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Zubler C, Punreddy A, Mayorga-Young D, Leckenby J, Grobbelaar AO. Approaches to the Management of Synkinesis: A Scoping Review. Facial Plast Surg 2024. [PMID: 38604247 DOI: 10.1055/a-2305-2007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
Postparalysis facial synkinesis (PPFS) can develop in any facial palsy and is associated with significant functional and psychosocial consequences for affected patients. While the prevention of synkinesis especially after Bell's palsy has been well examined, much less evidence exists regarding the management of patients with already established synkinesis. Therefore, the purpose of this review is to summarize the available literature and to provide an overview of the current therapeutic options for facial palsy patients with established synkinesis. A systematic literature review was undertaken, following the Preferred Reporting Items of Systematic Reviews and Meta-analyses 2020 guidelines. MEDLINE via PubMed and Cochrane Library were searched using the following strategy: ([facial palsy] OR [facial paralysis] OR [facial paresis]) AND (synkinesis) AND ([management] OR [guidelines] OR [treatment]). The initial search yielded 201 articles of which 36 original papers and 2 meta-analyses met the criteria for inclusion. Overall, the included articles provided original outcome data on 1,408 patients. Articles were divided into the following treatment categories: chemodenervation (12 studies, 536 patients), facial therapy (5 studies, 206 patients), surgical (10 studies, 389 patients), and combination therapy (9 studies, 278 patients). Results are analyzed and discussed accordingly. Significant heterogeneity in study population and design, lack of control groups, differences in postoperative follow-up, as well as the use of a variety of subjective and objective assessment tools to quantify synkinesis prevent direct comparison between treatment modalities. To date, there is no consensus on how PPFS is best treated. The lack of comparative studies and standardized outcome reporting hinder our understanding of this complex condition. Until higher quality scientific evidence is available, it remains a challenge best approached in an interdisciplinary team. An individualized multimodal therapeutic concept consisting of facial therapy, chemodenervation, and surgery should be tailored to meet the specific needs of the patient.
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Affiliation(s)
- Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Ankit Punreddy
- Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Danielle Mayorga-Young
- Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jonathan Leckenby
- Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Department of Plastic and Reconstructive Surgery, The Great Ormond Street for Sick Children, London, United Kingdom
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Plastic and Reconstructive Surgery, The Great Ormond Street for Sick Children, London, United Kingdom
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Leckenby JI, Chacon MA, Milek D, Lichtman JW, Grobbelaar AO. Axonal Regeneration Through Autologous Grafts: Does the Axonal Load Influence Regeneration? J Surg Res 2022; 280:379-388. [PMID: 36037615 DOI: 10.1016/j.jss.2022.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 07/05/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Two-stage free functional muscle transfers for long-standing facial palsy can yield unpredictable results. Earlier studies have demonstrated incomplete regeneration across neurorrhaphies in native nerve and higher donor axonal counts correlating with improved outcomes but axonal count in nerve grafts have not been as thoroughly reviewed. To investigate the impact of varying axonal counts in autologous grafts on functional outcomes of repair. MATERIALS AND METHODS Animals were allocated into three groups: Direct Nerve Repair (DNR, n = 50), Small Nerve Graft (SNG, n = 50), and Large Nerve Graft (LNG, n = 50). All grafts were inset into the Posterior Auricular Nerve with ear movement recovery (EMR) monitored as functional outcome. At various postoperative weeks (POWs), excised specimens were imaged with electron microscopy. Axonal counts were measured proximal to, distal (DAC) to, and within grafts. Total Success Ratio (TSR) was calculated. RESULTS In DNR, DAC was significantly lower than proximal axonal counts at all POWs, with maximum TSR of 80%. TSR for LNG and SNG were significantly lower at all POWs when compared to DNR, with maximums of 56% and 38%, respectively. LNG had a significantly larger DAC than SNG at POW12 and beyond. A direct relationship was present between DAC and EMR for all values. CONCLUSIONS Higher native axonal count of autologous nerve grafts resulted in higher percentage of regeneration across neurorrhaphies.
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Affiliation(s)
- Jonathan I Leckenby
- The Royal Free NHS Foundation Trust, Pond Street, London, United Kingdom; Division of Surgery and Interventional Science, University College London, Gower Street, London, United Kingdom; University of Rochester Medical Center, Rochester, New York.
| | | | - David Milek
- University of Rochester Medical Center, Rochester, New York
| | - Jeff W Lichtman
- Center for Brain Science, Department of Molecular & Cellular Biology, Harvard University, Cambridge, Massachusetts
| | - Adriaan O Grobbelaar
- The Royal Free NHS Foundation Trust, Pond Street, London, United Kingdom; Division of Surgery and Interventional Science, University College London, Gower Street, London, United Kingdom
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Brühlmann J, Lese I, O Grobbelaar A, Fischlin C, Constantinescu M, Olariu R. Post-bariatric contour deformity correction: an endeavour to establish objective criteria nationally. Swiss Med Wkly 2022; 152:w30131. [PMID: 35315267 DOI: 10.4414/smw.2022.w30131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A marked increase in bariatric surgery has led to higher numbers of patients with contour deformities after massive weight loss seeking plastic surgical correction. Insurance coverage for these post-bariatric interventions is highly subjective and a common set of objective criteria has not yet been established. AIM The aim was to evaluate the factors influencing insurance coverage for post-bariatric surgery, focusing on finding objective, reproducible criteria. METHODS This was a retrospective single centre chart review of all post-bariatric patients with redundant skin requesting body contouring surgery from 2013 to 2018. Demographic, bariatric and surgical, as well as insurance information were collected. A logistic regression model was used to identify predictors of successful insurance coverage. RESULTS 116 Patients were included in the study. Insurance approval for post-bariatric body contouring surgery was obtained for only 47 patients (41%). Mentioning the term "medical indication" in the application letter was associated with a 15.2 times higher rate of receiving a positive answer (p <0.001), whereas mentioning "mental suffering" was associated with 82.3% lower chance of getting a positive response (p <0.001). A high body mass index (BMI) (p <0.009) before the bariatric operation as well as a high BMI reduction (p <0.021) were associated with a higher approval rate by insurance companies . An additional application letter to the insurance company (p <0.024) as well as mentioning mechanical restriction (p <0.022) were associated with a positive response from the insurance companies. CONCLUSIONS We were able to establish certain objective predictive criteria for insurance coverage of post-bariatric surgery. However, it appears that the decisions of insurance companies for this condition are still rather randomly taken. Therefore, the establishment of objective criteria for insurance coverage may allow fairer treatment for this growing patient population.
