A Systematic Review of Conservatively Managed Isolated Extra-Articular Proximal Phalanx Finger Fractures in Adults.

Study design: Systematic review. Background: Proximal phalangeal fractures of the hand are challenging to treat, and significantly impact hand function and quality of life if poorly managed. Purpose: A systematic review to determine the efficacy of conservatively managed extra-articular proximal phalanx fractures to optimise recovery and prevent the need for surgical intervention and its associated risks. Methods: A literature search that included variations of the phrases 'proximal phalanx', 'fracture' and 'conservative management' was performed on 17 December 2023 using seven electronic databases and trial registries. Article screening, data extraction and critical appraisal using the Structured Effectiveness Quality Evaluation scale was performed independently. Results: Seven studies that captured 389 fractures from 356 unique patients were included. Studies were of level II to IV evidence and included one comparative cohort study and six prospective case series. Interventions involved timely rehabilitation, a plaster or orthotic device, controlled metacarpophalangeal joint flexion and free mobilisation of the interphalangeal joints. A weighted mean total active motion score of 249° was achieved, with 99.5% (387/389) of fractures achieving union. Conclusions: This systematic review cautions against definitive recommendations on conservative techniques for managing proximal phalanx fractures due to limitations of the available literature. However, our findings tentatively supports non-operative approaches as an alternative to surgery.

Evaluating Extended Curettage and Adjuvant Therapy Against Wide Resection and Reconstruction in the Management of Distal Radius Giant Cell Tumors: A Systematic Review and Meta-analysis.

BACKGROUND: The management of distal radius giant cell tumors (GCTs) remains challenging, and the optimal approach is still a matter of debate. This systematic review and meta-analysis aimed to compare the outcomes of extended curettage and wide resection, the mainstays of treatment. METHODS: Medline (via PubMed), Cochrane Library, Web of Science, Google Scholar, ClinicalTrials.gov, and Embase databases were searched for comparative studies that assessed extended curettage with adjuvant therapy and wide resection with reconstruction in patients with GCTs of the distal radius up to April 2023. Data were collected and analyzed on rates of local recurrence, metastasis, overall complications, and functional outcomes. The Newcastle-Ottawa scale was used to appraise the risk of bias within each study. RESULTS: Fifteen studies (n = 373 patients) were included and analyzed. Patients who underwent curettage were more likely to develop recurrence (risk ratio [RR] = 3.02 [95% confidence interval; CI, 1.87-4.89], P < .01), showed fewer complications (RR = 0.32 [95% CI, 0.21-0.49], P < .01), and showed greater improvement in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand scores (P < .00001) than those who underwent wide resection. No significant difference was found regarding metastasis (RR = 1.03 [95% CI, 0.38-2.78], P = .95). CONCLUSIONS: Regarding the surgical approach to GCT of the distal radius, curettage with adjuvant therapy was associated with a higher likelihood of recurrence compared with wide resection with reconstruction. Nevertheless, the curettage approach resulted in significantly lower rates of operative complications, decreased pain scores, and better functional outcomes in comparison to the resection group.

Neutrophil-lymphocyte ratio reflects tumour-infiltrating lymphocytes and tumour-associated macrophages and independently predicts poor outcome in breast cancers with neoadjuvant chemotherapy.

