Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience.

PURPOSE: Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS: Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS: Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS: Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.

The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations.

PURPOSE: The paramedian forehead flap (PMFF) is a reconstructive option for large eyelid defects and orbital exenterations. We report a series of cases where PMFF reconstruction was carried out at various institutions in Australia. METHODS: This study was a multi-centre, retrospective, non-comparative case series investigating the clinical outcomes of the PMFF for reconstructing periocular defects and orbital exenterations. RESULTS: This case series describes twenty-seven patients (Female = 15, Male = 12), operated between 1991 to 2019, with a median age of 81 years (range: 45-93 years). Defect locations involved combinations of the medial canthus (16/27, 59.3%), upper eyelids (7/27, 25.9%), lower eyelid (4/27, 14.8%), both upper and lower eyelids (5/27, 18.5%), and orbital (7/27, 25.9%). There were no cases of flap necrosis. Minor post-operative complications were observed in ten patients with the most common being lagophthalmos. Median duration of follow-up was 17months (Range: 2months- 23years). CONCLUSIONS: The PMFF is a versatile reconstructive tool for a range of periocular defects and orbital exenterations with minor post-operative complications.

Devices measuring transepidermal water loss: A systematic review of measurement properties.

OBJECTIVE: The objective of this review is to examine the reliability and measurement error of devices that measure transepidermal water loss (TEWL). INTRODUCTION: TEWL is a physiological property of skin which increases when the epidermis is damaged. It is, therefore, a commonly utilised measure of skin barrier integrity. Devices measuring TEWL are available as open, semi-open or closed chamber. Studies of reliability examine the consistency of measurement, and/or responsiveness whereas measurement error scores in absolute terms the amount of error due to sources of variation. INCLUSION CRITERIA: Studies examining the reliability and/or measurement error of TEWL measurement devices were included. Studies that only report on measurement of TEWL outcomes without examination of reliability and/or measurement error were excluded. METHODS: The search strategy aimed to locate published and unpublished studies. Databases searched included PubMed, Embase, CINAHL and Web of Science, utilising identified keywords and limited to studies in English. Grey literature sources were searched to identify any unpublished documents. Study selection using the inclusion criteria was then assessed by two reviewers for methodological quality utilising the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias tool to assess the reliability and measurement error of outcome measurement instruments. RESULTS: A total of 22 devices were examined in the 38 included studies. The quality of study design was on average rated as 'Adequate' however reliability and measurement error statistical methods were on average rated as 'Doubtful'. DISCUSSION AND CONCLUSION: TEWL measurement devices were found to demonstrate good reliability and frequently correlated with other devices. However, measurement error was highly variable but improves under in vitro conditions. Future research should consider risk of bias factors when designing studies.

Devices measuring transepidermal water loss of the skin: a systematic review protocol of measurement properties.

OBJECTIVE: The objective of this review is to examine the reliability and measurement error of devices that measure transepidermal water loss. INTRODUCTION: Transepidermal water loss is a physiological property of skin that increases when the epidermis is damaged. It is, therefore, a commonly utilized measure of skin barrier integrity. Devices measuring transepidermal water loss are available as open, semi-open, or closed chamber. Studies that examine the similarities and differences between transepidermal water loss measurement devices are available. However, there has not been a systematic review to comprehensively collate and critique these studies. The aim of this review will be to synthesize the data from these studies to aid in selection and use of transepidermal water loss measurement devices in clinical practice or research. INCLUSION CRITERIA: Studies examining the reliability and/or measurement error of transepidermal water loss measurement devices will be included. Studies that examine a single device to demonstrate how different handling affects measurements will also be included. Studies that only report on measurement of transepidermal water loss outcomes without examination of reliability and/or measurement error will be excluded. METHODS: The search strategy will aim to locate published and unpublished studies. Databases to be searched will include PubMed, Embase, CINAHL, and Web of Science, utilizing identified keywords and limited to studies in English. Gray literature sources will be searched to identify any unpublished documents. Study selection will adhere to the inclusion criteria and then be assessed by two reviewers for methodological quality utilizing COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) guidelines and risk of bias tools. Extracted data will be presented in a narrative synthesis and as tables and figures to aid data presentation.

Novel Sternal Reconstruction With Custom Three-Dimensional-Printed Titanium PoreStar Prosthesis.

Resection of sternal tumors can leave large defects, which exposes major mediastinal structures, and can affect respiratory mechanics. If feasible, resection is potentially a complex reconstructive challenge to restore normal and functional anatomy using conventional techniques. We report the first Australian use of a three-dimensional-printed titanium and PoreStar prosthesis in a 39-year-old woman for reconstruction after major surgical resection of the sternum for metastatic breast cancer. The patient successfully underwent excision of the sternum and costal cartilages as well as implantation of the prosthesis. We conclude that three-dimensional-printed prostheses are technically feasible to deliver excellent cosmetic result.

Reconstruction of an Anterior Cervical Necrotizing Fasciitis Defect Using a Biodegradable Polyurethane Dermal Substitute.