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Affiliation(s)
- Jérémy Brühlmann
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
| | - Ioana Lese
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
| | - Claudia Fischlin
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
| | - Mihai Constantinescu
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
| | - Radu Olariu
- Department of Hand and Plastic Surgery, University Hospital of Bern, Switzerland
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4
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Bayard IPE, Grobbelaar AO, Constantinescu MA. Necrotizing fasciitis caused by mono-bacterial gram-negative infection with E. coli - the deadliest of them all: A case series and review of the literature. JPRAS Open 2021; 29:99-105. [PMID: 34189236 PMCID: PMC8220291 DOI: 10.1016/j.jpra.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/28/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Unlike other skin and soft tissue infections, necrotizing fasciitis (NF) is a very rare but potentially fatal condition. Common organisms causing NF are poly-microbial (type I) infection with mixed organisms and mono-bacterial gram-positive infection with mainly streptococci (type II). Mono-bacterial gram-negative NF is a rare form of NF that is not included in the current classification. Case series We report four cases of mono-bacterial gram-negative NF caused by E. coli. All patients presented in septic shock and showed landscape-like skin necrosis and pain out of proportion. Radical debridement and escalation of antibiotic treatment was performed in all patients. Short-term survival was 50%. Two patients died of multiorgan failure. Two patients survived short term: One patient was amputated through the knee but died six months later of metastatic prostate cancer. One patient was covered with split thickness skin grafts and died three months later of catheter-associated sepsis with endocarditis. Discussion Recent findings suggest adding a type III fasciitis, which is caused by mono-bacterial gram-negative organisms. As patients are getting older with even more comorbidities, mono-bacterial gram-negative NF will be an increasing problem for physicians treating soft tissue and skin infections. In oncologic diseases, liver cirrhosis, renal diseases or otherwise immunocompromised patients, mono-bacterial gram-negative NF with E. coli is underestimated. Therefore, in these patients, antibiotic treatment should cover Gram-negative organisms including E. coli. However even with adjusted antibiotic treatment and radical debridement, the short-term survival and long-term outcome are poor.
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Affiliation(s)
- I P E Bayard
- Department of Plastic and Handsurgery Inselspital, Bern
| | - A O Grobbelaar
- Department of Plastic and Handsurgery Inselspital, Bern.,Great Ormond Street Hospital for Sick Children London.,Professor, University College of London, Division of Surgery and Interventional Science London
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Gasteratos K, Azzawi SA, Vlachopoulos N, Lese I, Spyropoulou GA, Grobbelaar AO. Workhorse Free Functional Muscle Transfer Techniques for Smile Reanimation in Children with Congenital Facial Palsy: Case Report and Systematic Review of the Literature. J Plast Reconstr Aesthet Surg 2021; 74:1423-1435. [PMID: 33637466 DOI: 10.1016/j.bjps.2021.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/15/2020] [Accepted: 01/23/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pediatric facial palsy represents a rare multifactorial entity. Facial reanimation restores smiling, thus boosting self-confidence and social integration of the affected children. The purpose of this paper is to present a systematic review of microsurgical workhorse free functional muscle transfer procedures with emphasis on the long-term functional, aesthetic, and psychosocial outcomes. MATERIALS AND METHODS We performed a literature search of the PubMed database from 1995 to 2019 using the following search strategy: "facial paralysis"[Title/Abstract] OR "facial palsy"[Title]. We used as limits: full text, English language, age younger than 18 years, and humans. Two independent reviewers performed the online screening process using Covidence. Forty articles met the inclusion criteria. The protocol was aligned with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was registered at the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019150112) of the National Institute for Health Research. RESULTS Free functional muscle transfer procedures include mainly segmental gracilis, latissimus dorsi, and pectoralis minor muscle transfer. Facial reanimation procedures with the use of the cross-face nerve graft (CFNG) or masseteric nerve result in almost symmetric smiles. The transplanted muscle grows harmoniously along with the craniofacial skeleton. Muscle function and aesthetic outcomes improve over time. All children presented improved self-esteem, oral commissure opening, facial animation, and speech. CONCLUSIONS A two-stage CFNG plus an FFMT may restore a spontaneous emotive smile in pediatric facial palsy patients. Superior results of children FFMT compared to adults FFMT are probably attributed to greater brain plasticity.
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Affiliation(s)
- Konstantinos Gasteratos
- Plastic and Reconstructive Surgery Department, Papageorgiou General Hospital, Thessaloniki, Greece.
| | - Saif Al Azzawi
- Microsurgery Fellow, Royal Adelaide Hospital, Port Rd, Adelaide SA 5000, Australia; Melbourne Institute of Plastic Surgery, Malvern, Victoria 3144 Australia; Department of Plastic and Reconstructive Surgery, St Thomas' Hospital, Westminster Bridge Road, London SE7 1EH, United Kingdom
| | - Nikolaos Vlachopoulos
- Graduate of the Aristotle University of Thessaloniki, School of Medicine -Hellenic Military Academy of Combat Support Officers, Thessaloniki, Greece
| | - Ioana Lese
- Department of Plastic and Hand Surgery; Inselspital, Bern University Hospital, Bern, Switzerland; Department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | | | - Adriaan O Grobbelaar
- Department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom; Department of Plastic and Hand Surgery; Inselspital, Bern University Hospital, Bern, Switzerland; Professor at University College of London, Division of Surgery and Interventional Science, London, United Kingdom
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Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2020; 74:512-522. [PMID: 33039304 DOI: 10.1016/j.bjps.2020.08.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. METHODS Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. RESULTS A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001). CONCLUSION If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland.
| | - Raphael Biedermann
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
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7
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Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. J Bone Joint Surg Am 2020; 102:510-518. [PMID: 31804239 DOI: 10.2106/jbjs.19.00648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Defects in the distal third of the leg are difficult to cover and often require free tissue transfer, even for defects of limited sizes. Propeller flaps have been designed specifically as an alternative to free tissue transfer but at times have been associated with unacceptably high complication rates. We therefore aimed to prospectively assess our own institutional experience with this technique and to define its role in lower-limb reconstruction. METHODS All patients who had been managed with reconstruction of the distal part of the leg with a propeller flap between 2014 and 2017 were included in the study. Demographic, clinical, and follow-up data on the patients and surgical procedures were recorded with special focus on the complication profile. RESULTS Twenty-six patients underwent propeller flap reconstruction of the distal part of the leg: 12 flaps were based on the posterior tibial artery, and 14 were based on the peroneal artery. Postoperative complications developed in association with 1 of the 12 flaps based on the posterior tibial artery, compared with 8 of the 14 flaps based on the peroneal artery (p = 0.015). Moreover, the presence of a higher Charlson comorbidity index (≥2) was strongly associated with the development of postoperative complications (p < 0.001). CONCLUSIONS Propeller flaps are a reliable option for traumatic reconstruction in carefully selected patients with lower-limb defects. In our experience, the rate of complications was higher for propeller flaps based on the peroneal artery and for patients with a Charlson comorbidity index of ≥2, whereas posterior tibial artery-based propeller flap reconstruction was a reliable surgical option for patients with a small defect in the distal third of the lower limb. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dan Sabau
- Department III, Surgical Clinic, Lucian Blaga University of Sibiu, Sibiu, Romania
| | - Alexandru V Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, and Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, University of Medicine Iuliu Hatieganu, Cluj Napoca, Romania
| | - Mihai A Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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8
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Butler DP, De la Torre A, Borschel GH, Hadlock TA, Beurskens C, Bogart K, Cárdenas Mejía A, Coombs C, Copeland J, Diels J, González-Otero T, Graham L, Ishii L, Malhotra R, Martinez A, McKinley L, Robinson MW, Suominen S, Takushima A, Vazquez Curiel E, Wachs FL, Grobbelaar AO. An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy. JAMA FACIAL PLAST SU 2020; 21:351-358. [PMID: 31070677 DOI: 10.1001/jamafacial.2019.0224] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population. Objective To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives. Design, Setting, and Participants A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016. Main Outcomes and Measures The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention. Results The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy. Conclusions and Relevance This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy. Level of Evidence NA.