AIMS: The neutrophil-lymphocyte ratio (NLR) is a systemic reflection of cancer-associated inflammation and a prognostic marker for breast cancer. For the local tumour microenvironment, tumour-infiltrating lymphocytes (TILs) and tumour-associated macrophages (TAMs) are also highly correlated with breast cancer survival. This study aimed to explore the relationship between the circulating and local immune microenvironment, and to further delineate the prognostic role of NLR in breast cancer patients receiving neoadjuvant chemotherapy (NAC). METHODS: A cohort of breast cancer patients receiving NAC with subsequent surgery was retrieved. Clinical data were reviewed. Histological slides and CD8 immunohistochemistry from biopsy (pre-chemotherapy) and excision (postchemotherapy) specimens were assessed for TILs and TAMs. RESULTS: A total of 146 patients were included. There was a significant positive correlation between pre- and postsurgery NLR at a cut-off of 2.6 (median pre-chemotherapy NLR) (P < 0.001). NLR pre-chemotherapy was associated positively with necrosis on biopsy (P = 0.027) and excision (P = 0.021) and TAMs on excision (P = 0.049). NLR 1 year postsurgery was associated with high tumour stage (P = 0.050) and low histological grade (P = 0.008). TIL count was lower in NLR-high cases at almost all time-points by histological assessment and CD8 immunostaining (P < 0.050). In multivariate analysis, postsurgery NLR is an independent predictor for overall survival [OS; hazard ratio (HR) = 9.524, P < 0.001], breast cancer-specific survival (BCSS) (HR = 10.059, P = 0.001) and disease-free survival (DFS; HR = 2.824, P = 0.016). CONCLUSIONS: The association between NLR with tumour necrosis, TAMs and TILs illustrates an interaction between the circulating and local immune microenvironment. Late NLR is a strong indicator of outcome and may be useful for prognostication and disease monitoring.

The use of carbon dioxide and intense pulsed light laser for the treatment of hypertrophic burn scars: A case series.

Introduction: Hypertrophic scarring is a common and debilitating consequence of burn scars. While there is limited evidence for current treatment options, laser therapy has been shown to be effective, low risk and minimally invasive. This study assesses the use of carbon dioxide lasers and intense pulsed light devices in the treatment of hypertrophic burn scars. Methods: In this case series, patients were recruited from a hypertrophic burn scar waitlist and completed a Patient and Observer Scar Assessment Scale prior to and six weeks after laser therapy. The Nordlys (intense pulsed light) and CO2RE (carbon dioxide) systems from Candela Medical were used, with a range of settings used depending on the assessment of the burn scar. The differences between scores were calculated for the total Patient and Observer Scar Assessment Scale score, pain, itch, colour, stiffness, thickness, irregularity and the overall opinion of the scar. Statistical analysis was completed using a paired, two-tailed student T test. Results: A total of 31 patients were recruited for this trial with a range of scar locations, surface areas and mechanism of burn injury. The calculated difference in mean showed a significant reduction for the overall Patient and Observer Scar Assessment Scale score (1.93, p < 0.0001), pain (1.39, p = 0.0002), itch (1.84, p = 0.0002), colour (1.97, p < 0.0001), stiffness (2.47, p < 0.0001), thickness (2.1, p < 0.0001), irregularity (1.89, p < 0.0001) and overall opinion (1.58, p = 0.0003). Conclusion: Current management options for hypertrophic scarring have limited evidence. Laser therapy presents a minimally invasive procedure that can be completed under topical anaesthetic and has shown to be effective following a single treatment of combined carbon dioxide laser and intense pulsed light device therapy. Lay Summary: Many people will suffer a burn injury throughout their life and up to almost 3 out of 4 people with burn injuries will suffer from hypertrophic scars (a thickened, red and itchy scar). These scars cause distress both due to their appearance and their reduction of function, particularly over a joint or muscle. Laser therapy, in which different wave lengths of light (pulsed light) or gas (carbon dioxide) target the scar, has been found to be effective and have minimal side effects in the management of hypertrophic scars. While individual lasers have been assessed and found to be effective and low risk, the combined use of multiple lasers on the same scar has not been extensively studied. We studied the effectiveness of both light and gas laser therapies on hypertrophic scars. Patients with hypertrophic scars completed a questionnaire that focused on their perspective of their scar (pain, itch, stiffness, thickness, irregularity, overall opinion) prior to the treatment. The patients then underwent laser therapy (with local anaesthetic gel) with either pulsed light and/or carbon dioxide (gas) laser. The type of laser used was decided by the clinician performing the therapy depending on scar location and thickness. Patients then re-completed the subjective survey six weeks following the laser therapy, and the results compared. We learnt that laser therapy (both light, gas and a combination of both) are effective (and low risk) in reducing the subjective burden of the scar for the patient.

Twelve tips for co-production of online learning.

