Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review.

Cranioplasties are common procedures in plastic surgery. The use of tissue expansion (TE) in staged cranioplasties is less common. We present two cases of cranioplasties with TE and systematically review literature describing the use of TE in staged cranioplasties and postoperative outcomes. A systematic review was performed by querying multiple databases. Eligible articles include published case series, retrospective reviews, and systematic reviews that described use of TE for staged bony cranioplasty. Data regarding study size, patient demographics, preoperative characteristics, staged procedure characteristics, and postoperative outcomes were collected. Of 755 identified publications, 26 met inclusion criteria. 85 patients underwent a staged cranioplasty with TE. Average defect size was 122 cm 2 , and 30.9% of patients received a previous reconstruction. Average expansion period was 14.2 weeks. The most common soft tissue closures were performed with skin expansion only (75.3%), free/pedicled flap (20.1%), and skin graft (4.7%). The mean postoperative follow-up time was 23.9 months. Overall infection and local complication rates were 3.53 and 9.41%, respectively. The most common complications were cerebrospinal fluid leak (7.1%), hematoma (7.1%), implant exposure (3.5%), and infection (3.5%). Factors associated with higher complication rates include the following: use of alloplastic calvarial implants and defects of congenital etiology ( p = 0.023 and 0.035, respectively). This is the first comprehensive review to describe current practices and outcomes in staged cranioplasty with TE. Adequate soft tissue coverage contributes to successful cranioplasties and TE can play a safe and effective role in selected cases.

The role of neurotization in autologous breast reconstruction: Can reconstruction restore breast sensation?

As the sophistication of microsurgical breast reconstruction continues to evolve, plastic surgeons are focusing on techniques to improve functional and psychosocial outcomes for patients, including breast sensation. Interest in neurotization of breast flaps, among both patients and surgeons, has grown significantly in recent years. This study aimed to review the outcomes of neurotization across autologous flap reconstructions, to provide a comprehensive analysis of the efficacy of this technique in improving postoperative sensory recovery.

Patient Characteristics Associated with Free Nipple Graft Reduction Mammoplasty.

PURPOSE: Surgical approaches for reduction mammoplasty most commonly incorporate a parenchymal vascular pedicle. For patients with larger breasts where pedicle viability may be compromised due to excessive length, the free nipple graft (FNG) technique provides a safe alternative. Criteria for whether a patient should undergo a FNG remains controversial due to variable reports in the literature with small sample sizes and inherent surgeon-dependent bias. To address this, we sought to investigate perioperative factors associated with performing FNGs at our institution in order to better elucidate specific indications for this surgery. METHODS: A retrospective chart review was performed for 323 patients who underwent a reduction mammoplasty from August 2009 to July 2019 at Keck Hospital and LAC+USC Medical Center. Data regarding patient demographics, comorbidities, pre-operative breast characteristics, and post-operative complications were extracted. Student's t-test, Fisher's exact test, and logistic regression were performed in R. RESULTS: Of 323 patients, 15 received an FNG. Independent variables analyzed included: age, body mass index (BMI), obesity, smoking, diabetes, hypertension, surgical indication, sternal notch-to-nipple length, nipple-to-inframammary fold length, and weight of breast specimens removed. BMI, obesity, gigantomastia, and weight of specimen resected were significantly associated with use of the FNG (p < 0.001, p < 0.05, p < 0.0001, p < 0.0001, respectively). Regression analysis revealed that patients who had an average of more than 1500 g of tissue removed from each breast were 1.41 (95% CI: 1.17-1.71, p<0.001) times more likely to undergo an FNG procedure than those who had less than 1500 g of tissue removed. Demographic data and breast characteristics, such as notch-to-nipple length and nipple-to-inframammary fold length, were not significantly associated. CONCLUSION: Total weight of the breast specimens removed and BMI were significantly associated with the FNG technique. Removing more than 1500 g gof total breast tissue was also significantly correlated. These findings may guide surgeons during the decision-making process of when to use an FNG.

Role of stem cell therapies in treating chronic wounds: A systematic review.