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Affiliation(s)
- Daniel P Butler
- Department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Alethse De la Torre
- Director of Standardisation and Latin America, International Consortium for Health Outcomes Measurement, Mexico City, Mexico
| | - Gregory H Borschel
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tessa A Hadlock
- Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Boston, Massachusetts
| | - Carien Beurskens
- Section of Physical Therapy, Department of Orthopedics, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Alexander Cárdenas Mejía
- Division of Plastic and Reconstructive Surgery, Hospital General Dr Manuel Gea Gonzalez, Postgraduate Division, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Christopher Coombs
- Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | - Jacqueline Diels
- Facial Retraining LLC, Madison, Wisconsin.,Facial Nerve Clinic, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin Hospital and Clinics, Madison
| | | | - Louise Graham
- Patient representative, Brighton, East Sussex, United Kingdom
| | - Lisa Ishii
- Johns Hopkins Hospitals, Baltimore, Maryland
| | - Raman Malhotra
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Adelaida Martinez
- The Portland Hospital for Women and Children, London, United Kingdom
| | - Lisa McKinley
- Facial Paralysis and Bell's Palsy Foundation, Beverly Hills, California
| | - Mara W Robinson
- Facial Nerve Center, Massachussetts Eye and Ear Infirmary, Boston
| | - Sinikka Suominen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Akihiko Takushima
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Faye L Wachs
- California State Polytechnic University, Los Angeles
| | - Adriaan O Grobbelaar
- University College London, London, United Kingdom.,The Royal Free Hospital, London, United Kingdom.,Great Ormond Street Hospital, London, United Kingdom
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9
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Abstract
The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice.
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Affiliation(s)
- Daniel P Butler
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Adriaan O Grobbelaar
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
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10
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Butler DP, Johal KS, Wicks CE, Grobbelaar AO. Objective sensory and functional outcomes at the donor site following endoscopic-assisted sural nerve harvest. J Plast Reconstr Aesthet Surg 2017; 70:659-665. [DOI: 10.1016/j.bjps.2017.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/10/2017] [Accepted: 02/17/2017] [Indexed: 11/28/2022]
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Abstract
This paper reports an unusual case of ectopic nail formation, reviews the literature and proposes a simple classification of this anomaly.
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Affiliation(s)
- A Abood
- Department of Plastic, Reconstructive and Burns Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK.
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12
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Abstract
Mallet finger injuries are common; treatment goals include achieving joint stability, preventing extensor lag, and subsequent swan-neck deformity. We describe a simple technique for improving intraoperative bony mallet reduction, which may avoid the requirement for closed Ishiguro extension blocking wires or open fixation, and present a prospective case series (n=12). Intraoperative percutaneous blunt needle reduction (PBNR) is achieved under image intensifier guidance. Using artery forceps, a blunt fill needle tip is manipulated onto the proximal avulsed fragment; this is then guided into a reduced position and maintained using a well-formed Zimmer splint across the distal interphalangeal joint in 15- to 30-degree extension. There were 5 injuries involving >1/3 of the articular surface (Doyle's classification IVb) and 7 injuries involving >1/2 of the articular surface (Doyle's classification IVc). Mean hand therapy follow-up was 10.6±1.0 weeks, extensor lag was 4.6±1.7 degrees, and all patients achieved full functional recovery with return to normal daily activity. No complications were reported. Closed techniques, for example, Ishiguro extension blocking wires, may reduce the risks associated with open reduction, but do not avoid further articular surface damage. PBNR offers the surgeon a useful adjunct to the treatment options for bony mallet injuries, without excluding progression to surgical fixation if required. PBNR represents a less-invasive management option for bony mallet injures where surgical fixation may also be indicated.
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Affiliation(s)
- Benjamin H Miranda
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
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13
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Niziol R, Henry FP, Leckenby JI, Grobbelaar AO. Is there an ideal outcome scoring system for facial reanimation surgery? A review of current methods and suggestions for future publications. J Plast Reconstr Aesthet Surg 2015; 68:447-56. [DOI: 10.1016/j.bjps.2014.12.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 11/03/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
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14
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Leckenby JI, Grobbelaar AO. Facial reanimation. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Marsh DJ, Fox A, Grobbelaar AO, Chana JS. Abdominoplasty and seroma: A prospective randomised study comparing scalpel and handheld electrocautery dissection. J Plast Reconstr Aesthet Surg 2015; 68:192-6. [DOI: 10.1016/j.bjps.2014.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/16/2014] [Accepted: 10/01/2014] [Indexed: 11/24/2022]
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Butler DP, Henry FP, Leckenby JI, Grobbelaar AO. The Incidence of Facial Vessel Agenesis in Patients with Syndromic Congenital Facial Palsy. Plast Reconstr Surg 2014; 134:955e-958e. [DOI: 10.1097/prs.0000000000000731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Leckenby JI, Harrison DH, Grobbelaar AO. Static support in the facial palsy patient: A case series of 51 patients using tensor fascia lata slings as the sole treatment for correcting the position of the mouth. J Plast Reconstr Aesthet Surg 2014; 67:350-7. [DOI: 10.1016/j.bjps.2013.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/05/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
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Abstract
Flexor tendon injuries remain a significant clinical problem, owing to the formation of adhesions or tendon rupture. A number of strategies have been tried to improve outcomes, but as yet none are routinely used in clinical practice. Understanding the role that growth factors play in tendon repair should enable a more targeted approach to be developed to improve the results of flexor tendon repair. This review describes the main growth factors in tendon wound healing, and the role they play in both repair and adhesion formation.
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Affiliation(s)
- O A Branford
- Institute for Plastic Surgery Research and Education, The Royal Free Hospital, London, UK
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Butler DP, Woollard A, Grobbelaar AO. Dual-consultant led elective microsurgery: the implications on service provision and training. J Plast Reconstr Aesthet Surg 2013; 66:1435-6. [PMID: 23623271 DOI: 10.1016/j.bjps.2013.04.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/04/2013] [Indexed: 11/19/2022]
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Verhoekx JSN, Beckett KS, Bisson MA, McGrouther DA, Grobbelaar AO, Mudera V. The mechanical environment in Dupuytren's contracture determines cell contractility and associated MMP-mediated matrix remodeling. J Orthop Res 2013; 31:328-34. [PMID: 22987740 DOI: 10.1002/jor.22220] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/07/2012] [Indexed: 02/04/2023]
Abstract
Matrix metalloproteinases (MMPs) are expressed in Dupuytren's contracture and play a role in matrix remodeling. We tested the role of tension on contractility and MMP expression in Dupuytren's nodule and cord cells. Cells were subjected to pre-determined loading patterns of known repeatable magnitudes (static load, unloading, and overloading) and tested for MMP gene expression (MMP-1, -2, -9, -13, and TIMP-1, -2) and force generation using a tension-culture force monitor. Matrix remodeling was assessed by addition of cytochalasin D and residual matrix tension was quantified. Nodule compared to cord and control cells demonstrate greater force generation and remodeling (p < 0.05). Nodule cells subjected to a reduced load and overloading led to threefold increase of MMP-1, -2, and -9 compared to static load, whilst cord and control cells only showed a twofold increase of MMP-9. Nodule cells subjected to overloading showed a twofold increase in TIMP-2 expression, whilst cord and control cells showed a twofold increase in TIMP-1 expression. Nodule cells differ from cord cells by increased force generation in response to changes in the mechanical environment and related MMP/TIMP-mediated matrix remodeling. In turn this may lead to permanent matrix shortening and digital contracture. Interventional therapies should be aimed at nodule cells to prevent contraction and subsequent permanent matrix remodeling.