In the digital age, experts in digital learning tools, or learning technologists (LTs), play an increasingly important role in the creation and delivery of online learning in health professions education. However, their expertise in the selection, curation and implementation of digital tools is often underutilized due to imbalanced relationships and lack of effective collaboration between faculty and LTs. Here, we describe how the co-production model can be applied to build equal and synergistic partnerships between faculty and LTs, so as to optimize the use of digital affordances and enhance online learning.

Surgical management of pressure ulcers in spinal cord injury patients.

BACKGROUND: Pressure ulcers (PU) are a common yet debilitating injury within the spinal cord injury (SCI) population. This retrospective data analysis is intended to identify the contributing factors, review the current management protocol, and risk of recurrence of PU in SCI patients at Victoria's state referral centre for traumatic spinal cord injuries. METHODS: A retrospective audit of the medical records of SCI patients with pressure ulcers was conducted for the period of January 2016 to August 2021. Patients aged 18 years and older who presented for surgical management of their PU were included in the study. RESULTS: Among the 93 patients who met the inclusion criteria, there were a total of 195 surgeries for 129 PU. Ninety-seven percent were classified as grade of 3 or 4 and 53% had osteomyelitis on presentation. 58% were either current smokers or ex-smokers, and 19% were diabetic. Debridement alone was the most common type of surgical management (58%), followed by flap reconstruction (25%). Those who underwent flap reconstruction were admitted for 71 days longer, on average. 41% of the surgeries were associated with a post-operative complication, with the most prominent being an infection at 26%. Of the 129 PU, 11% recurred at least 4 months post initial presentation. CONCLUSION: There are a multitude of a factors that impact prevalence, surgical complications, and recurrence of PU. This study provides insight into these factors to review our current practices and optimize surgical outcomes in the management of PU in the SCI population.

Novosorb® Biodegradable Temporising Matrix (BTM) and its Applications.

The NovoSorb® Biodegradable Temporising Matrix (BTM) (PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) is a fully synthetic dermal matrix that can be used to reconstruct complex wounds. It consists of a 2mm-thick NovoSorb® biodegradable polyurethane open-cell foam covered by a non-biodegradable scaling member. Application involves a two-stage procedure. In the first stage, BTM is laid onto a clean wound bed, and in the second stage, the sealing membrane is removed and a split skin graft is applied to the neo-dermis. BTM has been used to reconstruct deep dermal and full-thickness burns, necrotising fasciitis, and free flap donor sites in the early phase. This review documents examples from a comprehensive series of cases in which BTM was applied to a wide range of complex wounds, ranging from hand and fingertip injury, to Dupuytren's surgery, chronic ulcers, post excision of cutaneous malignancies, and hidradenitis suppurativa. BTM can be applied to a wide range of complex wounds which may otherwise require a more challenging reconstruction. It should be considered an important adjunct to the reconstructive ladder.

Impact of the COVID-19 pandemic on children's mental health: A systematic review.

Background: The outbreak of COVID-19 in December 2019 has caused unprecedented disruption to the structure of children's daily lives due to school closures, online learning, strict social distancing measures, limited access to outdoor activities and many other restrictions. Since children are more susceptible to stress than adults and there is a growing concern about the potential debilitating consequences of COVID-19 for children's mental health, the present review aims to provide empirical evidence on the groups who are most at risk of mental health problems and uncover the risk and protective factors of children's mental health. Methods: A systematic search was performed, in accordance with PRISMA guidelines, in the electronic databases Web of Science (including SSCI and A&HI) and EBSCOhost (including ERIC, MEDLINE and APA PsycArticles and APA PsycINFO), for any empirical studies published between January 2020 and February 2022 that focused on children ≤ 12 years old. Results: An initial search identified 2,133 studies. A total of 30 studies fulfilled the inclusion criteria and were analyzed. The evidence showed that many children were affected by the COVID-19 pandemic and experienced internalizing and externalizing behaviors. Worsened child mental health outcomes reflected socioeconomic inequalities as most at-risk children had parents with low educational attainment, were from families of low socioeconomic status and lived in small homes. Key risk factors were identified, including unhealthy lifestyle behaviors (extended screen time, sleep disturbances and less physical activity), increased pandemic-related stressors among parents and deteriorated mental health of parents, which were directly or indirectly associated with the pandemic safety measures, such as home confinement or social distancing. Protective factors including parents' resilience, positive parent-child relationship and school connectedness in relation to children's mental health were reported. Conclusion: The overall results highlight the urgent need for the implementation of tailor-made interventions for children with signs of internalizing and externalizing behaviors. Health promotion and prevention strategies by the government to maintain the mental health of children, particularly those from lower SES families who are at higher risk of worsened mental health are essential for post-pandemic policies.

