections for breast augmentation after ten years of treatment; (3) Results: A 51-year-old male patient presented to our emergency room with complaints of pain, firmness, major pre-pectoral swelling and asymmetry in his breasts. Due to the severity of the clinical appearance and the patient's discomfort, surgical intervention was deemed necessary. After undergoing three operations the patient was treated successfully and could be discharged for outpatient controls. The patient still did not show any signs of complications, three months after the event; (4) Conclusions: Although the patient has made a rapid recovery, as a result of the surgical procedure, we would recommend treating the breast region with small incisions and drainage in the future. This would have a better aesthetic result. Still there is no antidote available for the treatment of Aquafilling gel. It can only be removed by surgical debridement or irrigation and drainage.

Correction of Post-Surgical Temporal Hollowing with Adipo-Dermal Grafts: A Case Series

Background: Surgical dissection and partial detachment of the temporalis muscle during neurosurgical procedures might result in a temporal depression known as "temporal hollowing". Reconstructive procedures to correct this condition include the implantation of synthetic materials (e.g., hydroxyapatite, methacrylate or polyethylene), injection of autologous fat or fillers as well as the use of flaps (e.g., temporo-parietal local flap and latissimus dorsi free flap). However, none of these techniques proved to be an ideal option due to a high complication rate or need for invasive and complex surgery. Adipo-dermal grafts are autologous; the resorption rate seems to be limited and the complexity of the procedure is minor. Moreover, autologous fat grafting can be performed to enhance the final outcome by correcting residual contour deformities. Methods: In this series of five patients, an institutional experience is presented using multi-layered adipo-dermal grafts harvested from the supra-pubic area for the restoration of volume and contour in post-surgical temporal hollowing. During the last follow-up, patients were asked to express their satisfaction, which was assessed by a survey. Results: this approach demonstrates a marked improvement in temporal hollowing associated with a low complication rate and good patient satisfaction. Conclusions: the aim of this consecutive case series is to emphasize the effectiveness of this surgical technique as one of the options to address temporal hollowing.

Availability and Types of Pressure Ulcer Medications at Community Pharmacies in the Accra Metropolis of Ghana

Pressure ulcers (PU) arise from prolonged pressure on the skin and underlying tissue due to pathological changes in blood flow. They usually develop in people who are immobilized due to certain medical conditions. The incidence of chronic diseases such as cancer, cardio-vascular diseases are on the ascendency. These conditions, if not managed adequately could render patients incapacitated, leaving them bedridden for long periods. The chances of these individuals developing PU are very high. Currently in Ghana, information on medications for the management of various stages of PU are not readily available. Prevention of PU has been the goal of nursing care, however, in the case where preventive care is not successful, there should be effective and efficient medications for the management of the PU. Method: The study design was descriptive cross-sectional. To get a good representation of the availability of PU medications in the entire metropolis, a stratified sampling approach was used. The 10 districts within the metropolitan area were taken as the strata. Towns within each district were identified, and mapped out. From each town, community pharmacies were randomly selected. It was ensured that pharmacies selected were well spread out (located distance apart). Researchers had to collect data from three or more pharmacies from each town. Data was collected using a structured questionnaire from pharmacists working in these pharmacies. By this approach, the availability of PU medications across the entire metropolitan area was revealed. Results: 241 pharmacies were visited, out of which 192 respondents took part in the study. Approximately 83.3% of these pharmacies had pressure ulcer medications. Majority of the medications available in the community pharmacies visited were hydrophobic based dressings., while hydrophilic based dressings were less than 1%. Implying that patients having PU that produce scopious exudate will have challenges acquiring the necessary dressings to manage the wounds. The dressings which were mostly available, had other indications apart from Pressure Ulcer. Patronage of the available PU medications in the Accra metropolis was average. Conclusion: There are pressure ulcer medications available in pharmacies within the Accra metropolis of Ghana. Although the medications are averagely patronized, there are not many types available. Hydrophilic based dressings were not readily available.

Association of prenatal Cleft Lip and Palate ultrasound abnormalities with copy number variants at a single Chinese tertiary center

BACKGROUD

A systematic analysis was conducted to investigate the molecular etiology of fetal cleft lip and/or palate (CL/P) and the association between various types of CL/P and copy number variations (CNVs), as well as their impact on birth outcomes.

METHODS

In this retrospective study conducted between January 2016 and July 2022, a cohort of pregnancies diagnosed with fetal CL/P was enrolled and comprehensive clinical data for all cases were extracted from our medical record database, including demographic data about the pregnancies, ultrasound findings, results of Chromosomal microarray (CMA), as well as relevant pregnant and perinatal outcomes.