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Affiliation(s)
- Jennifer S N Verhoekx
- Institute of Orthopaedics and Musculoskeletal Sciences, University College London, Stanmore, United Kingdom.
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21
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Leckenby JI, Grobbelaar AO, Aston W. The use of a free vascularised fibula to reconstruct the radius following the resection of an osteosarcoma in a paediatric patient. J Plast Reconstr Aesthet Surg 2012; 66:427-9. [PMID: 22947773 DOI: 10.1016/j.bjps.2012.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 08/08/2012] [Accepted: 08/08/2012] [Indexed: 11/17/2022]
Abstract
Osteosarcoma is the most common high grade bone malignancy in children and the surgical treatment traditionally involves amputation. In our case, a 6-year-old girl was diagnosed with an osteosarcoma of the left distal radius after presenting with forearm pain. After initially being offered an amputation, a second opinion was sought and a limb salvage procedure was offered using a free vascularised fibula bone flap. This resulted in limb preserving surgery which allowed the potential for growth with the maximal preservation of function.
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Affiliation(s)
- J I Leckenby
- Department of Plastic and Reconstructive Surgery, The Royal Free London NHS Foundation Trust, Pond Street, Hampstead, London NW3 2QG, UK.
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22
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Abstract
The mechanics of adhesions at a local tissue level have not been extensively studied. This study compared microstrains and macrostrains in adhesions of immobilized and mobilized partially lacerated flexor digitorum profundus tendons in a New Zealand White rabbit model. At 2 weeks, 50 digits were randomized to either gross tensile testing or micromechanical assessment, in which the movement of fluorescently labelled cell nuclei, acting as dynamic markers, was visualized using real-time confocal microscopy. The structural stiffness and load at failure of immobilized adhesions were 140% and 160% of that of mobilized adhesions, respectively, and both differences were statistically significant. Micromechanically, different patterns of loading and failure were observed. Mobilized adhesions exhibited over a three-fold higher local strain, which was less uniformly distributed. Confocal microscopy provided an accurate measure of local strain. For the first time, it has been possible to visualize, define, and quantify local adhesion tissue mechanics. Mobilization appears to favour the formation of sites expressing increased local strain responses or those predisposed to heterogeneity and localized failure.
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Affiliation(s)
- O A Branford
- RAFT, Mount Vernon Hospital, Northwood, Middlesex, UK.
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23
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Harrison DH, Grobbelaar AO. Pectoralis minor muscle transfer for unilateral facial palsy reanimation: An experience of 35 years and 637 cases. J Plast Reconstr Aesthet Surg 2012; 65:845-50. [DOI: 10.1016/j.bjps.2012.01.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 01/04/2012] [Accepted: 01/29/2012] [Indexed: 11/24/2022]
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Branford OA, Lee DA, Rolfe KJ, Grobbelaar AO. The attachment of intrinsic and extrinsic, mobilized and immobilized adhesion cells to collagen and fibronectin. J Hand Surg Eur Vol 2012; 37:564-72. [PMID: 22095400 DOI: 10.1177/1753193411428994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study investigated the attachment of intrinsic and extrinsic, mobilized and immobilized adhesion cells to the extracellular matrix. Five New Zealand White rabbit forepaws were dissected to isolate the flexor tendon core, tendon surface and synovial sheath, which were explanted separately. A further 10 animals were subjected to flexor tendon injuries, randomized to either mobilization or immobilization, and adhesions were explanted at 2 weeks. Cell groups were tested for attachment to collagen type-I or fibronectin and morphometric analysis was made. The attachment of intrinsic tendon cells and adhesion cells from mobilized tendons to both matrix proteins was statistically significantly greater than that of extrinsic tendon cells and adhesion cells from immobilized tendons. Adhesion cells from mobilized tendons were statistically significantly more elongated, which may correlate with the deposition of a more organized matrix. Because the synovial sheath cells were least attached to matrix proteins, selective treatments that reduce cell attachment may be used to exclude them, without inhibiting intrinsic tendon healing.
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Affiliation(s)
- O A Branford
- RAFT, Mount Vernon Hospital, Northwood, Middlesex, UK.
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25
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Abstract
Wound healing is a complex process involving a number of processes. Fetal regeneration has been shown to have a number of differences compared to scar-forming healing. This review discusses the number of differences identified in fetal regeneration. Understanding these differences may result in new therapeutic targets which may reduce or even prevent scarring in adult healing.
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Affiliation(s)
- K J Rolfe
- Institute for Plastic Surgery Research and Education, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
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Penn JW, Grobbelaar AO, Rolfe KJ. The role of the TGF-β family in wound healing, burns and scarring: a review. Int J Burns Trauma 2012; 2:18-28. [PMID: 22928164 PMCID: PMC3415964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 12/30/2011] [Indexed: 06/01/2023]
Abstract
It is estimated worldwide that over 6 million people per annum experience a burn injury. Despite advances in management and improved survival rates, the incidence of hypertrophic scarring remains high. These scars are particularly common after burns and are often raised, red, hard and may cause abnormal sensations. Such pathological scarring can lead to severe functional impairment, psychological morbidity, and costly long term healthcare. Wound healing is an inherent process which restores the integrity of the skin after injury and although scarring is a frequent by-product, the scarless wound healing observed in early human gestational fetuses suggests that it is not an essential component of the response. This has lead to a large body of research attempting to understand the mechanisms behind scarring and in turn prevent it. One of the main focuses of recent research has been the role played by the growth factor TGF-β in the process of both wound healing and scar formation. The three isoforms (TGF-β1, TGF-β2 and TGF-β3) appear to have overlapping functions and predominantly mediate their effects through the intracellular SMAD pathway. Initial research suggested that TGF-β1 was responsible for the fibrotic scarring response whereas the scarless wound healing seen in fetal wounds was due to increased levels of TGF-β3. However, the reality appears to be far more complex and it is unlikely that simply altering the ratio of TGF-β isoforms will lead to scarless wound healing. Other aspects of the TGF-β system that appear promising include the downstream mediator CTGF, the proteoglycan decorin and the binding protein p311. Other putative mechanisms which may underlie the pathogenesis of hypertrophic scars include excessive inflammation, excessive angiogenesis, altered levels of matrix metalloproteinases, growth factors, and delayed apoptosis of fibrotic myofibroblasts either due to p53 genetic alterations or tensile forces across the wound. If an effective treatment for hypertrophic scars following burns injury is to be developed then further work must be carried out to understand the basic mechanisms of pathological scarring.
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Affiliation(s)
- Jack W Penn
- The Institute of Plastic Surgery, Research and Education. Dept Plastic Surgery, The Royal Free Hospital Pond St Hampstead, London UK, NW3 2QG
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27
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Rolfe KJ, Grobbelaar AO. The growth receptors and their role in wound healing. Curr Opin Investig Drugs 2010; 11:1221-1228. [PMID: 21157641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Abnormal wound healing is a major problem in healthcare today, with both scarring and chronic wounds affecting large numbers of individuals worldwide. Wound healing is a complex process involving several variables, including growth factors and their receptors. Chronic wounds fail to complete the wound healing process, while scarring is considered to be an overzealous wound healing process. Growth factor receptors and their ligands are being investigated to assess their potential in the development of therapeutic strategies to improve wound healing. This review discusses potential therapeutics for manipulating growth factors and their corresponding receptors for the treatment of abnormal wound healing.