BACKGROUND: The impairment of cutaneous wound healing results in chronic, non-healing wounds that are caused by altered wound environment oxygenation, tissue injury, and permissive microbial growth. Current modalities for the treatment of these wounds inadequately address the complex changes involved in chronic wound pathogenesis. Consequently, stem cell therapies have emerged as a potential therapeutic modality to promote cutaneous regeneration through trophic and paracrine activity. AIM: To investigate current literature regarding use of stem cell therapies for the clinical treatment of chronic, non-healing wounds. METHODS: PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus were queried with combinations of the search terms "mesenchymal stem cells," "adult stem cells," "embryonic stem cells," "erythroid precursor cells," "stem cell therapies," and "chronic wounds" in order to find relevant articles published between the years of 2000 and 2019 to review a 20-year experience. Reference lists from the articles were reviewed to identify additional pertinent articles. Retrieved manuscripts (reviews, case reports/series, retrospective/prospective studies, and clinical trials) were evaluated by the authors for their depiction of clinical stem cell therapy use. Data were extracted from the articles using a standardized collection tool. RESULTS: A total of 43 articles describing the use of stem cell therapies for the treatment of chronic wounds were included in this review. While stem cell therapies have been explored in in vitro and in vivo applications in the past, recent efforts are geared towards assessing their clinical role. A review of the literature revealed that adipose-derived stem cells, bone marrow-derived stem cells, bone marrow-derived mononuclear cells, epidermally-derived mesenchymal stem cells, fibroblast stem cells, keratinocyte stem cells, placental mesenchymal stem cells, and umbilical cord mesenchymal stem cells have all been employed in the treatment of chronic wounds of various etiologies. Most recently, embryonic stem cells have emerged as a novel stem cell therapy with the capacity for multifaceted germ cell layer differentiation. With the capacity for self-renewal and differentiation, stem cells can enrich existing cell populations in chronic wounds in order to overcome barriers impeding the progression of wound healing. Further, stem cell therapies can be utilized to augment cell engraftment, signaling and activity, and resultant patient outcomes. CONCLUSION: Assessing observed clinical outcomes, potential for stem cell use, and relevant therapeutic challenges allows wound care stakeholders to make informed decisions regarding optimal treatment approaches for their patients' chronic wounds.

A Pre-clinical Animal Model of Secondary Head and Neck Lymphedema.

Head and neck lymphedema (HNL) is a disfiguring disease affecting over 90% of patients treated for head and neck cancer. Animal models of lymphedema are used to test pharmacologic and microsurgical therapies; however, no animal model for HNL is described in the literature to date. In this study we describe the first reproducible rat model for HNL. Animals were subjected to two surgical protocols: (1) lymphadenectomy plus irradiation; and (2) sham surgery and no irradiation. Head and neck expansion was measured on post-operative days 15, 30 and 60. Magnetic resonance imaging (MRI) was acquired at the same time points. Lymphatic drainage was measured at day 60 via indocyanine green (ICG) lymphography, after which animals were sacrificed for histological analysis. Postsurgical lymphedema was observed 100% of the time. Compared to sham-operated animals, lymphadenectomy animals experienced significantly more head and neck swelling at all timepoints (P < 0.01). Lymphadenectomy animals had significantly slower lymphatic drainage for 6 days post-ICG injection (P < 0.05). Histological analysis of lymphadenectomy animals revealed 83% greater subcutis thickness (P = 0.008), 22% greater collagen deposition (P = 0.001), 110% greater TGFß1+ cell density (P = 0.04), 1.7-fold increase in TGFß1 mRNA expression (P = 0.03), and 114% greater T-cell infiltration (P = 0.005) compared to sham-operated animals. In conclusion, animals subjected to complete lymph node dissection and irradiation developed changes consistent with human clinical postsurgical HNL. This was evidenced by significant increase in all head and neck measurements, slower lymphatic drainage, subcutaneous tissue expansion, increased fibrosis, and increased inflammation compared to sham-operated animals.

Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis.