RESULTS

Among the 358 cases, 32 clinically significant variants in 29 (8.1%) fetuses with CL/P were detected by CMA. In 338 singleton pregnancies, the diagnostic yield of CMA in the context of CL/P fetuses was determined to be 7.7% (26/338). CP cases exhibited a relatively higher prevalence of pathogenic/likely pathogenic CNVs at a rate of 25% (3/12), followed by CLP cases at 8.0% (23/288). Notably, the CL group did not demonstrate any pathogenic/likely pathogenic CNV findings among the examined cases (0/38). The diagnostic rate of clinically significant variants was notably higher in the non-isolated CL/P group than in the isolated CL/P group (11/33, 33.3% vs. 15/305, 4.9%, p < 0.001). Within the remaining 20 twin pregnancies, three clinically significant variants (15%) were observed.

CONCLUSIONS

This study provides powerful evidence supporting the efficacy of CMA as a valuable tool for facilitating the prenatal genetic diagnosis of fetal CL/P. The presence of CP and CLP in fetal cases demonstrated a relatively higher incidence of pathogenic/likely pathogenic CNVs. Moreover, when these cases were accompanied by additional ultrasound abnormalities, the likelihood of identifying diagnostic CNVs significantly increased. Conversely, cases of CL alone might not be associated with positive CNVs. The present data may significantly enhance prenatal diagnosis accuracy and facilitate informed genetic counseling for cases of fetal CL/P.

Causal effect of obesity and adiposity distribution on the risk of pressure ulcers and potential mediation by type 2 diabetes mellitus: insights from multivariable mendelian randomization and mediation analysis

Previous observational studies have identified a link between obesity, adiposity distribution, type 1 Diabetes Mellitus (T1DM), type 2 Diabetes Mellitus (T2DM), and the risk of pressure ulcers (PUs). However, the definitive causality between obesity and PUs, and potential DM mediators remains unclear. Univariable, multivariable, and mediation Mendelian randomization (MR) analyses were conducted to explore the mediating role of T1DM or T2DM in the association between obesity, adiposity distribution, and PUs. Instrumental variables for obesity and adiposity distribution, including Body Mass Index (BMI), waist circumference, hip circumference, trunk fat mass, whole body fat mass, trunk fat percentage, and body fat percentage, were selected from two genome-wide association studies (GWAS). In univariable MR analysis, BMI, hip circumference, and obesity were associated with PUs using inverse variance weighted (IVW) regression. These findings were further corroborated by the replication cohorts and meta-analysis (BMI: OR = 1.537, 95% CI = 1.294-1.824, p < 0.001; Hip circumference: OR = 1.369, 95% CI = 1.147-1.635, p < 0.001; Obesity: OR = 1.235, 95% CI = 1.067-1.431, p = 0.005), respectively. Even after adjusting for confounding factors such as T1DM and T2DM, BMI and hip circumference remained statistically significant in multivariable MR analyses. T2DM may mediate the pathogenesis of BMI-related (OR = 1.106, 95% CI = 1.054-1.160, p = 0.037) and obesity-related PUs (OR = 1.053, 95% CI = 1.034-1.973, p = 0.004). These findings provide insights for the prevention and treatment of PUs, particularly in patients with obesity or DM.

Direct Subscarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety and Efficacy in 200 Consecutive Patients

BACKGROUND

Abdominoplasty procedures continue to evolve because combining techniques such as suction-assisted lipectomy or direct subscarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, concern has been expressed about combining techniques simultaneously given the potential to damage the vascularity of the abdominoplasty flap.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of simultaneous direct subscarpal lipectomy combined with liposuction in abdominoplasty patients.

METHODS

A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, the lower rib margins superiorly, and the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap.

RESULTS

The patients had a mean age of 42.19 years and BMI of 28.10 kg/m2; the mean follow-up time was 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in 1 patient (0.5%), and partial umbilical epidermolysis in 6 patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation.

CONCLUSIONS

Simultaneous direct excision of subscarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The technique described is safe and may provide superior abdominoplasty results.

LEVEL OF EVIDENCE: 3

Autologous Fat Grafting-A Panacea for Scar Tissue Therapy?

Scars may represent more than a cosmetic concern for patients; they may impose functional limitations and are frequently associated with the sensation of itching or pain, thus impacting both psychological and physical well-being. From an aesthetic perspective, scars display variances in color, thickness, texture, contour, and their homogeneity, while the functional aspect encompasses considerations of functionality, pliability, and sensory perception. Scars located in critical anatomic areas have the potential to induce profound impairments, including contracture-related mobility restrictions, thereby significantly impacting daily functioning and the quality of life. Conventional approaches to scar management may suffice to a certain extent, yet there are cases where tailored interventions are warranted. Autologous fat grafting emerges as a promising therapeutic avenue in such instances. Fundamental mechanisms underlying scar formation include chronic inflammation, fibrogenesis and dysregulated wound healing, among other contributing factors. These mechanisms can potentially be alleviated through the application of adipose-derived stem cells, which represent the principal cellular component utilized in the process of lipofilling. Adipose-derived stem cells possess the capacity to secrete proangiogenic factors such as fibroblast growth factor, vascular endothelial growth factor and hepatocyte growth factor, as well as neurotrophic factors, such as brain-derived neurotrophic factors. Moreover, they exhibit multipotency, remodel the extracellular matrix, act in a paracrine manner, and exert immunomodulatory effects through cytokine secretion. These molecular processes contribute to neoangiogenesis, the alleviation of chronic inflammation, and the promotion of a conducive milieu for wound healing. Beyond the obvious benefit in restoring volume, the adipose-derived stem cells and their regenerative capacities facilitate a reduction in pain, pruritus, and fibrosis. This review elucidates the regenerative potential of autologous fat grafting and its beneficial and promising effects on both functional and aesthetic outcomes when applied to scar tissue.