A qualitative study on the experience of stigma for Chinese parents of children with autism spectrum disorder.

Experiencing stigma related to having a child with autism spectrum disorder (ASD) can be difficult and is detrimental to parent well-being. Since the research on stigmatized experiences among parents of children with ASD in non-Western communities is limited, this qualitative study examined the experiences, reactions and impacts of stigma on parents of children with ASD in Hong Kong. In-depth interviews were conducted with 54 Chinese parents/caregivers of children with ASD aged between 35 and 73 years old. Data were analyzed using an inductive approach. The participants reported stigma which stemmed from negative labelling of their children by schools and healthcare professionals, bullying by peers, stereotypes of ASD and stigma linked to autistic children's behavior in the community. The reactions of participants towards stigmatization were classified into internalizing reactions including apologizing, ignoring and concealing ASD and externalizing reactions such as fighting back. The participants also reported impacts of stigma on both personal and emotional levels. The results point to the urgent need for the government to allocate resources and make concerted efforts to reduce stigma by educating the community to foster more positive attitudes towards individuals with ASD and offer support and counselling services to parents.

Identification of Unequal Flow-Carrying Capabilities of Choke Vessels in Rat Abdominal Flaps.

BACKGROUND: Although the angiosome concept is a well-accepted theory, unexpected necrosis suggests that other factors can influence the flap survival. Our study uses the rat model to explore the flow capacity of the choke vessels across 2 angiosomes. METHODS: The medioventral line of Sprague-Dawley rats' abdominal flap was equally divided into 4 sections, which were preserved in 7 different groups (n = 6/group): A, no dissection; B to D, preserve the inferior 1/4, 2/4, and 3/4 sections; E to G, preserve the superior 1/4, 2/4, and 3/4 sections. The ratio (%) of the survival area of the distal/proximal territory was calculated. Indocyanine green, lead-oxide gel imaging, hematoxylin and eosin, and CD31 histology tests were performed. RESULTS: Compared with 96.0 ± 1.4% flap survival in group A, groups B, C, and D had distal territory flap loss (34.8% ± 4.1%, 65.0% ± 3.7%, and 94.3% ± 3.1% respectively). Group E lost the majority of the distal territory (3.5% ± 2.4%), whereas groups F and G (15.5% ± 3.8% and 79.2% ± 3.3%, respectively) had larger flap survival. Except for groups A and D, each of the other 2 groups showed statistically significant results ( P < 0.001). Indocyanine green indicated no blood flow at the superior 1/4 part. Lead-oxide gel and histology showed that the choke vessels residing along the medioventral line had no significant difference. CONCLUSIONS: Choke vessels do not carry blood flow equally. Two categories of choke vessels-"resting" and "active"-are proposed. The "active" form has variable flow carrying capabilities when the flap is harvested in different designs.

An Innovative and Economical Device for Ischemic Preconditioning of the Forehead Flap Prior to Pedicle Division: A Comparative Study.