GENERAL PURPOSE: To present a systematic review of the literature assessing the efficacy of monitoring devices for reducing the risk of developing pressure injuries. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Explain the methodology of the literature review and its results.2. Discuss the scope of the problem and the implications of the research. ABSTRACT: OBJECTIVE: To assess the efficacy of monitoring devices for reducing the risk of developing pressure injuries (PIs). DATA SOURCES: The authors systematically reviewed the literature by searching PubMed/MEDLINE and CINAHL databases through January 2016. STUDY SELECTION: Articles included clinical trials and cohort studies that tested monitoring devices, evaluating PI risk factors on patients in acute and skilled nursing settings. The articles were scored using the Methodological Index for Non-randomized Studies. DATA EXTRACTION: Using a standardized extraction form, the authors extracted patient inclusion/exclusion criteria, care setting, key baseline, description of monitoring device and methodology, number of patients included in each group, description of any standard of care, follow-up period, and outcomes. DATA SYNTHESIS: Of the identified 1866 publications, 9 met the inclusion criteria. The high-quality studies averaged Methodological Index for Non-randomized Studies scores of 19.4 for clinical trials and 12.2 for observational studies. These studies evaluated monitoring devices that measured interface pressure, subdermal tissue stress, motion, and moisture. Most studies found a statistically significant decrease in PIs; 2 studies were eligible for meta-analysis, demonstrating that use of monitoring devices was associated with an 88% reduction in the risk of developing PIs (Mantel-Haenszel risk ratio, 0.12; 95% confidence interval, 0.04-0.41; I = 0%). CONCLUSIONS: Pressure injury monitoring devices are associated with a strong reduction in the risk of developing PIs. These devices provide clinicians and patients with critical information to implement prevention guidelines. Randomized controlled trials would help assess which technologies are most effective at reducing the risk of developing PIs.

Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006-2009.

Numerous international clinical guidelines for management of psoriasis have recently been published. We evaluated the quality of guidelines published between 2006 and December 2009 using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Eight guidelines from five separate working groups fulfilled inclusion criteria and were evaluated. Four used the standards established by the AGREE instrument in the process of development of their guidelines. Each of the guidelines uniformly received high domain scores (i.e., > 90%) for scope and purpose (range of 94-100%), and clarity and presentation (range of 92-100%). Nevertheless, each of the eight guidelines had important shortcomings (item scores < or = 2/4, in which 4 indicates strongly agree and 1 indicates strongly disagree that specific items have been adequately addressed) in at least one item including: stakeholder involvement (by lack of piloting and inadequate determination of patient views), development rigor (inadequate procedure for updating), applicability (by lack of discussion on organizational barriers), and editorial independence (from funding body). Despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.

Treatment of ingrown toenails in the pediatric population.

BACKGROUND/PURPOSE: Nail avulsion plus chemical matrixectomy (CM) using NaOH as an alternative to surgical matrixectomy (SM) has recently been used in the treatment of ingrown toenails (IGTNs) in adults. No studies exist to dictate the most effective and safe treatment method in the pediatric population. METHODS: A retrospective review of pediatric IGTNs treated at 2 institutions for 6 years was done, looking at presentation, treatment modality, SM vs CM, and outcomes. RESULTS: Eight hundred forty-eight IGTNs in 518 patients were reviewed with an average age of 12.5 years. Twenty-three percent were felt to be infected at the time of presentation, and 34% were being treated with antibiotics within the preceding week of surgery. Seventy-nine percent of toenails underwent surgical management with the most common procedure being avulsion plus SM (65%), followed by avulsion plus CM (17%), and avulsion alone (14%). The overall recurrence rate after initial surgery was 19.5%. After adjusting for covariates, recurrence was associated with treatment by avulsion alone (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.5-4.7), avulsion plus CM (OR, 0.3; 95% CI, 0.1-0.7), and treatment with antibiotics within the week before surgery (OR, 0.5; 95% CI, 0.3-0.9; P = .017). The overall postoperative infection rate was 6% and was unrelated to presence of preoperative infection, use of antibiotics, or surgical treatment method. CONCLUSIONS: Ingrown toenails present a significant problem to youth and should be addressed in a diligent fashion. Chemical matrixectomy using NaOH is a safe and effective alternative to SM and maybe associated with a lower rate of recurrence, especially when use in conjunction with preoperative antibiotics.