The Essential Role of Angiogenesis in Adenosine 2A Receptor Deficiency-mediated Impairment of Wound Healing Involving c-Ski via the ERK/CREB Pathways

Adenosine receptor-mediated signaling, especially adenosine A2A receptor (A2AR) signaling, has been implicated in wound healing. However, the role of endothelial cells (ECs) in A2AR-mediated wound healing and the mechanism underlying this effect are still unclear. Here, we showed that the expression of A2AR substantially increased after wounding and was especially prominent in granulation tissue. The delaying effects of A2AR knockout (KO) on wound healing are due mainly to the effect of A2AR on endothelial cells, as shown with A2AR-KO and EC-A2AR-KO mice. Moreover, the expression of c-Ski, which is especially prominent in CD31-positive cells in granulation tissue, increased after wounding and was decreased by both EC-A2AR KO and A2AR KO. In human microvascular ECs (HMECs), A2AR activation induced EC proliferation, migration, tubule formation and c-Ski expression, whereas c-Ski depletion by RNAi abolished these effects. Mechanistically, A2AR activation promotes the expression of c-Ski through an ERK/CREB-dependent pathway. Thus, A2AR-mediated angiogenesis plays a critical role in wound healing, and c-Ski is involved mainly in the regulation of angiogenesis by A2AR via the ERK/CREB pathway. These findings identify A2AR as a therapeutic target in wound repair and other angiogenesis-dependent tissue repair processes.

Serial tissue expansion and excision for reconstruction of giant dorsal congenital melanocytic nevus: A case report

Giant congenital melanocytic nevus often necessitates meticulous planning and multiple treatment stages for complete surgical excision. This report presents a case of giant congenital melanocytic nevus on the back managed through serial tissue expansion and excision. Initially, two expanders were placed at the deep fascia level. Sequential outpatient expansions over 10 weeks were followed by expander removal, partial nevus excision, defect coverage with expanded skin flaps, and simultaneous placement of a new expander. The subsequent single expander expansion over 12 weeks involved a total of 600 mL of saline. After three operations spanning approximately 6 months, 54 cm × 36 cm of giant congenital melanocytic nevus skin, covering 65% of the patient's back, was completely excised. Serial tissue expansion and excision may be an effective surgical approach for managing dorsal giant congenital melanocytic nevus, reducing the need for multiple surgeries and achieving favorable aesthetic outcomes.

Perspectives in Using Multiple Flaps Reconstructions for Advanced Head and Neck Tumors (Scoping Review)

Background and Objectives: Patients with advanced head and neck tumors require salvage surgery as a last resort. These extensive surgeries pose the challenge of complex reconstructions. The head and neck surgeon undertaking such complex cases needs to master different flaps. The team managing these patients needs input from various specialists, along with otorhinolaryngologists, plastic surgeons, maxillofacial surgeons, vascular surgeons, experienced radiologists, dedicated pathologists, oncologists and radiation therapists. We focus on the optimum solution between oncologic resections and the future quality of life of patients and overall survival. Each complex case requires a personalized medicine approach. This scoping review aims to assess the efficacy and outcomes of complex reconstructions using various flaps for head and neck tumors, with a focus on free flaps and emerging techniques. Materials and Methods: A systematic search of the literature was conducted following PRISMA guidelines, resulting in the inclusion of 44 articles that met the predefined criteria in the last 10 years. Results: The included studies encompassed diverse patient populations and evaluated various surgical techniques, outcomes, complications, and advancements in head and neck reconstruction. The review identified a variety of flaps utilized in head and neck tumor reconstruction, including free flaps such as the radial forearm, anterolateral thigh, scapular tip, and myocutaneous flaps, among others. The success rates for free flap reconstructions ranged from 85% to 100%, with notable variations attributed to patient selection, tumor characteristics, and surgical expertise. Conclusions: Complications such as flap necrosis, infection, hematoma, and donor site morbidity were documented across studies, highlighting the importance of meticulous surgical planning and postoperative care. Furthermore, the review revealed emerging techniques such as computer-aided design, virtual surgery, stereolithographic models, customized implants, tissue engineering, and allotransplants, offering promising reconstructive armamentarium. Advances in surgical techniques and emerging technologies hold promise for further enhancing reconstructive outcomes, minimizing morbidity, and improving patient quality of life.

