Long-Term Satisfaction with Breast Augmentation and Augmentation Mastopexy in the Latin American Population

OBJECTIVE

The primary objective of this study was to determine the long-term satisfaction levels of women who have undergone breast augmentation and augmentation mastopexy procedures, while identifying the factors influencing patient satisfaction.

METHODS

A self-reported retrospective case study design was used to collect data from women with breast implants. The study employed a survey that included demographic information, preoperative diagnosis, implant details, and patient-reported outcomes measured using the Breast-Q Instrument, which evaluates satisfaction with breasts, self-esteem, sexual well-being, and physical symptoms. Statistical analyses were conducted to identify correlations and differences in outcomes between the different variables.

RESULTS

The survey was completed by 1022 women from 19 countries, with Chile, Mexico, and Colombia being the most represented. Augmentation was performed on 72.2% of the patients, while 27.7% underwent augmentation mastopexy. Patient satisfaction with breast size and shape varied significantly between the two procedures, with patients undergoing augmentation mastopexy showing less satisfaction. In addition, patients who were unaware of their implant shape or placement reported lower satisfaction scores. The study also found that patient satisfaction decreased over time in the augmentation mastopexy cases and that patients with high body mass index had lower satisfaction.

CONCLUSION

Augmentation mastopexy in patients with breast ptosis yields lower satisfaction than augmentation alone. Dissatisfaction escalates with overweight/obesity (BMI), post-surgery time, and misinformation. Implant pocket (pre-vs. subpectoral), shape (round vs. anatomical), and size did not impact satisfaction.

LEVEL OF EVIDENCE III

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 .

What Makes a Beautiful Buttock Beautiful? A Case-Control Study Comparing Buttocks Models versus Normal Women by Magnetic Resonance Imaging, Photography and Anthropometry

OBJECTIVES

To describe characteristics of women with aesthetically ideal buttocks and differentiate them from women with normal buttocks.

METHODS

Case-control study comparing anatomy of women with ideal buttocks (buttocks models) to women with normal buttocks using magnetic resonance images, anthropometric measurements and photography.

RESULTS

Comparing to normal women, buttocks models have a narrower waist, narrower iliac crest, wider C point, wider hips and bigger and thicker gluteus maximus muscle (GMM). A bigger GMM adds more projection to the C point, point of maximum projection in the lateral view is 2.7 cm higher than the pubic bone. The amount of subcutaneous fat was equal in models and controls.

CONCLUSIONS

Our study provides new knowledge regarding the tridimensional aspects of the beauty of the buttocks area. A beautiful buttock is a conjunction of adequate bony shape, muscle development, subcutaneous fat layer, and tight skin. Comparing to normal women, buttocks models have a narrower waist, narrower iliac crest, wider C point, wider hips and bigger and thicker Gluteus Maximus Muscle. Accurate understanding of the aesthetic goals in a given patient can guide surgical technique.

LEVEL OF EVIDENCE III

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 .

Aesthetic Ideals of the Female Buttocks: Concepts and Techniques

This article explores the importance of understanding the tridimensional artistic anatomy of the back, pelvis, and thighs in gluteal surgery. It emphasizes the need for plastic surgeons to have a comprehensive knowledge of these anatomic structures to achieve successful outcomes. The authors highlight the significance of ethnic differences in determining ideal aesthetic results and stress the importance of considering and respecting these variations. Individualization of treatment is a key principle in gluteal surgery, as each patient has unique preferences and needs. Effective communication and collaboration between the surgeon and the patient are crucial in determining desired aesthetic goals and achieving satisfactory outcomes.

[Proposal of an informed consent form to obtain audiovisual material from patients]

BACKGROUND

An informed consent is mandatory to obtain any clinical audiovisual material from patients. Although there are some documents created for this purpose, there are some barriers for their application, such as the context in which they were created, the language and download availability.

AIM

To create a proposal for an informed consent form (ICF) for the capture and different uses for audiovisual material from patients.

MATERIAL AND METHODS

A bibliographic search was carried out to obtain different ICFs in Spanish and English, which were subjected to a process of translation, counter-translation and fragmentation. Subsequently, a panel of experts was formed by members of the Chilean Society of Plastic Surgery with extensive experience in social networks. Delphi methodology was applied to reach a consensus about the definitive content of the ICF based on the previously selected fragments.

RESULTS

ICFs available for download were identified. The panel was made up of seven Plastic Surgeons and two Delphi rounds were carried out through electronic surveys. At the end of the process, an ICF proposal was obtained for therapeutic, academic or scientific purposes and another for dissemination or education in the mass media.

CONCLUSIONS

The proposed ICFs were liberated for their use among health care professionals in Chile, who could use them, provided that they are approved by the local healthcare ethics committees.

Intraoperative Ketamine and Magnesium Therapy to Control Postoperative Pain After Abdominoplasty and/or Liposuction: A Clinical Randomized Trial

Purpose

This study aimed to compare the effects of ketamine and ketamine associated with magnesium on opioid consumption and pain scores in patients undergoing abdominoplasty and/or liposuction compared to standard treatment.