BACKGROUND: Ischemic preconditioning of the forehead flap prior to pedicle division helps to improve angiogenesis. Clamping the pedicle by a clamped rubber band with vessel forceps is often clinically applied. However, the severe pain and unstable blocking effect influenced the preconditioning process. In this study, we described an innovative device designed for ischemic preconditioning and compared its efficacy with the clamped rubber band. METHODS: The device consists of a self-locking nylon cable tie with a buckle and a rubber tube. The rubber tube is fed over the cable tie to act as a soft outer lining and the cable tie is tightened across the pedicle to block the perfusion for ischemic preconditioning. This device and the standard clamped rubber band were applied respectively before division surgery. The constriction effect, reliability, reproducibility, and the patients' pain tolerance were compared. RESULTS: A total of 20 forehead flaps were included. The cable tie had less incidence of loosening (7.7% vs. 16.6%, p < 0.05) and maintained the pressure more effectively. The pain score for the nylon cable tie was significantly lower than the clamped rubber band (4.25 ± 1.02 vs. 6.75 ± 1.12, p < 0.05), especially for 10 pediatric patients (4.50 ± 0.85 vs. 8.10 ± 1.20, p < 0.01). All 20 pedicles were successfully divided at 19 to 22 days with no surgical complications. CONCLUSION: Compared with the clamped rubber band, the cable tie produces a more reliable and reproducible ischemic preconditioning effect. It is also better tolerated by the patients. Therefore, we recommend using the nylon cable tie as the preferred device for ischemic preconditioning of the forehead flap.

Health-related Quality of Life Measurement Tools for Lymphedema: A Review of the Literature.

Lymphedema can significantly affect patients' health-related quality of life (HRQoL). Various quality of life scales have been developed to assess the extent of the disease burden. The purpose of this study is to review various HRQoL instruments that have been used in lymphedema studies and compare their qualities against the COSMIN checklist. Methods: A systematic literature review search was conducted for clinical lymphedema studies published between January 1, 1984, and February 1, 2020, using Pubmed database. All clinical lymphedema studies which used HRQoL instruments as outcome measures were identified. Results: One thousand seventy-six studies were screened-of which, 288 studies were individually assessed. Thirty-nine HRQoL instruments were identified in these clinical lymphedema studies. Of these, there are eight lymphedema-specific questionnaires that cover all HRQoL domains, all of which have been validated for use in lymphedema. We contrasted the two most popular questionnaires [LYMQOL and Upper Limb Lymphedema (ULL)-27] and compared their features. Conclusion: There is currently no ideal lymphedema HRQoL measurement tool available based on the COSMIN criteria. However, our review suggested that LYMQOL and ULL-27 are the most used and most validated instruments at present, but each has their own limitations. We recommend the use of LYMQOL and ULL-27 for future studies to allow direct HRQoL comparison to current literature. Further research is required to develop an optimal HRQoL questionnaire that can ultimately become the gold standard HRQoL instrument for lymphedema.

Using Modified Skin-Stretching Technique as an Alternative Solution for the Closure of Moderate and Extensive Skin Defects.

External skin-stretching devices have been developed and used for wound closure since 1970s. Devices such as Miami STAR®, SureClosure®, TopClosure®, and WiseBand® have their own advantages and disadvantages. The modified external skin-stretching technique of this case series study has the advantage to improve tension distribution and simplified the application. Between January 2014 and June 2017, 20 patients were treated with the modified external skin-stretching device for the closure of the skin defects of the trunk (n = 6) and extremities (n = 14). Skin defects ranged from 8 × 5 to 19 × 16 cm achieved primary closure with the utilization of the modified skin-stretching device without major complications. Subsequent minor revisions were performed under local anesthesia between 6 and 12 months postoperatively. The modified skin-stretching device utilized biomechanical properties and mechanical creep of skin tissue to achieve a reliable and effective primary closure for moderate to extensive skin defects. Therefore, this modified external skin-stretching technique provided, in the appropriate setting, an effective alternative to skin grafts or free flaps.

Medical Leadership: Experiences in the Use of Shared and Parental Leadership to Improve Academic Performance in the Management of a National Plastic Surgery Unit in China.