Effects on tissue oxygenation in the gluteal region with a smart pressure redistribution wheelchair cushion compared to a pressure relief manoeuvre

OBJECTIVE

The study examines the effects of the air-bladder offloading mode of a smart pressure redistribution wheelchair cushion on tissue oxygenation in the gluteal tissue of non-disabled participants. The hypothesis is that the cushion's offloading mode, which involves sequentially deflating its five air-bladders one at a time for a specific duration, would improve tissue oxygenation during sitting.

METHODS

Two procedures were conducted. The first compared the cushion's offloads to a loaded control (LC) with the cushion on static mode, and the second compared the cushion's offloading mode to a standard manual offload performed by the participant. Three trials of each procedure were performed in randomized order. Tissue oxygenation was continuously monitored with three oxygenation parameters analysed: oxygen saturation (SO2), oxygenated haemoglobin (OxyHb), and deoxygenated haemoglobin (DeoxyHb). Data recordings were segmented in each step of the offloading sequence for analysis. A paired t-test was performed for comparisons with significance considered at α = 0.05. Ten healthy adults participated in the study.

IMPACT

Results showed that as the air bladders deflated over time, the three evaluated parameters changed, affecting oxygenation even when other tissue areas were offloaded. The results indicated that the cushion's sacral offload had the greatest impact on improving tissue oxygenation among the five air-bladders in all ten subjects (p < 0.05). Furthermore, SO2 during the cushion's offload in the sacral region was similar to a manual offload. The study results suggest that the cushion could benefit tissue oxygenation, especially for individuals unable to change positions independently. Further research is needed to determine its effectiveness for wheelchair users.

Stepwise surgical management of binder syndrome with skeletal class III malocclusion in adults

Our study aimed to evaluate a stepwise treatment of class III malocclusion accompanied with flat nasal deformity, using orthodontics, orthognathic surgery, and rhinoplasty, as well as stability during long-term follow-up. In total, 27 patients with nasomaxillary hypoplasia and skeletal class III malocclusion were enrolled in this study. All patients had accepted orthodontic and orthognathic surgery, followed by rhinoplasty with costal cartilage as the second surgical procedure. Clinical results were evaluated by radiography, medical photography, questionnaire, and cephalometric analysis. All patients were satisfied with the surgical results and no serious complications occurred. During the follow-up, the patients showed well-corrected midface contour and nasal projection, and stable occlusion. The costal cartilage grafts were well fixed, without obvious absorption deformation. Lateral cephalometric analysis and overlay results showed that the postoperative point A had advanced approximately 5.20 ± 1.43 mm and the SNA angle had increased by approximately 5.59 ± 2.86°. Soft-tissue measurements showed a 14.22 ± 6.56° decrease in the facial lobe, while the nasolabial angle had increased by 16.83 ± 6.65° postoperatively. The results suggested that stepwise orthodontic-orthognathic surgery and rhinoplasty produce a predictable and stable result in long-term follow-up.

Cellular and Molecular Effects of Magnetic Fields

Recently, magnetic fields (MFs) have received major attention due to their potential therapeutic applications and biological effects. This review provides a comprehensive analysis of the cellular and molecular impacts of MFs, with a focus on both in vitro and in vivo studies. We investigate the mechanisms by which MFs influence cell behavior, including modifications in gene expression, protein synthesis, and cellular signaling pathways. The interaction of MFs with cellular components such as ion channels, membranes, and the cytoskeleton is analyzed, along with their effects on cellular processes like proliferation, differentiation, and apoptosis. Molecular insights are offered into how MFs modulate oxidative stress and inflammatory responses, which are pivotal in various pathological conditions. Furthermore, we explore the therapeutic potential of MFs in regenerative medicine, cancer treatment, and neurodegenerative diseases. By synthesizing current findings, this article aims to elucidate the complex bioeffects of MFs, thereby facilitating their optimized application in medical and biotechnological fields.

The effect of increasing motor end-plate innervation on smile activation in acute and early facial palsy

While it has been over half a century since primary cross-facial nerve grafting was first described for facial reanimation, the outcome of this procedure, remains inconsistent and provide lesser smile excursion when compared to the likes of the masseteric nerve. However, the latter itself has limitations in terms of the lack of spontaneity and resting tone. While combinations have been attempted more proximally, we ask the question as to whether more distal nerve transfers with vascularized nerve grafts are a better option. In a retrospective review of clinical practice at our institute, 16 consecutive patients had single, double, and finally triple distal nerve transfers, close to the target facial muscle to reinnervate the motor endplates directly, over a 6-year period (2018-23). All patients had the onset of facial palsy within 18 months. Statistical analysis of the comparison between three sub-cohorts was performed using student's t-test and one-way ANOVA, respectively. Qualitatively, masseteric neurotization of a single facial nerve branch translated into smile improvement in 50% of cases, as opposed to all cases of double- and triple-neurotization of the smile muscles. In terms of upper lip elevation, single neurotization showed improvement in 25% of cases, double-neurotization in 40% of cases and triple-neurotization in 100% of cases. Upper lip elevation was also significantly better in those who had a vascularized cross-facial nerve graft (Student's t-test <0.05). In summary, increasing neural input to the motor endplates of smile muscles can significantly improve smile activation, in acute flaccid facial palsies.