Patients and Methods

A total of 63 patients were included and randomized as follows: 21 patients in the Control group, 20 patients in the Ketamine group (Ket), and 22 patients in the Ketamine-magnesium group (KetMag). The KetMag group received an IV bolus of 0.3 mg/kg of ketamine and 50 mg/kg magnesium, followed by continuous infusion of ketamine (0.15 mg/kg/h) and magnesium (10 mg/kg/h) until extubation. The Ket group received the same bolus and infusion of ketamine, together with a bolus and continuous infusion of placebo instead of magnesium. The Control group received saline instead of ketamine and magnesium. The groups were compared in morphine consumption during the first 12h, body-postoperative pain and disability scale until the 90th day, the time until the first morphine request on the PCA pump, pain scores, and the adverse effects related to the use of study drugs.

Results

The KetMag group had a lower morphine consumption by almost 50% during the first 12h than the Control and the Ket groups. In addition, the KetMag group required the first dose of morphine later than the other two groups. There were no differences in the adverse effects of the proposed treatments. Finally, multiple linear regression and a nonlinear approach analysis indicated that the Control group experienced a higher degree of pain and increased morphine consumption per hour than Ket and KetMag groups.

Conclusion

Co-administration of intraoperative ketamine plus magnesium and ketamine alone are an effective and easy regime for reducing pain and opioid consumption in the postoperative period.

[Acute compartment syndrome as a complication of cutaneous loxoscelism mainly edematous]

Acute compartment syndrome (ACS) is the increase of pressure in a closed osteofascial space. This reduces capillary perfusion below the level necessary for tissue viability. Injury could be irreversible if proper treatment is not performed. Hand ACS secondary to cutaneous loxoscelism with edematous predominance is extremely infrequent. We present a clinical case of a 22-year-old patient who started a hand compartment syndrome secondary to cutaneous loxoscelism (CL), requiring emergency surgical treatment with dorsal and palmar fasciotomy.

Ultra HD Liposuction: Enhancing Abdominal Etching Using Ultrasound-Guided Rectus Abdominis Fat Transfer (UGRAFT)

High-definition (HD) liposuction has allowed surgeons to sculpt the abdomen, enhancing abdominal etching. To create a more athletic abdomen, fat grafting has been used subcutaneously, and rectus abdominis fat grafting has been performed in patients undergoing lipoabdominoplasty. With the objective of increasing muscle volume to obtain a natural-looking abdomen in patients who are not suitable for abdominoplasty, we propose the use of ultrasound-guided rectus abdominis fat grafting (UGRAFT) in association with HD liposuction.

PATIENTS

A prospective study with 10 consecutive patients undergoing UGRAFT was conducted. After HD liposuction, UGRAFT was performed from an incision in the umbilical region, using a blunt 2.5-mm cannula assisted by ultrasound. Fat injection was done closer to the anterior rectus sheath in the lower and middle muscle bellies.

RESULTS

UGRAFT was performed in 10 patients. The mean age was 34.8 years (range, 24-51 years). The mean body mass index was 23.83 kg/m2 (range, 20.58-28.39 kg/m2). The mean volume of fat injected per "pack" was 34 cm3 (range, 20-40 cm3). UGRAFT added a mean time of 20 minutes (range, 15-30 minutes) to HD liposuction. Comparing the rectus abdominis muscle thickness pre-UGRAFT and post-UGRAFT, average muscle thickness increase was 5.1 mm (55.7% ± 37%), with P < 0.0001.

CONCLUSION

UGRAFT showed to be helpful for obtaining muscle expansion and a more natural abdominal contour, avoiding that unnatural appearance that HD liposuction may provide in patients who gain weight or have skin laxity.

High-Definition Liposculpture: What are the Complications and How to Manage Them?

BACKGROUND

High-definition liposculpture is a novel surgical technique widely accepted among plastic surgeons. The aim of this article is to describe surgical outcomes with a special emphasis on complications in high-definition liposculpture patients.

METHODS

An historical cohort of patients who underwent high-definition liposculpture from two senior surgeons was reviewed. Technique, patient selection criteria, preoperative marks and surgical outcomes are described. Postoperative complications are discussed.

RESULTS

A total of 417 patients underwent high-definition liposculpture between 2015 and 2018. Primary liposuction and secondary liposuction were performed in 308 (74%) and 109 (26%), respectively. Combined surgeries were performed in 121 cases (29%). There were no systemic complications. Local complications included hyperpigmentation (n = 276), seroma (n = 125), nodular fibrosis (n = 83), unsatisfactory definition in superficial liposuction areas (n = 16), unnatural appearance of body contour (n = 17), VASER-related burns (n = 3) and Mondor's syndrome (n = 2). Most patients (94%) were satisfied with the results.

CONCLUSION

High-definition liposculpture is a body contouring technique that has shown excellent results. Despite non-serious complications were frequent, most complications were local and safely treated without affecting surgical outcome. To know these complications will help to recognize them earlier and to adjust patient expectation about the postoperative period.

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.

INTRODUCTION OF THE NEW LYMPHOPARIETAL INDEX FOR GASTRIC CANCER PATIENTS

Background:

The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients.

Aim:

Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent.

Method:

Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries.

Results:

A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96).

Conclusion:

The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.

Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes

Chest wall shape is an important aspect to consider when planning a breast augmentation. Minor chest wall deformities are usually underestimated by the patient and surgeon and may compromise postoperative outcomes. Lower costal cartilage dysmorphia or winged rib is one of these minor underestimated chest wall deformities characterized by a visible and palpable cartilaginous prominence under the inframammary fold and causes discomfort in patients decreasing the satisfaction with the breast augmentation surgery. For these patients, the author utilized an innovative surgical technique that allows resection of the protruding cartilages and placement of breast implants through the same surgical incision. Six patients with winged ribs underwent breast augmentation and costal cartilage resection via this method and there were no intraoperative or early postoperative complications, and all patients were satisfied with the aesthetical result after 6 months of follow-up. The presented surgical technique has a short learning curve with excellent postoperative results. Cases are presented to demonstrate the improved postoperative chest wall contour combined with breast augmentation outcome.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 .

Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort

BACKGROUND

Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL.

OBJECTIVES

The authors evaluated the effect of BCS on QoL and the durability of this effect over time.

METHODS

QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instrument's main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts.

RESULTS

Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort.

CONCLUSIONS

QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts.

LEVEL OF EVIDENCE 4

Effects of Abdominoplasty on Intra-Abdominal Pressure and Pulmonary Function

BACKGROUND

Abdominal wall weakness is a consequence of rectus abdominis diastasis and flaccidity of the myofascial component. A degree of plicature of the rectus abdominis generates an increase of intra-abdominal pressure (IAP), which may result in an increase of intrathoracic pressure, thus affecting thoracic hemodynamics and leading to inadequate ventilation.

OBJECTIVES

To assess changes generated by plicature of the rectus abdominis on IAP and pulmonary function in patients undergoing abdominoplasty.

METHODS

A total of 10 female patients with abdominal ptosis were included. Chronic smokers and patients with respiratory co-morbidities were excluded. The IAP was measured using a modified Kron's trans-bladder technique. Pulmonary function was assessed by pulmonary compliance (P-Comp) and was calculated with parameters provided by the mechanical ventilator. Both were calculated before and after plicature.

RESULTS

The mean values for IAP before and after plicature were 6.6 and 9.3 mmHg respectively. Before plicature, the mean P-Comp value was 38.97 mL/cm of water, and after it was 36.54 mL/cm. Both differences were statistically significant.

CONCLUSIONS

Based on the results obtained, it is possible to conclude that plicature of the rectus abdominis generates significant physiological changes, such as an increase in IAP and a decrease of P-Comp, which do not have a clinically relevant impact on healthy individuals. Measuring IAP with the modified technique and the assessment of pulmonary function using P-Comp are both reliable and provide a more accurate correlation with such physiologic changes. LEVEL OF EVIDENCE 3: Therapeutic.

The accuracy of different methods for diagnosing septal deviation in patients undergoing septorhinoplasty: A prospective study

OBJECTIVE

This study aimed to determine the diagnostic accuracy of different diagnostic tests in predicting nasal septum deformities during preoperative planning for septorhinoplasty.

METHODS

Consecutive patients who underwent septorhinoplasty between June 2011 and August 2012 were included (n = 30) and underwent a protocol of diagnostic tests, including nasal speculoscopy, craniofacial computed tomography (CT), three-dimensional (3D) reconstruction of the nasal septum by CT and nasal endoscopy. A modified Guyuron classification of septal deformities was used for classifying the septal deviations. Direct surgical assessment of the nasal septum during open septorhinoplasty was the reference standard with which each of the diagnostic tests was compared. Sensitivity, specificity and predictive values of each test were calculated.

RESULTS

The preoperative diagnosis was nasal bone fracture in 11 patients, nasal septal fracture in 15 and post-traumatic nasal deformity in four. For type A deviations (localised), craniofacial CT showed the highest performance with a sensitivity of 100%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 99%. For type B septal deformations (C shape), nasal endoscopy (sensitivity, 100%; specificity, 87.5%; PPV, 87.7%; and NPV, 100%) showed the highest performance. For type C deformities (S shape), nasal endoscopy (sensitivity, 70%; specificity, 100%; PPV, 100%; and NPV, 87%) showed the highest performance. The accuracy for nasal endoscopy was 27/30 (90%), 26/30 (87%) for craniofacial CT, 22/30 (73%) for 3D reconstruction and 10/28 (36%) for speculoscopy.

CONCLUSIONS

Nasal endoscopy and craniofacial CT were more accurate and precise than nasal speculoscopy and 3D reconstruction for preoperative evaluation of the nasal septum, thus enabling more appropriate surgical planning for septorhinoplasty.

Introducing the Body-QoL®: A New Patient-Reported Outcome Instrument for Measuring Body Satisfaction-Related Quality of Life in Aesthetic and Post-bariatric Body Contouring Patients

OBJECTIVE

To develop a new patient-reported outcome instrument (PRO) to measure body-related satisfaction quality of life (QoL).

METHODS

Standard 3-phase PRO design was followed; in the first phase, a qualitative design was used in 45 patients to develop a conceptual framework and to create preliminary scale domains and items. In phase 2, large-scale population testing on 1340 subjects was performed to reduce items and domains. In phase 3, final testing of the developed instrument on 34 patients was performed. Statistics used include Factor, RASCH, and multivariate regression analysis. Psychometric properties measured were internal reliability, item-rest, item-test, and test-retest correlations.

RESULTS

The PRO-developed instrument is composed of four domains (satisfaction with the abdomen, sex life, self-esteem and social life, and physical symptoms) and 20 items in total. The score can range from 20 (worst) to 100 (best). Responsiveness was 100 %, internal reliability 93.3 %, and test-retest concordance 97.7 %. Body image-related QoL was superior in men than women (p < 0.001) and decreased with increasing age (p = 0.004) and BMI (p < 0.001). Post-bariatric body contouring patients score lower than cosmetic patients in all domains of the Body-QoL instrument (p < 0.001). After surgery, the score improves by on average 21.9 ± 16.9 (effect size 1.8, p < 0.001).