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Affiliation(s)
- Kerstin J Rolfe
- The Royal Free Hospital, Institute for Plastic Surgery Research and Education, Pond Street, Hampstead, London, NW3 2QG, UK.
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28
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Woollard AC, Harrison DH, Grobbelaar AO. An approach to bilateral facial paralysis. J Plast Reconstr Aesthet Surg 2010; 63:1557-60. [DOI: 10.1016/j.bjps.2010.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 01/25/2010] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
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Ghali S, MacQuillan A, Grobbelaar AO. Reanimation of the middle and lower face in facial paralysis: review of the literature and personal approach. J Plast Reconstr Aesthet Surg 2010; 64:423-31. [PMID: 20471341 DOI: 10.1016/j.bjps.2010.04.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 04/06/2010] [Accepted: 04/09/2010] [Indexed: 11/29/2022]
Abstract
Facial paralysis refers to a condition in which all or portions of the facial nerve are paralysed. The facial nerve controls the muscles of facial expression, paralysis which results in a lack of facial expression which is not only an aesthetic issue, but has functional consequences as the patient cannot communicate effectively. The treatment of long-standing facial paralysis has challenged plastic surgeons for centuries, and still the ultimate goal of normality of the paralysed hemi-face with symmetry at rest as well as the generation of a spontaneous symmetrical smile with corneal protection has not yet fully been reached. Until the end of the 19th century, the treatment of this condition involved non-surgical means such as ointments, medicines and electrotherapy. With the advent and refinement of microvascular surgical techniques in the latter half of the 20th century, vascularised free muscle transfers coupled with cross-facial nerve grafts were introduced, allowing the possibility of spontaneous emotion being restored to the paralysed face became reality. The aim of this article is to revisit the surgical evolution and current options available as well as outcomes for patients suffering from facial paralysis concentrating on middle and lower face reanimation.
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Affiliation(s)
- Shadi Ghali
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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Klass BR, Branford OA, Grobbelaar AO, Rolfe KJ. The effect of epigallocatechin-3-gallate, a constituent of green tea, on transforming growth factor-beta1-stimulated wound contraction. Wound Repair Regen 2009; 18:80-8. [PMID: 20002896 DOI: 10.1111/j.1524-475x.2009.00552.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Dermal fibrosis, or scarring, following surgical incisions, traumatic wounds and burns presents a major clinical burden. Transforming growth factor (TGF)-beta1 is a major factor known to stimulate fibroblast proliferation, collagen production, and the differentiation of fibroblast to myofibroblast promoting wound contraction. Furthermore, excessive or prolonged TGF-beta1 has been shown to be associated with scarring. Green tea contains high amounts of polyphenols with the major polyphenolic compound being epigallocatechin-3-gallate (EGCG). EGCG has been shown to be anti-inflammatory, anti-oxidant, and may improve wound healing and scarring, though its precise effect on TGF-beta1 remains unclear. This study aimed at determining the effect of EGCG on TGF-beta1 collagen contraction, gene expression and the differentiation of fibroblast to myofibroblast. EGCG appears to affect the role that TGF-beta1 plays in fibroblast populated collagen gel contraction and this seems to be through both myofibroblast differentiation and connective tissue growth factor gene expression and reduces the expression of collagen type I gene regulation.
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Affiliation(s)
- Benjamin R Klass
- The RAFT Institute, Mount Vernon Hospital, Northwood, Middlesex, United Kingdom
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31
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Townley WA, Cambrey AD, Khaw PT, Grobbelaar AO. The role of an MMP inhibitor in the regulation of mechanical tension by Dupuytren's disease fibroblasts. J Hand Surg Eur Vol 2009; 34:783-7. [PMID: 19786408 DOI: 10.1177/1753193409345188] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Mechanical tension and contracture are two related facets of tissue biology. This study assessed the effect of ilomastat, a broad-spectrum matrix metalloprotease (MMP) inhibitor, on generation of tension by Dupuytren's disease fibroblasts. Nodule and cord-derived fibroblasts were isolated from five patients with Dupuytren's disease; flexor retinaculum acted as the control. A culture force monitor (CFM) provided an in vitro model of tissue organization to assess development of mechanical tension, lattice contraction and spatial remodelling by fibroblasts. Responses to ilomastat were compared to treatment with a control peptide. Nodule and cord-derived fibroblasts exhibited a two-fold increase in tension compared with flexor retinaculum. Ilomastat significantly inhibited development of tension by nodule and cord but not flexor retinaculum derived fibroblasts at 100 microM. These results imply that MMP activity mediates regulation of tensile strength by Dupuytren's disease fibroblasts and may be an important therapeutic target in patients with Dupuytren's disease.
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Affiliation(s)
- W A Townley
- RAFT Institute of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, UK.
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Abstract
INTRODUCTION Accurate clinical diagnosis depends on the reliable recognition of signs and symptoms. This expertise comes from experience in seeing patients which has been traditionally gained over a long training period. Shortened specialist training (Modernising Medical Careers) has led to a greater reliance on structured teaching and skills transfer programmes. The accuracy of clinical diagnosis and the rate at which diagnostic skills improve during training is important for the assessment of trainees, and the delivery of care. PATIENTS AND METHODS This study assessed the accuracy of clinical diagnosis of skin lesions by two junior plastic surgery trainees. They were asked to diagnose 120 consecutive skin lesions seen in a pigmented skin lesion clinic in 2005, with the histological diagnosis being confirmed following subsequent excision. The process was repeated a year later in 2006 to enable the rate of correct diagnosis to be compared. RESULTS Initially, 53.3% of diagnoses were correct. A year later, this had risen to 65.0%. Twenty-two different skin pathologies were present in excised specimens, and skin cancers comprised 30%. The trainees demonstrated 93.8% sensitivity in their initial diagnosis of malignancy (95% CI, 79.2-99.2) and 97.4% a year later (95% CI, 86.5-99.9). However, specificity was 69.3% (95% CI, 58.6-78.7) in 2005 and 71.6% (95% CI, 60.5-71.4) in 2006. CONCLUSIONS Accuracy in the diagnosis of the wide range of skin conditions presenting to an out-patient clinic was shown to increase over a 1-year period. We feel that this improvement resulted from regular clinical exposure supported by a structured learning programme. The shortening of the specialist training period may affect the acquisition of diagnostic skills by trainees and impact on the confidence with which they commence consultant practice.