Clinical comparison study of square flap method and five-flap Z-plasty technique for correction of post-burn axillary contractures: Analysis of length gain and evaluation of functional outcome

INTRODUCTION

While there is no consensus on the best surgical procedure for post-burn axillary contractures, it is crucial to consider the elongation rate along the scar axis as a useful measurement index for determining the optimal surgical approach. The square flap and five flap z-plasty techniques are commonly employed scar lengthening procedures to address scar contractures in the axilla. These approaches successfully disrupt the linear scar, leading to significant elongation while reducing transverse tension. Our study aims to compare the increase in band length and functional results of these two approaches for treating post-burn contractures in the axilla.

METHODS

A retrospective study was carried out utilizing data from 34 patients with mild-to-moderate band-like contractures located on the anterior or posterior axillary lines who underwent surgical correction through either the square flap method or five-flap z-plasty technique. The effectiveness of surgical methods was evaluated using two objective indices: improvement in contracture band length and improvement in abduction angle at the shoulder joint.

RESULTS

All patients achieved complete contracture release. There is no statistically significant difference between the two groups regarding the improvement in the degree of abduction postoperatively. Although there was a significant increase in the length of the contracture band postoperatively in both groups, the average increase in length for cases treated with a square flap was significantly greater than those managed with a five-flap Z-plasty (87.7 ± 44.8 % vs. 38.80 ± 11.119 %,) respectively.

CONCLUSION

The square flap technique is considered a better alternative to the commonly used 5-flap Z-plasty method because it can achieve higher elongation in the contracture band, restore joint function, and create optimal shape when dealing with single linear band contractures over the axilla.

Surgical management of extensive facial vascular malformation with skin graft: A multidisciplinary approach-Case report

Vascular malformations are rare congenital abnormalities of blood vessels that persist throughout life. Large vascular malformations affecting the facial region can be distressing and require meticulous management to achieve satisfactory outcomes and prevent recurrence. Here, we present a case of a 40-year-old man with a progressively growing tumor-like mass on the right side of his face, extending from the periorbital region to the chin. He was diagnosed with vascular malformations, which was further confirmed with contrast-enhanced magnetic resonance imaging. Eventually, he underwent surgical excision of the lesion with a split-thickness skin graft. The surgical management of this case was challenging due to the large size and complexity of the lesion, particularly because it was located in the facial region. This unique case report highlights the importance of diagnostic imaging techniques and effective surgical management in addressing large vascular malformations, especially those affecting the facial region while prioritizing desirable cosmetic outcomes.

Prenatal Diagnosis of Cleft Lip and Palate: A Retrospective Study

Cleft lip and/or palate are prevalent congenital anomalies. Early and accurate diagnosis allows proper case management. The Objective: This retrospective cohort study aimed to investigate the association between cleft lip and palate and other congenital anomalies. Methods: This study analyzed 17 pregnancies prenatally diagnosed with cleft lip and palate. The investigations consisted of ultrasound examination, fetal karyotyping through amniocentesis, and family tree analysis. In the presence of an abnormal fetal karyotype, the parental karyotype was also indicated. Results: Of the 17 cases identified, 9 (52.94%) were syndromic and 8 (47.06%) were non-syndromic. The genetic syndromes identified in association with cleft lip and palate in this study included translocation syndrome (one case), Patau syndrome, trisomy 13 (seven cases), and Edwards syndrome, mosaic trisomy 18 (one case). Conclusions: A comprehensive approach ensures a thorough assessment and accurate diagnosis. Early detection and a multidisciplinary approach allow appropriate case management.

Reprogramming macrophages with R848-loaded artificial protocells to modulate skin and skeletal wound healing

After tissue injury, inflammatory cells are rapidly recruited to the wound where they clear microbes and other debris, and coordinate the behaviour of other cell lineages at the repair site in both positive and negative ways. In this study, we take advantage of the translucency and genetic tractability of zebrafish to evaluate the feasibility of reprogramming innate immune cells in vivo with cargo-loaded protocells and investigate how this alters the inflammatory response in the context of skin and skeletal repair. Using live imaging, we show that protocells loaded with R848 cargo (which targets TLR7 and TLR8 signalling), are engulfed by macrophages resulting in their switching to a pro-inflammatory phenotype and altering their regulation of angiogenesis, collagen deposition and re-epithelialization during skin wound healing, as well as dampening osteoblast and osteoclast recruitment and bone mineralization during fracture repair. For infected skin wounds, R848-reprogrammed macrophages exhibited enhanced bactericidal activities leading to improved healing. We replicated our zebrafish studies in cultured human macrophages, and showed that R848-loaded protocells similarly reprogramme human cells, indicating how this strategy might be used to modulate wound inflammation in the clinic.