CONCLUSIONS

Body satisfaction-related QoL can be measured reliably with the Body-QoL instrument. It can be used to quantify the improvement in cosmetic and post-bariatric patients including non- or minimally invasive procedures, suction assisted lipectomy, abdominoplasty, lipoabdominoplasty, and lower body lift and to give an evidence-based approach to standard practice.

LEVEL OF EVIDENCE I

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.

Intravenous lidocaine for the treatment of background or procedural burn pain

BACKGROUND

This is an update of the review on "Lidocaine for pain relief in burn injured patients" first published in Issue 3, 2007, and first updated in 2012. Pain is a major issue for people with many different types of wounds, in particular those people with burn injuries. Prompt, aggressive use of opioid analgesics such as morphine has been suggested as critical to avert the cycle of pain and anxiety, but adverse effects are encountered. It has been proposed that newer agents such as lidocaine could be effective in reducing pain and alleviating the escalating opioid dosage requirements in people with burn injury.

OBJECTIVES

To assess the safety and effectiveness of intravenous lidocaine as a means of pain relief versus no therapy, placebo, other drugs, or a combination of these therapies in people with burn injury.

SEARCH METHODS

For this third update, we searched the Cochrane Central Register of Controlled Trials (Issue 11, 2013), and Ovid MEDLINE, MEDLINE in Process and Ovid EMBASE (up to December 2013).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs), published and unpublished, which assessed the efficacy of intravenous lidocaine in varying doses as a single-agent therapy with no therapy, placebo, other analgesics (such as opioids), lidocaine plus another drug, or a combination of these therapies as a means of pain relief in people with burn injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed the risk of bias of the studies identified.

MAIN RESULTS

In this 2014 update, we found no new studies. The one small randomised double-blind placebo-controlled cross-over trial found in 2012, which included only 45 participants and compared intravenous lidocaine against placebo as a means of pain relief in people with burns still remains central to this review. We assessed this study as being at a high risk of bias due to its small size (fewer than 50 participants per treatment arm). Subjective pain ratings, as measured by the verbal rating scale, increased during procedures for both treatment arms; however, the increase was less in the lidocaine treatment group. There were no significant clinical or statistical differences regarding the effects of lidocaine and placebo on opioid requests and consumption, anxiety or level of satisfaction during a wound care procedure, but the small included study provided insufficient data to draw any conclusions.

AUTHORS' CONCLUSIONS

As current clinical evidence is based on only one RCT as well as case series and reports, intravenous lidocaine must be considered a pharmacological agent under investigation in burns care, the effectiveness of which is yet to be determined with further well-designed and conducted clinical trials.

The Body-QoL(®): patient reported outcomes in body contouring surgery patients [corrected]

BACKGROUND

This study aimed to design a new patient-reported outcome (PRO) instrument to measure patient satisfaction after body-contouring procedures such as liposculpture, abdominoplasty, body-lift, thigh-lift, and arm-lift.

METHODS

Phase 1a involved an extensive literature review, 16 in-depth patient interviews, and expert focus groups with 5 plastic surgeons to develop a conceptual framework for the outcomes deemed important for body image and preliminary PRO instruments. In phase 1b, the preliminary instrument was tested with a second independent sample of 29 patients with whom simple interviews were additionally performed. In the second sample, scale reliability was calculated.

RESULTS

In phase 1a, the domains identified for the conceptual framework included clothing and body image, sexual and affective life, self-image and self-esteem, social relationships, and physical symptoms. In phase 1b, the scale internal consistency was 91.5 %.

CONCLUSIONS

When psychometric evaluation is completed, the Body-Shape-Related Quality of Life instrument and its subscales will provide a reliable tool for plastic surgeons, researchers, and patients to use in measuring the impact and effectiveness of body-contouring procedures from the patient's perspective.

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 . This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-B.

Immunonutrition as an adjuvant therapy for burns

BACKGROUND

With burn injuries involving a large total body surface area (TBSA), the body can enter a state of breakdown, resulting in a condition similar to that seen with severe lack of proper nutrition. In addition, destruction of the effective skin barrier leads to loss of normal body temperature regulation and increased risk of infection and fluid loss. Nutritional support is common in the management of severe burn injury, and the approach of altering immune system activity with specific nutrients is termed immunonutrition. Three potential targets have been identified for immunonutrition: mucosal barrier function, cellular defence and local or systemic inflammation. The nutrients most often used for immunonutrition are glutamine, arginine, branched-chain amino acids (BCAAs), omega-3 (n-3) fatty acids and nucleotides.

OBJECTIVES

To assess the effects of a diet with added immunonutrients (glutamine, arginine, BCAAs, n-3 fatty acids (fish oil), combined immunonutrients or precursors to known immunonutrients) versus an isonitrogenous diet (a diet wherein the overall protein content is held constant, but individual constituents may be changed) on clinical outcomes in patients with severe burn injury.