Introduction: Although we have previously described the use of a novel polyurethane biodegradable dermal substitute in the reconstruction of 20 free flap donor sites, and extensive cutaneous defects, including a large area of exposed calvarium secondary to burn injury, our experience with this material now extends to 35 free flap donor site reconstructions and 13 major or complex burns. Methods: The polyurethane material (NovoSorb BTM; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) was recently employed in another complex wound scenario, implanted into a large anterior cervical cutaneous and soft-tissue defect remaining after serial radical debridement for necrotizing fasciitis. Results: Implantation, integration, delamination, and split-skin graft application proceeded without complication, mirroring our previous experience in other wounds (including major burns). The result was a robust, supple, mobile, and well-contoured reconstruction over the deep tissues of the neck. The functional and cosmetic outcomes exceeded all expectation. Discussion: The wound environment created after necrotizing fasciitis infection and debridement is austere. In this particular case, reconstructive options were limited to large free flap repair, skin graft alone, and skin graft augmented by commercially available collagen/glycosaminoglycan dermal matrix. Each option was discarded for various reasons. Our previous success with NovoSorb BTM, developed at our center, prompted its use following regulatory approval. The patient was physiologically stronger after the temporization afforded by the biodegradable temporizing matrix over 4 weeks of integration. Conclusion: This is the first description of the successful use of an entirely synthetic biodegradable dermal substitute for the reconstruction of both necrotizing fasciitis and an anterior cervical defect.

The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity.

BACKGROUND: Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. METHODS: Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. RESULTS: Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. CONCLUSION: Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.

In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

Reconstruction of Extensive Calvarial Exposure After Major Burn Injury in 2 Stages Using a Biodegradable Polyurethane Matrix.

OBJECTIVES: To share our experience of an extensive calvarial reconstruction in a severely burn-injured, elderly patient in a 2-stage procedure utilizing a novel biodegradable temporizing matrix (NovoSorb BTM), followed by autograft. MATERIALS AND METHODS: A 66-year-old patient with 75% full-thickness burns, including 7% total body surface area head and neck, with calvarial exposure of approximately 350 cm(2), complicated by acute renal failure and smoke inhalation injury. Exposed calvarium was burred down to diploe and biodegradable temporizing matrix was applied. Over the next 29 days, the biodegradable temporizing matrix integrated by vascular and tissue ingrowth from the diploe. Delamination and grafting occurred, however, at 43 days postimplantation of biodegradable temporizing matrix due to skin graft donor-site constraints. RESULTS: Graft take was complete, yielding a robust and aesthetically pleasing early result (26 days post-graft application). CONCLUSIONS: Biodegradable temporizing matrix offers an additional resource for reconstructive surgeons faced with fragile patients and complex wounds.

Free Flap Donor Site Reconstruction: A Prospective Case Series Using an Optimized Polyurethane Biodegradable Temporizing Matrix.

INTRODUCTION: We recently published a 10-patient case series where free flap donor site reconstruction was performed as a 2-stage procedure using an integrating biodegradable polyurethane matrix (to form a neodermis), followed by definitive closure with an autologous split-skin graft. Two issues were revealed by this pilot study that led to further modification of the biodegradable temporizing matrix. This involved alterations to the seal thickness and bonding to the foam matrix and the introduction of fenestrations to the seal. OBJECTIVE: This article documents a second cohort of patients requiring free flap (fibular and radial forearm) donor site reconstruction with this optimized material. METHODS: The biodegradable temporizing matrix was implanted when the free flap was detached from its donor site. Subsequent integration was monitored closely. Five weeks was the usual time of integration before delamination (seal removal), dermabrasion, and definitive closure with autograft. RESULTS: Integration was complete and uncomplicated in every case, delamination occurred in 1 piece in 1 action, and subsequent graft take was 100% for every patient. Long-term scar outcomes improved compared with the pilot group. Degradation is complete by 12 months, other than occasional microscopic remnants undergoing phagocytosis. CONCLUSION: This study has reiterated that the biodegradable temporizing matrix can be implanted into humans, followed by neovascularization and integration. No infection was observed, and split-skin overgrafting was successful and uncomplicated.

A biodegradable polyurethane dermal matrix in reconstruction of free flap donor sites: a pilot study.

We have developed a biodegradable temporizing matrix (BTM) capable of supporting secondary split-skin graft-take in animal studies. We report its first long-term implantation and use as a dermal scaffold in humans. This preliminary study assesses its ability to integrate, its ease of delamination, its ability to sustain split-skin graft in complex wounds, the degree of wound contraction, and ultimately the quality of the scar at 1 year postimplantation. Ten patients were recruited, each requiring elective free flap reconstruction. Free flap donor sites created were anterolateral thigh flaps, fibular osseocutaneous flaps, or radial/ulnar forearm (RF/UF) flaps. The BTM was implanted when the flap was detached from its donor site. Dressing changes were performed twice weekly. The time elapsed between implantation and delamination depended on the type of flap and thus the wound bed left. Once integrated, the BTMs were delaminated in theatre, and the surface of the "neodermis" was refreshed by dermabrasion, prior to application of a split-skin graft. The BTM integration occurred in all patients (100% in 6 patients, with 90%, 84%, 76%, and 60% integration in the remainder). Integrated BTM sustained successful graft-take in all patients. Complete take was marred in 2 patients, over areas of BTM that had not integrated and graft application was performed too early. The BTM can be applied into wounds in humans and can integrate, persist in the presence of infection, and sustain split-skin overgrafting, despite the trial group presenting with significant comorbidities.