[Clinical application of perforator-based propeller flaps in repair of hand wound]

Objective

To investigate the effectiveness of the perforator-based propeller flaps (PPFs) based on digital artery (DA) and dorsal metacarpal artery (DMA) in repairing hand wounds.

Methods

The clinical data of 45 patients with hand wounds between January 2018 and March 2023 were retrospectively analyzed. There were 27 males and 18 females with an average age of 41.2 years (range, 14-72 years). The causes of injury included twist injury in 15 cases, crush injury in 19 cases, and cut injury in 11 cases. The injured parts included 32 cases of digits, 10 cases of dorsal hand, and 3 cases of palmar hand, all of which had tendon, joint, and bone exposure. The time from injury to operation ranged from 2 to 8 hours (mean, 4.3 hours). The wound sizes after debridement ranged from 1.8 cm×1.0 cm to 5.0 cm×3.5 cm. Twenty-eight cases were repaired by the PPFs based on DA and 17 cases were repaired by the PPFs based on DMA. The flap size ranged from 2.5 cm×1.1 cm to 8.5 cm×4.0 cm. The defects of the donor sites in 14 patients were closed directly and the defects in the left 31 patients were resurfaced with free full-thickness skin graft from the proximal medial forearm.

Results

All the flaps survived after operation. Two cases of the PPF based on DA and 1 case of the PPF based on DMA underwent partially blisters at the distal end and healed after dressing change. The incisions in the donor site healed by first intention and the skin grafts survived. All patients were followed up 10-33 months, with a mean of 15.4 months. At last follow-up, the static two-point discrimination of the PPFs based on DA and DMA were 4-14 mm and 8-20 mm with the averages of 8.1 mm and 13.3 mm, respectively. According to the Michigan Hand Outcomes Questionnaire, 20 patients were very satisfied with the appearance of the PPF based on DA and 8 patients were satisfied; 8 patients were very satisfied with the appearance of the PPF based on DMA and 9 patients were satisfied. Based on the Vancouver Scar Scale (VSS), the appearance scores of the donor site of the PPFs based on DA and DMA were 2-7 and 4-9, with the averages of 4.2 and 6.1, respectively.

Conclusion

The two kinds of PPFs are reliable in blood supply and easy to harvest, which provide a good method for emergency repair of small and medium area wounds in the hand.

The genetic characterization of germplasm and identification of the litter size trait associated candidate genes in Dexin mutton and fine-wool sheep

Xinjiang is a major province of sheep breeding in China, which plays an important role in meeting people's needs for meat products, increasing farmers' income and sustainable development of animal husbandry. However, the genetic differentiation relationship between breeds was not clear, and most sheep had low fecundity, which seriously restricted the efficient development of sheep industry. Therefore, this study used the whole genome resequencing to detect the genetic variation of Dexin mutton and fine-wool sheep, explored the selected regions and important genes of the litter size traits, analyzed the genetic mechanism of reproductive traits, and provided new insights for the high fecundity breeding of sheep. A total of 5,236.338 G genome data and 35,884,037 SNPs were obtained. Furthermore, we identified 39 selection signals spanning candidate genes, 99 genes were significantly associated related to growth, reproduction and immunity, among which, BRIP1, BMPR1B, BMP4, NGF, etc. genes, and MAKP signaling pathway, Fanconi anemia pathway and Thyroid hormone signaling pathway and other signaling pathways were significantly correlated with litter size trait. Among them, we identified NGF, TrKA and BRIP1 genes was the important genes for sheep litter size traits and the mutation frequencies of 9 SNPs in BRIP1 gene were significantly different in domestic sheep in the world. The research provided new insights for the breeding of self-cultivated meat fine-wool sheep.

Management of Serious Adverse Events Following Deoxycholic Acid Injection for Submental and Jowl Fat Reduction: A Systematic Review and Management Recommendations