SEARCH METHODS

The search was run on 12 August 2012. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), ISI WOS SCI-EXPANDED & CPCI-S and four other databases. We handsearched relevant journals and conference proceedings, screened reference lists and contacted pharmaceutical companies. We updated this search in October 2014, but the results of this updated search have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials comparing the addition of immunonutrients to a standard nutritional regimen versus an isonitrogenated diet or another immunonutrient agent.

DATA COLLECTION AND ANALYSIS

Two review authors were responsible for handsearching, reviewing electronic search results and identifying potentially eligible studies. Three review authors retrieved and reviewed independently full reports of these studies for inclusion. They resolved differences by discussion. Two review authors independently extracted and entered data from the included studies. A third review author checked these data. Two review authors independently assessed the risk of bias of each included study and resolved disagreements through discussion or consultation with the third and fourth review authors. Outcome measures of interest were mortality, hospital length of stay, rate of burn wound infection and rate of non-wound infection (bacteraemia, pneumonia and urinary tract infection).

MAIN RESULTS

We identified 16 trials involving 678 people that met the inclusion criteria. A total of 16 trials contributed data to the analysis. Of note, most studies failed to report on randomisation methods and intention-to-treat principles; therefore study results should be interpreted with caution. Glutamine was the most common immunonutrient and was given in seven of the 16 included studies. Use of glutamine compared with an isonitrogenous control led to a reduction in length of hospital stay (mean stay -5.65 days, 95% confidence interval (CI) -8.09 to -3.22) and reduced mortality (pooled risk ratio (RR) 0.25, 95% CI 0.08 to 0.78). However, because of the small sample size, it is likely that these results reflect a false-positive effect. No study findings suggest that glutamine has an effect on burn wound infection or on non-wound infection. All other agents investigated showed no evidence of an effect on mortality, length of stay or burn wound infection or non-wound infection rates.

AUTHORS' CONCLUSIONS

Although we found evidence of an effect of glutamine on mortality reduction, this finding should be taken with care. The number of study participants analysed in this systematic review was not sufficient to permit conclusions that recommend or refute the use of glutamine. Glutamine may be effective in reducing mortality, but larger studies are needed to determine the overall effects of glutamine and other immunonutrition agents.

Analgesic efficacy of lidocaine for suction-assisted lipectomy with tumescent technique under general anesthesia: a randomized, double-masked, controlled trial

BACKGROUND

Suction-assisted lipectomy is one of the most common procedures performed in plastic surgery. To minimize blood loss and to obtain adequate analgesia, a liquid solution is infiltrated into the subcutaneous plane before suction. The objective of this study was to determine whether the use of lidocaine in the infiltration solution reduces postoperative pain.

METHODS

A prospective, randomized, double-masked, clinical trial was designed. Each side of patients' body zones to be treated with suction-assisted lipectomy was randomized to receive infiltration solution with or without lidocaine. Treatment allocation was performed using computer-generated random numbers in permuted blocks of eight. Pain was assessed using the visual analogue scale and registered 1, 6, 12, 18, and 24 hours after the procedure.

RESULTS

The trial was stopped after a first interim analysis. The use of lidocaine in the dilute solution reduced pain by 0.5 point on the visual analogue scale (95 percent CI, 0.3 to 0.8; p<0.001). The effect was independent of the suctioned body zone (p=0.756), and lasted until 18 hours after surgery. Its analgesic effect was lost at the 24-hour postoperative control. Pain increased an average of 0.018 point on the visual analogue scale per hour (95 percent CI, 0.001 to 0.036; p=0.043).

CONCLUSIONS

The use of lidocaine in the infiltration solution is effective in postoperative pain control until 18 hours after surgery. Nevertheless, its clinical effect is limited and clinically irrelevant, and therefore it is no longer used by the authors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Intravenous lidocaine for the treatment of background or procedural burn pain

BACKGROUND

This is an update of the review on 'Lidocaine for pain relief in burn injured patients' first published in Issue 3, 2007. Pain is a major issue for patients suffering from many different types of wounds, in particular those with burn injuries. Prompt, aggressive use of opioid analgesics such as morphine has been suggested as critical to avert the cycle of pain and anxiety, but side effects are encountered. It is proposed that newer agents such as lidocaine could be effective in reducing pain and alleviating the escalating opioid dosage requirements in patients with burn injury.

OBJECTIVES

To assess the safety and effectiveness of intravenous lidocaine as a means of pain relief versus no therapy, placebo, other drugs or two or more of the above therapies in combination in patients exposed to burn injury.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (1966 to April 2011 week 4) and EMBASE (1980 to 2011 week 17).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs), published and unpublished, which assessed the efficacy of intravenous lidocaine in varying doses as a single-agent therapy with no therapy, placebo, other analgesics such as opioids, lidocaine plus another drug, or two or more of the above therapies as a means of pain relief in patients exposed to burn injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed the risk of bias of the studies identified.

MAIN RESULTS

This update identified one new randomised, double-blind, placebo-controlled, cross-over trial which included 45 participants and compared intravenous lidocaine against placebo as a means of pain relief in those with burns. Subjective pain ratings as measured by the verbal rating scale increased during procedures for both treatment arms, however, the increase was less for the lidocaine treatment arm. There were no significant clinical or statistical differences regarding the effects of lidocaine and placebo on opioid requests and consumption, anxiety or level of satisfaction during a wound care procedure.

AUTHORS' CONCLUSIONS

As current clinical evidence is based on only one single RCT as well as case series and reports, intravenous lidocaine must be considered a pharmacological agent under investigation in burns care, the effectiveness of which is yet to be determined with further well-designed and conducted clinical trials.

Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: a systematic review

INTRODUCTION

Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians.

METHODS

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients.

RESULTS

The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain.

CONCLUSION

The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.

Progressive Tension Sutures in the Prevention of Postabdominoplasty Seroma: A Prospective, Randomized, Double-Blind Clinical Trial

BACKGROUND

The purpose of this study was to evaluate the seroma reduction capabilities of progressive tension sutures and compare them with the conventional use of drains.

METHODS

Sixty female patients were randomized into four groups: group 1 (control, no drains, and no progressive tension sutures), group 2 (progressive tension sutures alone), group 3 (drains alone), and group 4 (progressive tension sutures and drains). All patients underwent a classic abdominoplasty and drains were left for 7 days in the corresponding groups. Clinical and ultrasound assessments were performed 2 weeks after the operation by blinded evaluators. Punctures, volumes, nonseroma complications, and aesthetic outcome were also measured.

RESULTS

Surgical time was 50 minutes longer in groups 2 and 4. Drain outputs were higher in group 3 than in group 4. The clinical and ultrasound seroma frequency was 35 percent and 90 percent respectively, without significant differences among the groups. The control group was interrupted at 10 patients because of considerably larger seromas and an increased amount of punctures needed for treatment. No differences were found in the other groups. There were no differences with respect to complication rates and aesthetic outcome after follow-up.

CONCLUSIONS

Progressive tension sutures increase surgical time, reduce drain outputs, and have the same clinical and ultrasound seroma frequency as the use of drains alone. The combination of both methods simultaneously does not add any advantages. However, complications and interventions increase if at least one of them is not used. The mechanism of action of progressive tension sutures could be the compartmentalization of the fluid collection under the flap facilitating absorption.

A New Technique of ???Double-A??? Bilateral Flaps Based on Perforators for the Treatment of Sacral Defects

BACKGROUND

Myocutaneous and fasciocutaneous flaps can provide stable coverage of sacral defects. For neurologically intact patients, sensate innervated gluteal artery perforator flaps are the ideal solution. For patients with spinal cord injury, soft-tissue coverage can be performed with a variety of noninnervated flaps.

METHODS

Between 1997 and 2004, the authors operated on 30 patients, 21 men and nine women, using bilateral gluteal distal fasciocutaneous and proximal musculocutaneous vertical vector rotation-advancement flaps, based on perforators with V-Y closures. The ages of the patients ranged from 32 to 74 years. Twenty-five patients had spinal cord injuries and all had sacral pressure sores extending to the bone. Three patients had low-grade malignant tumors (sacral chordomas); one had a sacral radiation-induced necrosis and two senile patients with large sacral defects had chronic renal failure and multiple sclerosis. No comorbidities were found in the sample.

RESULTS

All the lesions were closed successfully. After follow-up of 1 to 8 years, 27 patients never required repeated surgery after wound complications. Three patients had infection and partial dehiscence of the flaps that healed after reoperation with V-Y readvancement; three died as a result of their primary diseases.

CONCLUSIONS

This flap design has been used only in selected cases because, after its elevation, use of other gluteal-based flaps for future sacral reconstructions may not be possible. Five neurologically intact patients were found to have good sensitive protection of the flaps and adequate cushion contour after surgery because the authors conserved the gluteal arteries, perforators, and their corresponding sensory nerves.

Patellofemoral evaluation with radiographs and computed tomography scans in 60 knees of asymptomatic subjects

PURPOSE

The objectives of this study were to show the results of patellofemoral joint imaging in healthy volunteers, to propose a standardization of the technique, and to test the statistical correlation and reliability of the different imaging results.

METHODS

In 30 healthy police academy student volunteers of both sexes, standard knee radiographs and computed tomography (CT) scans were obtained. The angles and distances were measured, and a statistical analysis was applied. The results are presented as mean +/- 2 SDs throughout.

RESULTS

The mean Laurin lateral patellofemoral angle on radiographs was 16.4 degrees +/- 8.7 degrees. The mean Insall-Salvati and Caton-Deschamps indexes were 1.09 +/- 0.24 and 0.95 +/- 0.29, respectively. The CT scan values for tilt were determined for the lateral patellofemoral angle by use of both facets (-8.1 degrees +/- 9.8 degrees), the Laurin lateral patellofemoral angle (8.1 degrees +/- 14.5 degrees), the condyle-patellar angle with the lateral facet (14.5 degrees +/- 14 degrees), and the patella major axis (-11.1 degrees +/- 10.6 degrees). The sulcus angle, congruence angle (Merchant angle), and condyle-lateral angle were also obtained on CT scans, with mean values of 139.7 degrees +/- 20.4 degrees , 5.15 degrees +/- 32.6 degrees , and 22.1 degrees +/- 9 degrees , respectively. The tibiofemoral rotation was assessed with the indexes for the distance between the trochlear groove and anterior tibial tuberosity and the distance between the posterior femoral dome and anterior tibial tuberosity. The values for these two indexes were 13.6 +/- 8.8 mm and 17.8 +/- 9.2 mm, respectively. Some parameters showed sex differences.

CONCLUSIONS

There are good statistical correlations between some of the tilt values on the radiographs and CT scans, indicating that they move together. The values on the CT scans show good reliability. The CT scans and radiographs are good tests by which to evaluate and quantify patellar alignment.

