The Art of Local Tissue Rearrangements in Burn Reconstruction: Z-Plasty and More.

In recent decades, advances in surgical anatomy, burn pathophysiology, surgical techniques, and laser therapy have led to a paradigm shift in how we approach burn scars and contractures. Scar excision and replacement with uninjured tissue, which predominated burn scar treatment for much of the 20th century, is no longer appropriate in many patients. A scar's intrinsic ability to remodel can be induced by reducing tension on the scar using various techniques for local tissue rearrangement. Often in combination with laser therapy, local flaps can optimally camouflage a burn scar with adjacent normal tissue and restore a patient more closely to their preinjury condition.

Evolution of Burn Care: Past, Present, and Future.

Burn care evolved slowly from primitive treatments depicted in cave drawings 3500 years ago to a vibrant medical specialty which has made remarkable progress over the past 200 years. This evolution involved all areas of burn care including superficial dressings, wound assessment, fluid resuscitation, infection control, pathophysiology, nutritional support, burn surgery, and inhalation injury. Major advances that contributed to current standards of care and improved outcomes are highlighted in this article. New innovations are making possible a future where severe burn injuries will require less morbid interventions for acute care and outcomes will restore patients more closely to their pre-injury condition.

Posttraumatic Penile Replantation with Minimal Skin Necrosis.

Penile amputation is a surgical emergency where practical and timely perioperative management is crucial for ensuring a successful outcome. Tenuous viability of penile and scrotal skin has been well described in the literature, with a putative mechanism attributed to the transection of distal branches of the external pudendal artery. Although the perforasomes critical to penile replantation have been debated, this case report details a patient who successfully recovered sensation and function with minimal necrosis after penile replantation. Surgically, this was facilitated by intentional drain placement, aggressive debridement beyond the zone of injury, and planned redundancies with dorsal artery/vein anastomoses via interposition grafts of the dorsal penile vessels alone.

Pediatric Postburn Ear Reconstruction of Significant Cartilage Defects.

The external ear is a vulnerable appendage susceptible to trauma. Repairing and recreating its intricate architecture presents a formidable challenge after burn injury, especially when scar tissue, impaired vasculature, and damage to cartilage all influence reconstructive options. The authors share their institutional experience and provide a guide for reconstruction of significant postburn auricular cartilage defects. A retrospective review was conducted on 54 patients (61 ears) aged 0-21 years old admitted to a specialized pediatric burn hospital between January 2004 and January 2021 for postburn ear cartilage reconstruction. Conchal cartilage grafting was performed in 9 patients (9 ears) with an average age of 14.0 ± 5.1 years, requiring an average of 2.0 ± 1.0 procedures that resulted in one case of infection. A total of 21 patients (24 ears) with an average age of 15.1 ± 4.5 years underwent a conchal transposition flap, requiring an average of 1.8 ± 0.4 procedures that resulted in no major complications. A total of 20 patients (23 ears) with an average age of 12.0 ± 5.3 years underwent porous polyethylene implantation, requiring an average of 3.5 ± 1.5 operations that resulted in 3 complications. Costal cartilage grafting was performed in 4 patients (5 ears) with an average age of 13.2 ± 5.3 years, requiring an average of 3.2 ± 2.2 operations that resulted in one case of infection. Postburn ear cartilage defects necessitate an individualized approach tailored to a patient's reconstructive goals. In addition to defect size and location, factors such as reconstructive course duration, complication potential, and anticipated aesthetic results should be discussed with the patient.

Posttraumatic Lip Replantation in a Pregnant Woman.

Traumatic lip amputation is a devastating injury. No other tissue replicates its unique histology, often limiting the reconstructive outcome. Replantation is a technically challenging procedure, requiring extensive postoperative optimization, including systemic anticoagulation, leech therapy, significant blood loss, and antibiosis. Given the rarity of replantation in the context of pregnancy, there are no documented accounts of lip replantation in pregnant patients. We report a case of a 25-year-old pregnant woman who sustained an avulsion injury of the right upper lip from a dog bite. The patient presented with the amputated lip and emergent microvascular replantation was performed. Postoperative course consisted of management of controlled yet significant blood loss through leech therapy and close collaboration with obstetric colleagues. The patient was ultimately discharged with successful cosmetic and functional outcome and, importantly, with maintenance of a healthy pregnancy.

Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports.

INTRODUCTION: Hypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications. METHODS: A literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars. RESULTS: We identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS. CONCLUSION: We found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases "complicated SIRS" and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation. APPLICABILITY OF RESEARCH TO PRACTICE: We urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.