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Affiliation(s)
- R A Pearl
- Department of Plastic Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK; Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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Klass BR, Rolfe KJ, Grobbelaar AO. In vitro flexor tendon cell response to TGF-beta1: a gene expression study. J Hand Surg Am 2009; 34:495-503. [PMID: 19258148 DOI: 10.1016/j.jhsa.2008.10.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 10/26/2008] [Accepted: 10/29/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Adhesion formation around zone II flexor tendon repairs remains an important clinical challenge. Tendon healing is complex, and when uncontrolled it may lead to adhesion formation. Transforming growth factor-beta1 (TGF-beta1) is a multipotent growth factor known to be involved in wound healing and scar formation. It has also been shown to have a role in both tendon healing and adhesion formation. METHODS Uninjured rabbit flexor tendons were divided into endotenon, epitenon, and sheath cells and cultured separately. The in vitro effect of TGF-beta1 gene expression was determined on quiescent tendon cells using real-time polymerase chain reaction for collagen type 1, collagen type 3, fibronectin, plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator (t-PA). RESULTS Endotenon-derived cells showed a statistically significant down-regulation of collagen type I gene expression in response to TGF-beta1 compared with untreated endotenon cells and with both epitenon and sheath cells at a number of time points. However, endotenon cells showed an increase in collagen type 3 gene expression compared with untreated cells and epitenon cells. All cells showed a statistically significant increase in fibronectin in the later time points compared with the untreated cells. Endotenon-derived cells showed an early increase in PAI-1, whereas sheath cells showed a later increase. CONCLUSIONS We have shown that cells cultured from 3 separate parts of the flexor tendon-sheath complex respond in different ways when stimulated with TGF-beta1. The down-regulation of collagen types 1 and 3 in endotenon cells may give further insight into the effects of TGF-beta1 in tendon healing. Also, the upregulation of fibronectin and PAI-1, combined with a down-regulation of tissue plasminogen activator, could explain the association of TGF-beta1 with tendon adhesion formation. Treatments aimed at improving tendon healing and the prevention of adhesions may arise from modification of the effects of TGF-beta1.
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Affiliation(s)
- B R Klass
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK.
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Klass BR, Grobbelaar AO, Rolfe KJ. Transforming growth factor 1 signalling, wound healing and repair: a multifunctional cytokine with clinical implications for wound repair, a delicate balance. Postgrad Med J 2009; 85:9-14. [PMID: 19240282 DOI: 10.1136/pgmj.2008.069831] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- B R Klass
- The RAFT Institute, Mount Vernon Hospital, Middlesex, UK.
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Townley WA, Cambrey AD, Khaw PT, Grobbelaar AO. Matrix metalloproteinase inhibition reduces contraction by dupuytren fibroblasts. J Hand Surg Am 2008; 33:1608-16. [PMID: 18984345 DOI: 10.1016/j.jhsa.2008.06.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 06/09/2008] [Accepted: 06/12/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Dupuytren's disease is a common fibroproliferative condition of the hand characterized by fibrotic lesions (nodules and cords), leading to disability through progressive digital contracture. Although the etiology of the disease is poorly understood, recent evidence suggests that abnormal matrix metalloproteinase (MMP) activity may play a role in cell-mediated collagen contraction and tissue scarring. The aim of this study was to investigate the efficacy of ilomastat, a broad-spectrum MMP inhibitor, in an in vitro model of Dupuytren fibroblast-mediated contraction. METHODS Nodule-derived and cord-derived fibroblasts were isolated from Dupuytren patients; carpal ligament-derived fibroblasts acted as control. Stress-release fibroblast-populated collagen lattices (FPCLs) were used as a model of contraction. FPCLs were allowed to develop mechanical stress (48 hours) during treatment with ilomastat (0-100 micromol/L), released, and allowed to contract over a 48-hour period. Contraction was estimated by measuring lattice area compared with untreated cells or treatment with a control peptide. MMP-1, MMP-2, and MT1-MMP levels were assessed by zymography, Western blotting, and enzyme-linked immunosorbent assay. RESULTS Nodule-derived fibroblasts contracted lattices (69% +/- 2) to a greater extent than did cord-derived (55% +/- 3) or carpal ligament-derived (55% +/- 1) fibroblasts. Exposure to ilomastat led to significant inhibition of lattice contraction by all fibroblasts, although a reduction in lattice contraction by nodule-derived fibroblasts was most prominent (84% +/- 8). In addition, treatment with ilomastat led to a concomitant suppression of MMP-1 and MMP-2 activity, whereas MT1-MMP activity was found to be upregulated. CONCLUSIONS Our results demonstrate that inhibition of MMP activity results in a reduction in extracellular matrix contraction by Dupuytren fibroblasts and suggest that MMP activity may be a critical target in preventing recurrent contracture caused by this disease.
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Affiliation(s)
- William A Townley
- RAFT Institute of Plastic and Reconstructive Surgery, Mount Vernon Hospital, The Leopold Muller Building, Northwood, UK.
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36
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MacQuillan AHF, Grobbelaar AO. Functional muscle transfer and the variance of reinnervating axonal load: part II. Peripheral nerves. Plast Reconstr Surg 2008; 121:1708-1715. [PMID: 18453995 DOI: 10.1097/prs.0b013e31816c3bb6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peripheral limb reconstruction using functional muscle transfer following injury or tumor resection has been widely reported in the literature. Such procedures often fail to deliver the physiologic contractile strength that might be hoped for in relation to the size of the transplanted muscle. Pure motor nerves of differing sizes were used to reinnervate a constant-sized muscle flap to see whether functional results could be improved in an experimental model analogous to clinical peripheral limb reconstruction. METHODS Twenty-four New Zealand White rabbits were divided into two groups of 12 animals each. The rectus femoris muscle was raised as a free flap and transplanted back to the donor site orthotopically (coapted back to its original motor nerve) in the rectus femoris group or heterotopically (coapted to the larger motor nerve to the vastus lateralis-double the axonal load of the indigenous nerve) in the vastus lateralis group. Half the animals from each group were euthanized at 6 months, and the remaining animals were at 9 months. In all cases, the contralateral rectus femoris muscle served as a control. RESULTS Physiologic assessment of the transplants for maximal tetanic contractural force was undertaken, together with immunohistochemical and histologic analysis of muscle and nerve tissue. Result analysis demonstrated that the double-sized nerve failed to produce significant improvements in physiologic outcome between the two groups at either the 6- or 9-month time point. The results were further endorsed by the histologic findings. CONCLUSION Increasing the axonal load to a functional muscle transplant beyond that of its indigenous motor nerve does not improve outcome.
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Rolfe KJ, Cambrey AD, Richardson J, Irvine LM, Grobbelaar AO, Linge C. Dermal fibroblasts derived from fetal and postnatal humans exhibit distinct responses to insulin like growth factors. BMC Dev Biol 2007; 7:124. [PMID: 17988375 PMCID: PMC2211318 DOI: 10.1186/1471-213x-7-124] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 11/07/2007] [Indexed: 12/19/2022]
Abstract
Background It has been well established that human fetuses will heal cutaneous wounds with perfect regeneration. Insulin-like growth factors are pro-fibrotic fibroblast mitogens that have important roles in both adult wound healing and during development, although their relative contribution towards fetal wound healing is currently unknown. We have compared responses to IGF-I and -II in human dermal fibroblast strains derived from early gestational age fetal (<14 weeks) and developmentally mature postnatal skin to identify any differences that might relate to their respective wound healing responses of regeneration or fibrosis. Results We have established that the mitogenic response of fetal cells to both IGF-I and -II is much lower than that seen in postnatal dermal fibroblasts. Further, unlike postnatal cells, fetal cells fail to synthesise collagen in response to IGF-I, whereas they do increase synthesis in response to IGF-II. This apparent developmentally regulated difference in response to these related growth factors is also reflected in changes in the tyrosine phosphorylation pattern of a number of proteins. Postnatal cells exhibit a significant increase in phosphorylation of ERK 1 (p44) in response to IGF-I and conversely the p46 isoform of Shc on IGF-II stimulation. Fetal cells however only show a significant increase in an unidentified 100 kDa tyrosine-phosphorylated protein on stimulation with IGF-II. Conclusion Dermal fibroblasts exhibit different responses to the two forms of IGF depending on their developmental maturity. This may relate to the developmental transition in cutaneous wound healing from regeneration to fibrosis.