LEVEL OF EVIDENCE

Level I, testing of previously developed diagnostic criteria.

Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial

OBJECTIVES

To determine the effectiveness of the negative pressure closure (NPC) technique in the integration of split-thickness skin grafts (STSG) to the recipient site.

METHODS

Randomized, double-masked, controlled trial.

SETTING

A tertiary burn unit.

PATIENT CHARACTERISTICS

Between May 2003 and October 2004, 60 patients having wounds with skin loss which hindered primary closure, were incorporated to this study. We excluded patients with > or =20% of total body surface burns, polytraumatized, surgical contraindications, those who were enlisted in other clinical trials, and those who rejected the informed consent.

INTERVENTIONS

In all the patients, surgical cleaning of the recipient site and STSG were performed after which they were randomly assigned between 2 groups: a group that received a NPC dressing and were connected to the central aspiration system at -80 mm Hg versus a control group with similar dressing but without connection to negative pressure. Loss of STSG area at the fourth postoperative day, days of hospital stay.

RESULTS

Sixty patients were included. The median loss of the STSG in the NPC group was 0.0 cm versus 4.5 cm in the control group (P = 0.001). The median hospital stay was of 13.5 days in the NPC group versus 17 days in the control group (P < 0.001).

CONCLUSIONS

The use of NPC significantly diminishes the loss of STSG area, as well as shortens the days of hospital stay. Therefore, it should be routinely used for these kinds of procedures.

A Prospective, Randomized, Double-Blind, Controlled Clinical Trial Comparing Laser-Assisted Lipoplasty with Suction-Assisted Lipoplasty

BACKGROUND

The authors randomized and prospectively analyzed their clinical experience with the use of internal neodymium:yttrium-aluminum-garnet low-level laser-assisted lipoplasty compared with suction-assisted lipoplasty.

METHODS

Suction-assisted lipoplasty was generated through a SmartLipo machine and delivered into the subcutaneous tissues through 2-mm solid optical probes. Ipsilateral suction-assisted lipoplasty and contralateral laser-assisted lipoplasty were performed on one or more comparable topographic areas of the body in the same patient. Laser-assisted lipoplasty and suction-assisted lipoplasty sides of 25 patients were compared with preoperative and postoperative photographs at 3 to 5 days, 12 to 15 days, and 6 to 11 months. Statistical analysis considered surgeon and patient satisfaction, time used in the procedures, learning curves, lipocrits, operative technique, postoperative pain, edema, ecchymosis, time of recovery, body mass index, DNA proteins, free fatty acids, and cytologic patterns of post-laser-assisted lipoplasty and suction-assisted lipoplasty adipocyte architecture. Photographs were sent to the patients (blinded to the operated sides) and two plastic surgeons unfamiliar with the cases for evaluation of results.

RESULTS

All patients completed the preestablished follow-ups. No complications were observed. Less pain, lower lipocrits, higher triglycerides, and DNA cellular membrane traces were detected in the laser-assisted lipoplasty sides. All other considerations studied showed no differences with either technique in the three periods of the follow-up controls. Cytologic studies showed more damage of the adipocytes in the laser-assisted lipoplasty sides.

CONCLUSIONS

No major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty were found. Higher concentrations of free-fatty acids after laser-assisted lipoplasty must alert us to possible hepatic and renal toxicity.

Use of aerosolized bovine-prepared fibrin glue for skin fixation after primary open rhinoplasty: a prospective randomized and controlled trial

BACKGROUND

Fibrin glue has been used in diverse areas of plastic surgery. To the authors' knowledge, no clinical controlled trial studies have reported its use for open rhinoplasty.

METHODS

A prospective, randomized, masked clinical trial was designed to demonstrate that aerosolized bovine-prepared fibrin glue used in open rhinoplasty controls skin fixation (flap movement), edema, hematomas, ecchymosis, bleeding, and cosmetic results 1 and 12 months postoperatively. The results were reviewed by two blinded plastic surgeons who assessed postoperative photographs using the Strasser score. Other items such as columella scar, pain, surgery/recovery time, and patient satisfaction also were evaluated.

RESULTS

A computer system was used to randomize 22 consecutive open primary rhinoplasties. Cosmetic analysis did not differ significantly between the group redraped with fibrin glue and the control group. Patient satisfaction was the only outcome that significantly favored the active group. None of the other items or adverse events significantly differed between the two groups, including operative time and pain.

CONCLUSIONS

Fibrin glue is believed to reduce bleeding and to improve the adherence of tissues. The only statistical difference in this study favored the patient satisfaction cosmetic score of the group that received fibrin glue.

A clinical retrospective study comparing two short-scar face lifts: minimal access cranial suspension versus lateral SMASectomy

BACKGROUND

The purpose of this study was to retrospectively compare the short- and long-term cosmetic outcomes of two minimal incision rhytidectomies and analyze their advantages and disadvantages.

METHODS

The results of minimal access cranial suspension face lift versus minimal incision rhytidectomy with lateral SMASectomy were evaluated after 1 and 24 months. Statistical analysis considered surgeon/patient satisfaction, time used in the procedures, pain, and learning curves. Photographs were sent to the patients and two plastic surgeons, unfamiliar with the cases, for evaluation of results that were assessed by an objective grading system described by Strasser.