Pivotal Phase 3 randomized control trials have demonstrated a favorable safety profile for ATX-101 in submental fat (SMF) reduction; however, in real-world settings, several serious adverse events (SAEs) have been reported, most of which are procedure related and avoidable. Current understanding of the management of uncommon AEs and SAEs is based on the aesthetic surgeon's discretion, and overzealous protocols for sclerosis agents are being applied for ATX-101-induced arterial injury. This review focuses on showcasing the management of SAEs reported previously and updating it with personal clinical experiences with ATX-101 for SMF and jowl fat reduction. Along with adherence to the standard procedures for ATX-101 administration, the authors recommend investigating other potential causes of SMF accumulation and jowling mechanism, appropriate demarcation of the surface area to determine the number of vials, and assessment of the fat pad thickness to determine the number of required treatment cycles for optimal therapeutic outcomes. Surgery is preferable for jowling caused by compartment displacement (ptosis), whereas fat-reducing treatments such as ATX-101 are contraindicated for jowling caused by subcutaneous tissue atrophy. Some proactive measures that can be employed to prevent AEs include avoiding intradermal injections to prevent skin ulceration/necrosis, injecting lidocaine to check for smile asymmetry as an indication of marginal mandibular nerve proximity, administering 1 to 2 mm deeper injections in males to prevent alopecia, employing good aseptic techniques to prevent abscess formation, injecting 1 product at a time using correctly labeled syringes, and confirming the diagnosis of pyoderma gangrenosum before treating it as an infection.

Level of Evidence 3

Coverage of lateral soft tissue defects with sartorius muscle flap after distal femoral replacement for malignant bone tumors

INTRODUCTION

To prevent infection after limb-sparing surgery for primary malignant bone tumors, it is important to cover the megaprosthesis with muscle tissue that has sufficient blood flow. Coverage with a lateral gastrocnemius flap has been reported in cases of distal femoral replacement in which the vastus lateralis and vastus intermedius muscles have been resected; however, the risk of peroneal nerve palsy is reportedly high because the muscle flap passes near the peroneal head. This study was performed to examine the postoperative outcomes of patients with primary malignant bone tumors of the distal femur who underwent wide resection (including the vastus lateralis and vastus intermedius muscles) followed by reconstruction with a megaprosthesis and coverage of the lateral side of the prosthesis with a sartorius muscle flap.

METHODS

We retrospectively analyzed three patients who underwent reconstruction with a megaprosthesis after wide resection of a primary malignant bone tumor of the distal femur involving the vastus lateralis and vastus intermedius muscles and reconstruction of the soft tissue defect on the lateral side of the prosthesis with a sartorius muscle flap.

RESULTS

The average defect size was 6 × 13 cm, the average time required for a sartorius muscle flap was 100 min, and the average implant coverage was 93%. The average postoperative follow-up period was 35 months, during which no postoperative complications such as infection, skin necrosis, or nerve palsy occurred.

DISCUSSION

The distally based sartorius muscle flap is easy to elevate in the supine position, has minimal functional loss after harvesting, and has minimal risk of nerve palsy. It can be advocated as the first option for coverage of soft tissue defects lateral to distal femoral replacement.

Perceptions, expectations, and recommendations of trans adults on gender-affirming care in France: a qualitative study

Trans people have diverse life experiences which may include gender-affirming care (GAC). GAC positively impacts the quality of life of trans adults. However, they are often met with barriers to care and are particularly vulnerable within the healthcare system. The needs and expectations surrounding GAC may vary between individual patients. This article aims to analyze trans adults' perceptions, expectations, and recommendations on GAC. Twenty-seven semi-structured interviews were conducted by a team of academic and peer researchers; transcribed interviews were then analyzed using a codebook and thematic analysis. Three main themes were identified; the liberating experience of GAC; the uneven distribution of knowledge and power between patients and providers; and the recommended practices in GAC. Additional training and research are necessary to facilitate high-quality care for trans adults accessing GAC.

Exploring the role of dermal sheath cells in wound healing and fibrosis

Wound healing is a complex, dynamic process involving the coordinated interaction of diverse cell types, growth factors, cytokines, and extracellular matrix components. Despite emerging evidence highlighting their importance, dermal sheath cells remain a largely overlooked aspect of wound healing research. This review explores the multifunctional roles of dermal sheath cells in various phases of wound healing, including modulating inflammation, aiding in proliferation, and contributing to extracellular matrix remodelling. Special attention is devoted to the paracrine effects of dermal sheath cells and their role in fibrosis, highlighting their potential in improving healing outcomes, especially in differentiating between hairy and non-hairy skin sites. By drawing connections between dermal sheath cells activity and wound healing outcomes, this work proposes new insights into the mechanisms of tissue regeneration and repair, marking a step forward in our understanding of wound healing processes.

Comparison of combination skin substitutes and skin grafts versus skin grafts only for treating wounds measured by Vancouver Scar Scale: A comprehensive meta-analysis

Background

Skin is the largest organ in the body and has multiple significant functions. A malformation or injury that compromises its integrity can lead to major issues or even mortality. Wound healing is a vital physiological process of the human skin which facilitates the repair of any damage and the preservation of homeostasis. Possible complications or infections that are fatal may ensue if the patient does not recover within the specified time. Therefore, it is essential to develop biomaterials which facilitate tissue regeneration and exhibit robust biological properties. We conducted a meta-analysis of randomized controlled trials to compare combinations of skin replacements and skin grafts to skin grafts alone for wound treatment, as measured by the Vancouver Scar Scale.