Comparison of Transumbilical Laparoscopically Assisted Appendectomy to Conventional Laparoscopic Appendectomy in Children.

PURPOSE: To compare surgical outcomes of children with appendicitis treated with the transumbilical laparoscopically assisted appendectomy (TULAA) versus the conventional 3-port laparoscopic appendectomy (TPLA). MATERIALS AND METHODS: Retrospective study of pediatric patients with appendicitis treated with TULAA or TPLA between January 2010 and December 2015. Operative time (OT), length of stay, cost, and surgical site infection rate were compared between the 2 groups. RESULTS: Six hundred twenty-five appendectomies were performed [263 TULAA, 362 TPLA: acute (457), gangrenous (39), and perforated (129)]. TULAA had a shorter OT (median, 40 vs. 67 min; P<0.001), a shorter length of stay (median, 20 vs. 23 h; P<0.001), and a lesser cost (median $6266 vs. $8927; P<0.001). Surgical site infection rate was slightly higher in the TULAA group (6% vs. 4%; P=0.19). CONCLUSIONS: TULAA had a shorter OT and was less costly than conventional TPLA. TULAA should be considered as the first surgical approach at treating appendicitis in children.

Transumbilical laparoscopically assisted extracorporeal appendectomy in children and young adults: A retrospective cohort study.

BACKGROUND: To compare surgical outcomes of pediatric patients aged 0-15 with acute appendicitis treated with single-port, transumbilical, extracorporeal laparoscopically assisted appendectomy (SP) with young adult patients aged 16-21. MATERIALS AND METHODS: Single center retrospective chart review in patients 21 years and younger with a pre-operative diagnosis of appendicitis who underwent SP between January 2010 and December 2015. Patients were divided into two groups based on age. Operative time (OT), length of stay (LOS), cost, rates of conversion to standard three-port laparoscopic appendectomy (TP), and rates of infection were compared between the groups. RESULTS: SP was performed in a total of 263 patients: 211 in pediatric patients aged 0-15 and 52 in patients aged 16-21. Age groups did not differ significantly on cost, LOS, operative time, rates of conversion to TP, or rates of infection. CONCLUSIONS: SP has comparable surgical outcomes in adolescent, adult, and pediatric patients.

Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think!

BACKGROUND: A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation. PURPOSE: We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis. METHODS: A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR). RESULTS: The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different. CONCLUSIONS: Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

p53 mutations and survival in stage I non-small-cell lung cancer: results of a prospective study.

BACKGROUND: The p53 gene is frequently mutated in non-small-cell lung cancer (NSCLC); however, the effect of p53 gene mutations on patient prognosis remains unclear. Therefore, we initiated a prospective study to determine the association of p53 gene mutations with survival in patients with stage I NSCLC. METHODS: Tumor samples were collected prospectively from 188 patients with operable NSCLC (stages I, II, and IIIA). p53 mutations were detected by direct dideoxynucleotide sequencing and p53 GeneChip analysis. Association of clinical and pathologic variables (e.g., alcohol consumption, sex, age, pathologic stage) with mutation of the p53 gene was determined by logistic regression. Associations between p53 mutation status, clinical and pathologic variables, and survival were assessed using a Cox proportional hazards regression model. All statistical tests were two-sided. RESULTS: p53 mutations were detected in 55% (104/188) of tumors. These mutations were associated with non-bronchoalveolar tumors, a history of alcohol consumption, and younger patient age. The risk of death was statistically significantly higher in patients with p53 mutations in their tumors (hazard ratio [HR] = 1.6, 95% confidence interval [CI] = 1.0 to 2.4; P =.049) than in patients with wild-type p53 in their tumors. Tumor stage, the presence of a p53 mutation, and increasing patient age were statistically significant predictors of patient death in the entire patient group; however, the statistically significant prognostic effect of p53 mutation was limited to patients with stage I NSCLC (stage I HR = 2.8, 95% CI = 1.4 to 5.6; stage II HR = 1.8, 95% CI = 0.74 to 4.4; and stage III HR = 0.70, 95% CI = 0.32 to 1.5). Among patients with stage I NSCLC, actuarial 4-year survival was statistically significantly higher in those with wild-type p53 than in those with mutant p53 (78% versus 52%, respectively; difference in 4-year survival = 26%, 95% CI = 6% to 46%; P =.009, log-rank test). CONCLUSION: Tumor p53 mutations are a statistically significant predictor of poor outcome in patients with stage I NSCLC.