BACKGROUND: Effective leadership is an integral component for optimal academic performance of surgical units. As one of the leading plastic surgery academic medical centers in China, the authors would like to share their experiences of using the combined parental and shared leadership approach in managing their surgical staff within the department. It has taken into account the essence of Eastern moral philosophies and Western leadership theories. METHODS: The authors performed a review of the academic development of their staff and changes in the academic productivity of the department between 1999 and 2018. The difference between the first 10 years (1999 to 2008) and second 10 years (2009 to 2018) was analyzed to assess the effectiveness of the authors' leadership approach. RESULTS: There is an increase in the number of Science Citation Index articles published in the past decade with a higher impact factor and more articles published in international journals. The timing to promotion was on average 8.4 years. The average age of promotion to consultants has increased, likely because of a later start in the training. With similar average age, prior education, and gender ratio of surgeons in the unit, the department also received 14 times more in research funding and four times more in national key topic research topic. CONCLUSIONS: The effective application of this combined leadership approach has significantly improved the academic productivity and quality of the authors' residents and surgeons and the academic advancement of the unit.

Experience with NovoSorb® Biodegradable Temporising Matrix in reconstruction of complex wounds.

BACKGROUND: The NovoSorb® Biodegradable Temporising Matrix (BTM) is a synthetic polyurethane dermal matrix used to reconstruct complex wounds including deep dermal and full-thickness burns, necrotising fasciitis and free flap donor site. We hope to further explore its potential applications in this series. METHODS: Patients who received BTM application across four centres over an 18-month period were included. Patients were followed up to assess BTM and graft take, the aesthetic, the return of sensation and complications. RESULTS: A total of 27 patients with 35 wounds were identified with a range of aetiologies. Thirty-three wounds had 100% integration of BTM at the time of sealing membrane removal. Seven wounds had partial graft loss that later healed by secondary intention. In two cases, re-epithelialisation occurred with BTM alone without split-skin graft. CONCLUSION: BTM offers a safe and reliable reconstructive option in challenging wounds that would otherwise require more complex operations.

Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction.

BACKGROUND: Pre-expanded pedicled flaps possess a more flexible transfer pattern and higher tissue utilization than random flaps, but the perfusion is fully dependent on the chosen axial vessels. A precise mapping of the vessels would assist the surgical design and increase the likelihood of success. The application of Infrared thermography (IRT) has been previously reported for perforator location. The aim of this study is to report the use of IRT in mapping the course and distribution of axial vessels in the pre-expanded flap to guide the designing and harvesting. METHODS: Patients who underwent head and neck reconstruction using pre-expanded flaps were included. After tissue expansion, IRT was used to mark the vessel distribution along the expanded flap. The results were compared with color Doppler ultrasound (CDU) and/or computed tomographic angiography (CTA). The flap was designed and raised based on the pre-operative marking by IRT. The mark was verified intraoperatively. RESULTS: A total of 26 expanded flaps were performed, including 20 pedicled flaps and 6 free flaps. IRT succeeded to map the vessel distribution in all cases. All marked results were verified by CDU, CTA, and intraoperative dissection (26/26, 100%). IRT showed more comprehensive distribution of vascular branches than CDU or CTA, and could be utilized intraoperatively to identify the arteries. CONCLUSION: IRT provides accurate and comprehensive mapping of the axial vessel distribution in the pre-expanded flaps, assisting with flap design and harvest. It is easy to use and non-invasive as an important tool pre- or intraoperatively to ensure the safe elevation.

In vitro susceptibility of Mycobacterium abscessus complex and feasibility of standardizing treatment regimens.

OBJECTIVES: To determine the in vitro susceptibility of members of the Mycobacterium abscessus complex to routinely tested antibiotics and to an extended antibiotic panel. METHODS: Non-duplicate isolates for which susceptibility testing results were available were included in this study. Retrospective laboratory records were reviewed, including tigecycline susceptibility results, and testing was performed with additional drugs, including vancomycin, dalbavancin, telavancin, oritavancin, rifabutin, delafloxacin, eravacycline, clofazimine and bedaquiline using broth microdilution (Sensititre, Thermo Fisher). RESULTS: A total of 218 M. abscessus complex isolates were included for retrospective review, of which 151 were respiratory isolates. Of these 218 isolates, 211 were available for additional testing with the extended antibiotic panel. Of these, 146 were respiratory isolates. One isolate had a vancomycin MIC of 2 mg/L and MICs of all other isolates were >8 mg/L. All isolates had MICs of >8 mg/L for oritavancin, dalbavancin and telavancin. One isolate had a delafloxacin MIC of 4 mg/L and MICs of all other isolates were >8 mg/L. The MIC50/MIC90s of rifabutin, tigecycline, eravacycline, clofazimine and bedaquiline were 16/32, 0.5/1, 0.12/0.25, 0.12/0.25 and 0.06/0.12 mg/L, respectively. CONCLUSIONS: In vitro activity was demonstrated for clofazimine, bedaquiline and eravacycline, indicating potential for inclusion as standardized therapy for M. abscessus complex infections.

Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model.

BACKGROUND: Fractional CO2 laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode. METHODS: A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling. RESULTS: A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks. CONCLUSIONS: Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.

The modified bilobed flap for reconstructing sacral decubitus ulcers.

BACKGROUND: Sacral pressure ulcers are associated with high morbidity and, in some cases, result in mortality from severe sepsis. Local flaps are frequently used for reconstruction of stage III and IV pressure ulcers. An ideal flap should be simple to design, have a reliable vascular supply and minimal donor site morbidity. Our study evaluates the use of a bilobed flap based on the superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery to reconstruct the sacral pressure ulcer. CASE PRESENTATION: We performed a retrospective analysis of paraplegic patients with sacral pressure ulcers treated with our bilobed flaps from January 2015 to December 2019. A description of our management, operative protocol, outcome and complications is outlined. Seven paraplegic patients (6 male, 1 female; average age 53.1 years) with sacral pressure ulcers were treated with our bilobed flap based on the superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery. The average size of the pressure ulcers was 7 × 5 cm (range 6.2 × 4.5 cm to 11 × 10 cm). All 7 flaps survived. The patients were followed up for 12 months without significant complications, such as flap necrosis or recurrence. CONCLUSIONS: The superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery reliably supplies the bilobed flap. The superior cluneal nerve can be included in the design. The technique is simple and reliable. It should be included in the reconstructive algorithm for the management of sacral pressure ulcers.

A Prospective Comparative Study of Color Doppler Ultrasound and Infrared Thermography in the Detection of Perforators for Anterolateral Thigh Flaps.

BACKGROUND: Preoperative localization of the perforators allows precise planning of the flap design and improves surgical efficiency. Recently, infrared thermography is introduced as a reliable alternative, where the perforator corresponds to the "hot spot" on the thermogram. This study aims to compare the application of color Doppler ultrasound (CDU) and infrared thermography in preoperative perforator mapping of the anterolateral thigh (ALT) perforator flap. PATIENTS AND METHODS: From September 2017 to January 2019, CDU and infrared thermography were both applied on 20 patients to locate the perforators originated from lateral circumflex femoral artery preoperatively. The perforators identified using each modality were marked on the anterolateral thigh region. The accuracy of both mapping methods was analyzed according to the intraoperative findings. The relation between location bias and the thickness of subcutaneous tissue was analyzed. RESULTS: A total of 20 ALT flaps were included. Fifty-three perforators were detected by CDU, and 51 "hot spots" were identified by infrared thermography, in which 50 "hot spots" corresponded to CDU, and the consistency test showed that the κ index was 0.712 (P < 0.05), representing high consistency. The infrared thermography has a sensitivity of 94.3% and a specificity of 85.7% compared with CDU. The deviation between thermal imaging and CDU was positively correlated with the thickness of the subcutaneous tissue. The Pearson correlation coefficient was 0.84 (R = 0.84). Forty-four perforators marked by CDU were selected for designing the flap. Anatomical findings showed that the accuracy rate of CDU and infrared thermal was 93.2% (41 of 44) and 86.3% (38 of 44), respectively. There was no statistical difference (P > 0.05). CONCLUSIONS: Compared with CDU, infrared thermography can be used to locate perforators, in this case, the ALT perforators, with a high degree of consistency. It is portable, economical, noninvasive, and easy to operate. It has higher accuracy in patients with thinner subcutaneous tissue. We believe that infrared thermography can be a useful technique for perforator mapping, especially in patients where the subcutaneous tissue is thinner.