Methods

This meta-analysis utilized various databases, including as PubMed, ProQuest, Web of Science, Science Direct, Scopus, EBSCOhost, and ClinicalTrials.gov, to conduct a comprehensive search for randomized controlled trials that compared the effectiveness of combined skin substitutes and skin grafts to skin grafts alone in the treatment of wounds. The results primarily consisted of scar features assessed using the Vancouver Scar Scale.

Results

Meta-analysis was conducted on a sample of 216 participants from 7 randomized controlled trials. The trials were conducted from 2002 to 2015. The study demonstrated that the use of skin substitutes resulted in a statistically significant improvement in Vancouver Scar Scales ratings compared to skin grafts alone. The mean change was 1.38 (95% CI: 0.13-2.63; p = 0.03).

Conclusion

This meta-analysis indicates that the use of skin replacements provides substantial advantages and effectively aids in the closure of wounds. There is no inherent superiority among different skin substitutes. Instead, their suitability for specific patient wound circumstances is the determining factor. A comprehensive and advantageous skin substitute of significant magnitude is needed, rather than relying solely on grafts.

Water-powered, electronics-free dressings that electrically stimulate wounds for rapid wound closure

Chronic wounds affect ~2% of the U.S. population and increase risks of amputation and mortality. Unfortunately, treatments for such wounds are often expensive, complex, and only moderately effective. Electrotherapy represents a cost-effective treatment; however, its reliance on bulky equipment limits its clinical use. Here, we introduce water-powered, electronics-free dressings (WPEDs) that offer a unique solution to this issue. The WPED performs even under harsh conditions-situations wherein many present treatments fail. It uses a flexible, biocompatible magnesium-silver/silver chloride battery and a pair of stimulation electrodes; upon the addition of water, the battery creates a radial electric field. Experiments in diabetic mice confirm the WPED's ability to accelerate wound closure and promote healing by increasing epidermal thickness, modulating inflammation, and promoting angiogenesis. Across preclinical wound models, the WPED-treated group heals faster than the control with wound closure rates comparable to treatments requiring expensive biologics and/or complex electronics. The results demonstrate the WPED's potential as an effective and more practical wound treatment dressing.

A 360° Approach to Patient Care in Aesthetic Facial Rejuvenation

Background

Aesthetic medicine has traditionally focused on addressing perceived problem areas, with lack of long-term planning and engagement.

Objectives

This article describes a patient-centric model for nonsurgical aesthetic medical practice, termed the 360° approach to facial aesthetic rejuvenation.

Methods

The 360° approach was divided into 4 foundational pillars. Medical literature, the authors' clinical experiences, and results from patient satisfaction surveys were used to support the approach.

Results

Pillar 1 describes the development of a complete understanding of the patient, based on the use of active listening principles, to characterize the patient's current aesthetic concerns, lifestyle, medical and treatment history, treatment goals, attitude toward aesthetic treatment, and financial resources. Pillar 2 involves conducting a comprehensive facial assessment in contrast to a feature-specific assessment, considering multiple facial tissues and structures and their interrelationships, thus helping to prevent the unanticipated consequences of narrowly focused treatment. Pillar 3 describes leveraging all available treatments and techniques in the development of an initial treatment plan arising from the facial assessment. Pillar 4 adds a time dimension to treatment planning, working toward the goal of a long-term modifiable treatment timeline, with full patient support and involvement; this is designed to facilitate a durable, sustained relationship between the patient and aesthetic healthcare professional (HCP).

Conclusions

Although implementation involves substantial commitment and time, the patient-oriented focus of the 360° approach can help achieve optimal patient outcomes and the development of enduring patient-HCP relationships.

Level of Evidence 5

Prevalence and Trend of Depression in Burn Survivors: A Single Center Cohort Study

Burn injuries are frequently disastrous catastrophes that can cause significant skin damage and frequently result in hypertrophic scarring. Recovery from burn injury includes 3 domains-medical, functional, and psychiatric. Psychological concerns affect both the quality of life and the disease recovery. This study assesses the prevalence of major depression or clinically significant symptoms of depression among patients hospitalized for acute burn injury, as well as their persistence once diagnosed. It is a prospective cohort that was studied in 1%-40% of patients with body surface area burn, where the Beck Depression Inventory was used as a depressive symptom measure. A total of 108 patients were included in the study, out of which 42 (38.8%) exhibited depressive symptoms. Type of burn did not affect the prevalence of depression, whereas total body surface area had an impact on prevalence rate. The Beck Depression Inventory score assessment during the study revealed that 8.4% of participants exhibited worsening of scores during the study period and only 3.4% showed improvement throughout the study. Patients with mild depressive symptoms at admission were likely to recover, whereas those with severe depressive symptoms were less likely to recover from the psychological state. To conclude, depression was more prevalent among burn survivors from the Indian community.