RESULTS

Eighty-two patients completed 1 and 24 months' follow-up. Complications were two hematomas, two retroauricular-lobule dog-ears, and one hypertrophic preauricular scar. Surgical time was longer for the SMASectomy. Postoperative pain was worse for minimal access cranial suspension face lift. There were no differences in cosmetic results between the two techniques at 1-month and 2-year follow-up. Incorporating age, sex, postoperative pain, and duration of surgery as confounding factors did not modify the model. Surgeon/patient satisfaction showed no difference with either technique, but the photographic evaluation of all cases at 24 months revealed that more than 50 percent of the sample needed a tuck procedure to correct jowling and redundant skin.

CONCLUSIONS

Advantages of short-scar face lifts are the avoidance of the postauricular and occipital incisions, and the disadvantages are the moderate results in the neck and nasolabial folds and their potential short duration. For 24 months in this study, the duration of results was similar for both minimal access cranial suspension and lateral SMASectomy.

Nonresective Shrinkage of the Septum and Fat Compartments of the Upper and Lower Eyelids: A Comparative Study with Carbon Dioxide Laser and Colorado Needle

BACKGROUND

The purpose of this article is to describe an alternative nonresective treatment of the fat-septum component of the eyelids during blepharoplasty, using shrinkage desiccation with two low-energy modalities: a carbon dioxide laser and a low-range grid of electrocautery with a Colorado microdissection needle.

METHODS

Thirty-six patients underwent a four-lid blepharoplasty. During surgery, after exposure (not opening) of the septum and assessment of the amount of bulging by gentle globe compression, a grid spray of electrocautery (right eye) and carbon dioxide laser (left eye) was applied over the entire septum until shrinkage and correction of the bulging was achieved. Preoperative, postoperative day 15, and 1-year follow-up photographs were evaluated using an objective grading system by blinded surgeons. For statistical analysis, the Wilcoxon matched-pairs signed-ranks test was used, with p < 0.05 indicating statistical significance.

RESULTS

All the patients completed the 15-day evaluation, but only 32 completed the 1-year follow-up. No major eye or eyelids complications were observed. There were no statistical differences in surgical time and postoperative pain on either side. In this study, laser fat-septum shrinkage achieved substandard results compared with electrocautery when analyzed as a continuous variable, but it did not influence the categorical Strasser scale final result in the short- and long-term follow-up.

CONCLUSIONS

The method described is simple and safe, and provides a subtle but long-lasting, adequate result. No statistical clinical differences were observed between the electrocautery and laser fat-septum shrinkage techniques.

Concordance between qualitative and quantitative cultures in burned patients

OBJECTIVE

To determine the concordance between superficial cultures (SC) and quantitative cultures (QC) in the diagnosis of wound infection in burn patients.

METHOD

SAMPLE

All SC and QC taken from the same patient, site and during the same surgery were analysed.

VARIABLES

On the SC, the microorganism (MO) and its amount defined subjectively by the microbiologist was recorded (negative, very low, low, regular and abundant). On the QC, the MO and its amount were expressed as colony forming units per gram of tissue (CFUs/g).

STATISTICS

Kappa index of agreement beyond chance; Wilcoxon and Kruskall-Wallis for continuous variables and chi(2) for categorical variables were used with a p<0.05 indicating statistical significance.

RESULTS

One thousand four hundred and forty three pairs of cultures were analyzed. The concordance between SC and QC (Kappa index) was 52%. On the SC, only when the microbiologist subjectively informed "abundant" MOs there was a significant difference (p<0.0001). There were 6.1% of QCs with more than 10(5) CFUs/g and the most frequent MOs isolated were: S. aureus (27.9%), E. coli (11.6%), P. aeruginosa (11.6%), E. faecalis (11.6%) and S. epidermidis (7.0%).

CONCLUSIONS

SC has a moderate concordance with the QC showing a low reliability between the two methods. The subjective information given by the microbiology technician in the SC is not precise. A study in which the two methods be compared blindly against the reference standard, in a prospective cohort of patients, it is needed to discriminate which of two methods it is the most accurate one determining sensitivity and specificity.

Geometric Analysis of the V-Y Advancement Flap and Its Clinical Applications

BACKGROUND

Geometry is fundamental in the comprehension of local flap design. The purpose of this study was to discuss the differences between the V-Y advancement flap and other local flaps, understand its geometry, and analyze its clinical applications.

METHODS

The analysis was based on qualitative measurements of an injury, taking into consideration the following dimensions: largest diameter, shortest diameter, and depth. Standardization of the flap design consisted of directing its advancement over the shortest diameter and making the V base match the size of the largest diameter. The flap was analyzed in two planes: the horizontal plane includes the V-Y design and the vertical plane includes the flap pedicle. The height of the flap can be obtained by simple trigonometry, taking into consideration the largest diameter and alpha angle in the horizontal plane. In the vertical plane, where the pedicle and pivot plane are positioned, for known shortest diameter and depth, the final depth of the pivot plane can be calculated using Pythagoras' principles.

RESULTS

This analysis was applied to 25 patients with adequate skin coverage at follow-up. A correction factor was added to reduce the overdeepening of the vertical plane calculations. The final concepts for clinical application in the classic deep pedicle V-Y flap design are to calculate the length of the V by modifying the alpha angle and to move the pivot plane deeper to accomplish optimal flap movement.

CONCLUSIONS

Using these principles, tension-free closure of the Y and appropriate advancement of the flap are obtained.