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Affiliation(s)
- Kerstin J Rolfe
- RAFT Institute of Plastic Surgery, Leopold Muller Building, Mount Vernon Hospital, Northwood Middlesex, UK.
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38
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Stevens RJG, Grobbelaar AO. A simple barrier drape for breast implant placement. Plast Reconstr Surg 2007; 119:1956-1957. [PMID: 17440393 DOI: 10.1097/01.prs.0000259770.35123.9c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Roger J G Stevens
- RAFT Institute for Plastic Surgery, Mount Vernon Hospital, Northwood, Middlesex, United Kingdom
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Urso-Baiarda FG, MacQuillan AH, Grobbelaar AO. The Bottleneck Theory: Accounting for Clinical and Experimental Variability in the Outcome of Functional Muscle Transfer. Plast Reconstr Surg 2007; 119:1129-31. [PMID: 17312544 DOI: 10.1097/01.prs.0000253451.50796.e3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Pearl RA, Pacifico MD, Richman PI, Stott DJ, Wilson GD, Grobbelaar AO. Ki-67 expression in melanoma. A potential method of risk assessment for the patient with a positive sentinel node. J Exp Clin Cancer Res 2007; 26:109-15. [PMID: 17550139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Melanoma patients with a positive sentinel node biopsy generally proceed to regional lymph node dissection, though ultimately only around 20% have evidence of tumour in their "non-sentinel" nodes. A means to identify patients at high risk of non-sentinel node involvement could potentially spare a large number of patients a procedure with significant morbidity. The proliferation marker Ki-67 has been associated with tumour progression in primary melanoma but has not been extensively studied in metastases. The study aims to investigate Ki-67 in primary melanoma and lymph node metastases and investigate any relationship with disease progression. Tissue Arrays of primary melanoma (n=79) and lymph node metastases (n=92) were constructed from paraffin embedded tissue and Ki-67 expression examined by immunohistochemistry. Staining positivity and intensity were assessed and correlated with standard staging criteria and clinical outcome. High Ki-67 expression was associated with both Breslow thickness (chi(2)=8.54, p=0.035) and presence of ulceration (Fisher's Exact test p=0.003) in primary melanoma. In lymph node metastases high Ki-67 expression correlated with Nodal (N) Stage (chi(2)=8.193, p=0.0 17). High Ki-67 expression is associated with melanoma progression and multiple lymph node involvement. This might potentially form the basis of a risk analysis for patients with positive sentinel nodes.
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Affiliation(s)
- R A Pearl
- RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK.
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41
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Abstract
Microsurgeons may choose to avoid caffeine to prevent potentially deleterious caffeine tremor, although an adverse effect on surgical skill has never been shown. This double-blind placebo-controlled crossover study investigated the effect of moderate caffeine intake on microsurgical ability among microsurgical training course attendees. Subjects were randomized to receive either morning placebo and afternoon caffeine, or the reverse, thereby acting as their own controls. Performance in end-to-end vessel anastomosis was graded by a single observer during both sessions using a global rating scale. Subjects consuming caffeine in the morning demonstrated significantly improved scores from morning to afternoon, whereas subjects consuming caffeine in the afternoon showed no such improvement. These results are consistent with an adverse effect of caffeine on microsurgical skill combined with a learning curve among the study population of novice microsurgeons, and support the view that caffeine has a detrimental effect on microsurgical ability among this study group.
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Affiliation(s)
- Fulvio Urso-Baiarda
- Restoration of Appearance and Function Trust (RAFT), Leopold Muller Building, Mount Vernon Hospital, Northwood, Middlesex, UK.
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42
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Rogge FJ, Pacifico MD, Grobbelaar AO. Earlobe perforation after prolonged use of a topical corticosteroid. J Plast Reconstr Aesthet Surg 2007; 60:100-1. [PMID: 17126275 DOI: 10.1016/j.bjps.2006.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 05/14/2006] [Accepted: 05/31/2006] [Indexed: 11/20/2022]
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Abstract
Histopathological examination of peripheral nerves is often complemented by morphometric analysis in both clinical and research settings. However, existing manual or semi-automated methods are highly tedious, labour intensive and time-consuming, whereas fully automated morphometry is prone to error from the conversion of maldetected particles to spurious data. Both fully and interactive-automated morphometry have significant hardware requirements and may be difficult to implement. A new method for nerve morphometry is described aiming to combine the speed of automated morphometry with the accuracy of manual or semi-automated methods, and requiring only a digital image of the nerve section and two widely available software packages. Comparison with a standard digitizer pen method of nerve morphometry without sampling yielded statistically similar axon counts, mean area assessments and axonal area frequency distribution histograms, with assessment times of the new method between 35% and 45% of those of the standard method. This has widespread potential experimental and clinical applications and offers a means of relieving much of the tedium currently associated with nerve morphometry.
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Affiliation(s)
- Fulvio Urso-Baiarda
- Restoration of Appearance and Function Trust, Mount Vernon Hospital, Middlesex HA6 2RN, UK.
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44
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Affiliation(s)
- W A Townley
- RAFT Institute of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood HA6 2RN.
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45
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Abstract
BACKGROUND Fibroproliferative disorders, such as Dupuytren's contracture of the hand, are characterized by excessive production of collagen. 5-Fluorouracil has been used to treat fibroproliferative disorders of the eye and skin and is thought to inhibit thymidylate synthetase blocking DNA replication. 5-Fluorouracil has been shown to down-regulate fibroblast proliferation and differentiation in vitro. METHODS This study investigated the dose-dependent effect of 5-fluorouracil on fibroblast extracellular matrix production. Fibroblasts were derived from tendon and primary Dupuytren's disease of the hand, a fibroproliferative disorder of the palmar aponeurosis (n = 4 patients). Total collagen synthesis was determined by means of the incorporation of radiolabeled proline. Fibroblast secretion of the profibrotic factor transforming growth factor-beta1 (TGF-beta1) was measured by a sandwich enzyme-linked immunosorbent assay. Gene expression of collagen types I and III and TGF-beta1 were quantified by means of reverse-transcriptase polymerase chain reaction assays. RESULTS The authors found that 5-fluorouracil caused a dose-dependent, selective, and specific decrease in collagen production by Dupuytren's fibroblasts compared with noncollagenous protein synthesis. By contrast, procollagen types I and III mRNA were unaffected by 5-fluorouracil treatment. These changes did not appear to be mediated by alterations in the endogenous secretion of TGF-beta1 or its autocrine effect on collagen metabolism. CONCLUSIONS The clinical implication is that 5-fluorouracil could possibly reduce extracellular matrix production and therefore reduce recurrence of Dupuytren's disease of the hand.
