Perineal reconstruction supplemented by abdominal advancement following recurrent penile cancer: Two cases

Reconstruction after excision of locoregionally recurrent penile cancer can be a surgical challenge. In this short study, we present two cases of perineal reconstruction using bilateral gracilis flaps supplemented by abdominal advancement for salvage of recurrent penile cancer, reviewing relevant literature and outlining our local approach to the perineum.

Management of wounds in the community: five principles

The care of any wound in the community requires multidisciplinary working between healthcare professionals. In this article, the authors offer five generalisable principles that colleagues providing community care can apply in order to achieve timely wound healing: (1) assessment and exclusion of disease processes; (2) wound cleansing; (3) timely dressing change; (4) appropriate (dressing choice; and (5) considered antibiotic prescription. High-quality wound care is an essential aspect of healthcare practice but lacks an evidence base and standardised practice at present. The practice and teaching of wound care should be more greatly emphasised in healthcare training for all disciplines.

Cartilage-like composition of keloid scar extracellular matrix suggests fibroblast mis-differentiation in disease

Following wound damage to the skin, the scarring spectrum is wide-ranging, from a manageable normal scar through to pathological keloids. The question remains whether these fibrotic lesions represent simply a quantitative extreme, or alternatively, whether they are qualitatively distinct. A three-way comparison of the extracellular matrix (ECM) composition of normal skin, normal scar and keloids was performed using quantitative discovery-based proteomics. This approach identified 40 proteins that were significantly altered in keloids compared to normal scars, and strikingly, 23 keloid-unique proteins. The major alterations in keloids, when functionally grouped, showed many changes in proteins involved in ECM assembly and fibrillogenesis, but also a keloid-associated loss of proteases, and a unique cartilage-like composition, which was also evident histologically. The presence of Aggrecan and Collagen II in keloids suggest greater plasticity and mis-differentiation of the constituent cells. This study characterises the ECM of both scar types to a depth previously underappreciated. This thorough molecular description of keloid lesions relative to normal scars is an essential step towards our understanding of this debilitating clinical problem, and how best to treat it.

Spatial and Single-Cell Transcriptional Profiling Identifies Functionally Distinct Human Dermal Fibroblast Subpopulations

Previous studies have shown that mouse dermis is composed of functionally distinct fibroblast lineages. To explore the extent of fibroblast heterogeneity in human skin, we used a combination of comparative spatial transcriptional profiling of human and mouse dermis and single-cell transcriptional profiling of human dermal fibroblasts. We show that there are at least four distinct fibroblast populations in adult human skin, not all of which are spatially segregated. We define markers permitting their isolation and show that although marker expression is lost in culture, different fibroblast subpopulations retain distinct functionality in terms of Wnt signaling, responsiveness to IFN-γ, and ability to support human epidermal reconstitution when introduced into decellularized dermis. These findings suggest that ex vivo expansion or in vivo ablation of specific fibroblast subpopulations may have therapeutic applications in wound healing and diseases characterized by excessive fibrosis.

Risk of Thromboembolism Following Body-Contouring Surgery After Massive Weight Loss

BACKGROUND

"Postbariatric" patients are at significant risk for increased postoperative complications. This study aimed to define the risk of venous thromboembolism following body-contouring surgery after massive weight loss.

METHODS

A retrospective analysis was performed on all patients who had undergone all forms of body-contouring procedures after massive weight loss between January 2005 and August 2012 at St George's Hospital, South West London, United Kingdom. Data were collected on patient demographics, comorbidities, risks factors for thromboembolism, preoperative and postoperative body mass index, and type of surgery.

RESULTS

A total of 135 operations were performed on 53 patients (43 females, 10 male), with an average age of 44.8 years (range, 26-56 years). Most had staged procedures including 55 abdominoplasties, 23 brachioplasties, 31 thigh lifts, 14 lower-body lifts, and 12 mastopexies. All patients received venous thromboembolism prophylaxis postoperatively including low-molecular-weight heparin (dalteparin) within an average of 22.5 hours after surgery and the application of intraoperative graduated compression stockings. Patients received dalteparin for an average of 4 days (range, 2-14 days), which correlated to their length of stay. One patient had a deep venous thrombosis 14 days postoperatively and then 2 days later developed a nonfatal pulmonary embolus, giving a venous thromboembolism prevalence of 0.74% (1/135).

CONCLUSIONS

The clinically apparent venous thromboembolism prevalence was low among patients undergoing body-contouring procedures after massive weight loss in this study. We provide evidence of a successful algorithm to prevent venous thromboembolism for patients undergoing body-contouring procedures after massive weight loss.

A preliminary report on the development of a validated tool for measuring psychosocial outcomes for massive weight loss patients

AIM

To validate the newly developed patient report outcome measure (PROM): the Post Bariatric Outcome Tool (PBOT). The tool is designed and developed for massive weight loss patients seeking body contouring procedures.

METHOD

The PBOT was piloted with three cohorts: massive weight loss patients seeking body contouring; massive weight loss patients who have had body contouring; and healthy, non-obese subjects as controls matched for age and gender. Each cohort completed two PROMS at week one, and then for a second time at week three. The PROMS used were the new Post Bariatric Outcome Tool (PBOT) and the Derriford Appearance Scale 24 (DAS24).

CONCLUSION

The PBOT was shown to be reliable both in terms of its internal consistency and test-retest reliability. Comparison to the DAS24 demonstrated the PBOT to be valid. However, the cohorts were small and responsiveness was not tested. This needs to be tested in further larger validation studies, ideally, with comparison to functional scales such as the SF-36 or other validated massive weight loss body contouring PROMs; such as the Body Q.