Thoracic outlet syndrome following breast implant rupture.

We present a patient with bilateral breast implant rupture who developed severe locoregional silicone granulomatous lymphadenopathy. Poly Implant Prothese silicone implants had been used for bilateral breast augmentation 5 years prior. Extracapsular implant rupture and bilateral axillary lymphadenopathy indicated explantation, capsulectomy, and selective lymph node excision. Histology demonstrated silicone lymphadenopathy with no evidence of malignancy. Over the subsequent 12 months, she developed progressive locoregional lymphadenopathy involving bilateral cervical, axillary, and internal mammary groups, resulting in bilateral thoracic outlet syndrome. We report the unusual presentation, progression, and the ultimate surgical management of this patient.

Relative active motion programs following extensor tendon repair: A pilot study using a prospective cohort and evaluating outcomes following orthotic interventions.

STUDY DESIGN: Prospective cohort. INTRODUCTION: The Immediate Controlled Active Motion program, used to manage extensor tendon repairs in the hand, immobilizes the wrist in an orthosis with the affected finger(s) placed in a separate yoke orthosis allowing controlled flexion. PURPOSE: To compare our outcomes using similar programs in patients with simple extensor tendon lacerations to those previously reported. To compare our 4-week orthotic intervention to our 6-week orthotic intervention. METHODS: 18 subjects received a 4-week orthotic intervention, 45 subjects received a 6-week orthotic intervention. Range of motion was measured 4, 6 and 8 weeks post-repair, grip strength at 6 and 8 weeks, and patient-rated outcomes at baseline, 6 and 12 weeks post-repair. RESULTS: Significant improvements in all outcomes were seen over time (p < 0.0001), with no significant differences between programs. CONCLUSION: Outcomes were comparable with those previously published and similar between the 4-week and 6-week orthotic interventions. LEVEL OF EVIDENCE: III.

Approaches to routine handling of basal cell carcinoma re-excision specimens: a survey of Australian histopathologists.

AIMS: To investigate and assess variation in routine approaches to the handling of basal cell carcinoma (BCC) re-excision specimens by Australian histopathologists. METHODS: A questionnaire was sent to 440 Australian histopathologists requesting details of their routine approach to the handling of BCC re-excision specimens. Responses were collated and compared to demonstrate any variation in approach. RESULTS: Responses received from 208 pathologists indicated that variation was present in most aspects of specimen handling, including cut-up, examination of the specimen and reporting. CONCLUSIONS: Variation demonstrated in the routine handling of BCC re-excision specimens may have important academic and clinical implications. It is important for pathologists to communicate their specimen handling approach to the surgeon. Further study should be conducted to specifically compare the various specimen handling approaches that were identified in this study. The development of evidence-based guidelines for the routine handling of BCC re-excision specimens may be appropriate.

Approaches to routine handling of basal cell carcinoma re-excision specimens: a survey of Australian histopathologists.

AIMS: To investigate and assess variation in routine approaches to the handling of basal cell carcinoma (BCC) re-excision specimens by Australian histopathologists. METHODS: A questionnaire was sent to 440 Australian histopathologists requesting details of their routine approach to the handling of BCC re-excision specimens. Responses were collated and compared to demonstrate any variation in approach. RESULTS: Responses received from 208 pathologists indicated that variation was present in most aspects of specimen handling, including cut-up, examination of the specimen and reporting. CONCLUSIONS: Variation demonstrated in the routine handling of BCC re-excision specimens may have important academic and clinical implications. It is important for pathologists to communicate their specimen handling approach to the surgeon. Further study should be conducted to specifically compare the various specimen handling approaches that were identified in this study. The development of evidence-based guidelines for the routine handling of BCC re-excision specimens may be appropriate.

The medial sural artery as recipient vessel and the impact on the medial gastrocnemius.

Microsurgical free tissue transfer is a valuable technique for the reconstruction of soft-tissue defects around the knee, and the medial sural artery (MSA) is an ideal recipient vessel for anastomosis. Previously, the vessel has been described as the dominant supply to the medial gastrocnemius, but no research has addressed the subsequent effect to the muscle after interruption of MSA. The volume of the postoperative medial gastrocnemius of 4 patients treated with free flap reconstruction using MSA as recipient, was assessed clinically and using magnetic resonance imaging, with muscle function assessed using a patient questionnaire, and measurement of ankle torque with concurrent electromyography. Magnetic resonance imaging volume assessment revealed the postoperative medial head of gastrocnemius proportional to its synergist of separate blood supply, the lateral gastrocnemius and functional assessment suggest little difference between limbs such that the MSA should be used with confidence as recipient vessel for free flap reconstruction of soft-tissue defects around the knee.