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Affiliation(s)
- Neil W Bulstrode
- RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Middlesex, United Kingdom
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46
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Abstract
This was a retrospective study examining the psychosocial morbidity of patients before and after ear reconstruction. Semistructured questionnaires were sent to 90 patents with significant congenital or acquired auricular deformity 2.2 years (range 3 months to 5 years) following autogenous or osteointegrated reconstruction. Sixty-two patients (69%) responded. Twenty-two of the patients below 12 years, who had undergone reconstructive surgery, also completed the Childhood Experience Questionnaire. These were compared with a cohort of 362 normal patients. There was significant psychosocial morbidity in both children and adults with auricular deformity. Seventy-one percent of patients reported reduced self-confidence that affected both social life and leisure activity. Teasing was a prominent symptom in both children (88%) and adults (85%) but was a motivational factor for surgery in children only. Dissatisfaction with the appearance (73.1%), on the other hand, was the main reason for treatment in adults. Following ear reconstruction, 74% of adults and 91% of children reported an improvement in self-confidence resulting in enhanced social life and leisure activities in both adults and children. There was no difference between osteointegrated and autogenous reconstruction. Sixty percent of patients reported their result as excellent. The patients scored their result better than the surgeon. We conclude that auricular reconstruction has significant psychosocial benefit in the majority of children and adults despite donor-site morbidity and a range of technical result.
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Affiliation(s)
- Nigel Horlock
- Regional Centre for Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK
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Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing three rehabilitation regimes. ACTA ACUST UNITED AC 2005; 30:175-9. [PMID: 15757771 DOI: 10.1016/j.jhsb.2004.10.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2002] [Accepted: 10/12/2004] [Indexed: 11/19/2022]
Abstract
Forty-two patients with 46 complete extensor tendon injuries were prospectively allocated to one of three rehabilitation regimes: static splintage; interphalangeal joint mobilization with metacarpophalangeal joint immobilization or; the "Norwich" regime. All 42 patients were operated on by one surgeon and assessed by one hand therapist. At 4 weeks the total active motion in the static splintage group was significantly reduced but by 12 weeks there was no difference between the regimes. There was no difference in total active motion between the repaired and uninjured hand at 12 weeks, with all patients achieving good or excellent results. However, grip strength at 12 weeks was significantly reduced compared to the uninjured hand after static splintage. There was no difference in hand therapy input between the regimes.
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Affiliation(s)
- N W Bulstrode
- Department of Plastic Surgery and Hand Therapy Unit, Mount Vernon Hospital, Northwood, Middlesex, HA6 2RN, UK
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Tulley PN, Neale M, Jackson D, Chana JS, Grover R, Cree I, Grobbelaar AO, Wilson GD. The relation between c-myc expression and interferon sensitivity in uveal melanoma. Br J Ophthalmol 2004; 88:1563-7. [PMID: 15548813 PMCID: PMC1772437 DOI: 10.1136/bjo.2003.033498] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIM Interferons (IFN) are currently being used to treat melanoma, including some patients with uveal melanoma. IFN is thought to inhibit tumour growth through downregulation of the c-myc oncogene; the overexpression of which has been shown to be associated with resistance in cell lines. The aim of this study was to investigate the relation between c-myc gene expression and IFN sensitivity in a series of uveal melanomas in a short term chemosensitivity assay. METHODS Tumours from 45 patients with uveal melanoma who had undergone enucleation were studied. The ATP chemosensitivity assay was used to study sensitivity to IFN-alpha-2b in freshly isolated cells from each tumour. Flow cytometry was used to assess c-myc expression in formalin fixed material from the primary specimens. RESULTS There was a wide range of IFN sensitivity between the specimens whereas c-myc expression was universal and present in 80% of the tumour cells in 80% of the specimens. Higher c-myc expression was associated with IFN-alpha resistance as measured by the maximum percentage of inhibition (p = 0.05) and there was a trend with the IFN sensitivity index (p = 0.07). CONCLUSIONS These results demonstrate that tumours with high c-myc expression are also associated with IFN resistance. Future research is required to explore the potential of c-myc gene manipulation combined with IFN therapy.
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Affiliation(s)
- P N Tulley
- RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Northwood, Middlesex HA6 2JR, UK.
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Bulstrode NW, Bisson M, Jemec B, Pratt AL, McGrouther DA, Grobbelaar AO. A prospective randomised clinical trial of the intra-operative use of 5-fluorouracil on the outcome of dupuytren's disease. ACTA ACUST UNITED AC 2004; 29:18-21. [PMID: 14734063 DOI: 10.1016/j.jhsb.2003.08.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
5-Fluorouracil reduces proliferation rates of fibroblasts, myofibroblast differentiation and contractility of ocular fibroblasts in vitro. This double-blind randomized clinical trial assesses whether intra-operative topical treatment with 5-fluorouracil reduces the recurrence rate after limited excision of Dupuytren's tissue. Patients with two-digit disease were randomized to having 5-fluorouracil (25mg/ml) treatment for 5 minutes on one digit and placebo on the other. Fifteen patients were enrolled with 18 months follow-up. There were no peri-operative complications. Wound healing was not delayed and there was no deterioration in the flexion deformity of the 5-fluorouracil treated digits. Patients were subsequently assessed by joint angle measurement at 3, 6, 12 and 18 months. There was no significant difference between control and 5-fluorouracil treated digits.
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Affiliation(s)
- N W Bulstrode
- From the RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Northwood, HA6 2RN, UK
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50
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Bisson MA, Mudera V, McGrouther DA, Grobbelaar AO. The Contractile Properties and Responses to Tensional Loading of Dupuytren???s Disease???Derived Fibroblasts Are Altered: A Cause of the Contracture? Plast Reconstr Surg 2004; 113:611-21; discussion 622-4. [PMID: 14758224 DOI: 10.1097/01.prs.0000101527.76293.f1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dupuytren's disease causes disability because of the development of finger flexion deformities, with distinct nodule and cord formation. This results in physical shortening of the diseased fascial tissue through a combination of cell-mediated contraction and matrix remodeling. It is this fixed tissue fabric shortening that prevents finger extension. In this experimental study, the relative contractile properties of Dupuytren nodule- and cord-derived fibroblasts were quantified in a culture force monitor model, in comparison with normal carpal ligament fibroblasts. Nine nodule, 10 cord, and four carpal ligament fibroblast cell lines were studied; each cell line was derived from a separate patient. The contractile forces generated by nodule and cord fibroblasts were significantly greater than the force generated by carpal ligament fibroblasts. There were also significant differences between nodule- and cord-derived fibroblasts, with the nodule cells demonstrating the greatest contractile force generation. The contraction profiles of both cord and nodule Dupuytren fibroblasts demonstrated delays in the attainment of tensional homeostasis, with an absence of a plateau phase by 20 hours. After the contraction phase, cell-seeded constructs were subjected to a series of four uniaxial mechanical overloads and cellular responses were monitored during each subsequent 30-minute period. Dupuytren nodule and cord fibroblast responses were significantly altered, compared with carpal ligament fibroblasts, exhibiting an increased and opposite response. Dupuytren fibroblasts, particularly nodule fibroblasts, exhibited increased force generation and a delay in reaching tensional homeostasis. The data suggest that these cells have an inherently higher basal tension and contractile ability. This results in increased shortening of the matrix, and the delay in reaching tensional homeostasis might exacerbate this response. These results represent a theoretical framework regarding the fundamental processes involved in the pathogenesis and progression of clinical flexion deformities in Dupuytren disease.
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