Changing Body Image and Well-Being: Following the Experience of Massive Weight Loss and Body Contouring Surgery

This paper reports on the perception of changing body image and well-being for patients who had undergone plastic surgery following massive weight loss. The exploratory, qualitative study was undertaken with 20 patients from one teaching hospital in the south of England. Semi-structured interviews were carried out and a thematic analysis of the data undertaken. The results provide important insights regarding body contouring influencing body image change and the adjustment process involved. The ability to pursue self-esteem and the accruing social benefits is emphasized in the interrelated sub themes including social acceptance, undoing depression and sexual vitality. Body contouring surgery following massive weight loss appears to facilitate improvement in body image and well-being. Adjustment to the changing body image is both empowering and challenging. Supportive educational programmes need to be developed to assist this transition to a more positive body image and appreciation; these could usefully include access to and involvement with patient support groups.

Identity transformation and a changed lifestyle following dramatic weight loss and body-contouring surgery: An exploratory study

This article reports on two major quality-of-life perception changes for patients who had undergone plastic surgery following dramatic weight loss. The exploratory, qualitative study was undertaken with 20 patients from one teaching hospital. In-depth interviews were conducted, and a thematic analysis of the data was undertaken. The results provide unique glimpses of surgical consumption empowering and facilitating ‘identity transformation’, embracing improved physical function and enhanced self-esteem, confidence and quality of life, and a ‘changed lifestyle’. For a minority, identity transformation was sometimes interrupted by ‘identity lag’, posing the need for additional health-care support throughout the adjustment process. The study provides additional insight into existing quantitative studies, adding to the body of knowledge in this area.

Impact of necrotising fasciitis on quality of life: a qualitative analysis

Mortality rates from severe necrotising soft tissue infections are improving progressively, therefore more emphasis should be placed on assessing and improving the quality of life of surviving patients. We investigated the functional and psychological issues, ability to social integration and self-perception of appearance in such patients presenting to our unit over 4 years. To conduct the study, we used the Short Form-36 and the Derriford Appearance Scale-24, which were distributed to those willing to participate. Ten patients have returned fully completed questionnaires. The overall quality of life and level of distress about the changed appearance were moderate (average SF-36 score of 65.8, DAS-24 score of 38). Statistical correlations between the scores and demographics were carried out using the Spearman rank correlation test. The capability of psychosocial adjustment was shown to improve with longer follow-up time and older age. However pain, physical limitations and energy levels were considerably more relevant in the older individuals and improved slower with time compared to psychological issues. Our results act as a good indicator of the quality of life in people dealing with the aftermath of necrotising soft tissue infections, but further, more extensive studies are required to achieve comprehensive and statistically significant results.

Patient satisfaction with receiving skin cancer diagnosis by letter: comparison with face-to-face consultation

Providing patients with clear and concise information is central to modern medical practice. Patients diagnosed with skin cancer are traditionally told their result by face-to-face consultation in the outpatient clinic. Previous studies have shown poor patient satisfaction with the traditional outpatient consultation. The skin oncology service at Kingston Hospital uses two different methods to inform selected patients of their skin cancer diagnosis. Those diagnosed with thin melanoma (MM) or squamous cell carcinoma (<2 cm) (SCC) are informed by letter (with an accompanying information leaflet), or seen in outpatient clinic for a face-to-face consultation. However, it is unclear which of these methods patients prefer. We performed a retrospective postal questionnaire survey to elicit the views of patients that had been informed of their skin cancer by these two methods. Patients had been diagnosed with either MM or SCC between February 2005 and March 2006. Demographic details and patient satisfaction using five-point Likert scales were determined. Of the eligible 118 patients, 90 (76%) completed the questionnaire. Questionnaires from five respondents were incorrectly completed and excluded from further analysis. Of the final 85 patients, 41 (48%) were told their diagnosis via face-to-face consultation (clinic) and 44 (52%) by letter. The demographic profile of both groups was similar (P>0.05). Patients of both groups had a similar expectation of being told a skin cancer diagnosis (P>0.05). A high level of satisfaction was expressed for both methods of communication, with no difference between the groups (P>0.05). In the letter group, patients placed more value on convenience than preference to seeing a doctor (P<0.001). The option of contacting a support nurse was also cited as a reassuring feature. The findings of this study suggest disclosure of skin cancer diagnosis by letter has high satisfaction, for selected patients. Using this method of communication may ultimately lessen the burden on outpatient service.

Pyoderma gangrenosum—Case report

We report the case of a woman of 34 years who had ulcerative colitis and atypical pyoderma gangrenosum. The pyoderma gangrenosum responded to conservative treatment.

The Split Skin Graft Donor Site: Can Pretreatment with Vitamin a Cream Help?

Background

A skin graft donor site that heals rapidly with less cosmetic sequelae is of particular benefit to children with burns. Vitamin A cream has been shown to speed up healing after controlled ‘burns’ (dermabrasion and CO2 laser) if it is applied six weeks before treatment.

Objective

To assess whether pretreatment with vitamin A cream increases the rate of healing of split skin graft donor sites in children with burns.

Methods

Prospective study of children with hot water burns of 8% to 30% that required split thickness skin grafting. Vitamin A cream was applied bidaily to one thigh and/or buttock of each child for five to seven days before skin grafting. At surgery, equal thickness grafts were harvested from both thighs and/or buttocks. Biopsies were taken from each thigh and/or buttock and were sent for histological analysis. The rate of donor site healing was monitored clinically and with serial photographs.

Results

No difference in the rate of healing was noted between the treated and untreated sides by either histological or clinical criteria.

Conclusions

Vitamin A cream applied bidaily for a period of five to seven days did not affect the healing rate of the split skin graft donor sites in children with burns.