Macklin Effect: From Pathophysiology to Clinical Implication.

Air leak syndromes (such as pneumomediastinum, pneumothorax, or subcutaneous emphysema) are frequent complications of acute respiratory distress syndrome (ARDS). Unfortunately, the development of air leaks is associated with worse outcomes. In addition, it has been hypothesized that the development of pneumomediastinum could be a marker of disease severity in patients with respiratory failure receiving noninvasive respiratory support or assisted ventilation. The so-called Macklin effect (or pulmonary interstitial emphysema) is the air dissection of the lung bronchovascular tree from peripheral to central airways following injury to distal alveoli. Ultimately, the progression of the Macklin effect leads to the development of pneumomediastinum, subcutaneous emphysema, or pneumothorax. The Macklin effect is identifiable on a chest computed tomography (CT) scan. The Macklin effect could be an accurate predictor of barotrauma in patients with ARDS (sensitivity = 89.2% [95% CI: 74.6-96.9]; specificity = 95.6% [95% CI: 90.6-98.4]), and may be a marker of disease severity. Accordingly, the detection of the Macklin effect on a chest CT scan could be used to select which patients with ARDS might benefit from different treatment algorithms, including advanced respiratory monitoring, early intubation, or, potentially, the institution of early extracorporeal support with or without invasive ventilation. In this video, the authors summarize the pathophysiology and potential clinical significance and applications of the Macklin effect in patients with acute respiratory failure.

Testing ChatGPT ability to answer laypeople questions about cardiac arrest and cardiopulmonary resuscitation.

INTRODUCTION: Cardiac arrest leaves witnesses, survivors, and their relatives with a multitude of questions. When a young or a public figure is affected, interest around cardiac arrest and cardiopulmonary resuscitation (CPR) increases. ChatGPT allows everyone to obtain human-like responses on any topic. Due to the risks of accessing incorrect information, we assessed ChatGPT accuracy in answering laypeople questions about cardiac arrest and CPR. METHODS: We co-produced a list of 40 questions with members of Sudden Cardiac Arrest UK covering all aspects of cardiac arrest and CPR. Answers provided by ChatGPT to each question were evaluated by professionals for their accuracy, by professionals and laypeople for their relevance, clarity, comprehensiveness, and overall value on a scale from 1 (poor) to 5 (excellent), and for readability. RESULTS: ChatGPT answers received an overall positive evaluation (4.3 ± 0.7) by 14 professionals and 16 laypeople. Also, clarity (4.4 ± 0.6), relevance (4.3 ± 0.6), accuracy (4.0 ± 0.6), and comprehensiveness (4.2 ± 0.7) of answers was rated high. Professionals, however, rated overall value (4.0 ± 0.5 vs 4.6 ± 0.7; p = 0.02) and comprehensiveness (3.9 ± 0.6 vs 4.5 ± 0.7; p = 0.02) lower compared to laypeople. CPR-related answers consistently received a lower score across all parameters by professionals and laypeople. Readability was 'difficult' (median Flesch reading ease score of 34 [IQR 26-42]). CONCLUSIONS: ChatGPT provided largely accurate, relevant, and comprehensive answers to questions about cardiac arrest commonly asked by survivors, their relatives, and lay rescuers, except CPR-related answers that received the lowest scores. Large language model will play a significant role in the future and healthcare-related content generated should be monitored.

Rotating Abdominal Flap: A New and Simple Technique to Treat and Avoid Lower Pole Contour Deformities in Breast Augmentation.

BACKGROUND: Double-contour deformity represents a common complication following inframammary fold lowering in augmentation mammaplasty that mostly occurs in patients with a short distance from the nipple to the inframammary fold or tight breasts. The authors describe a technique that consists of exploiting a cranially based abdominal fat flap that is hinged and rotated upward to correct or prevent this deformity. METHODS: A retrospective study of two groups of patients was conducted. Group A comprised 25 patients who presented with visible double-contour deformity after breast augmentation; group B comprised 22 patients with a constricted lower pole and short distance from the nipple to the inframammary fold undergoing primary augmentation. RESULTS: Of 25 patients in group 1, 22 showed good outcomes. Two patients experienced bilateral and one, unilateral undercorrection of the deformity. One patient had a liponecrotic mass that did not need treatment. No patients in group 2 experienced obvious double-contour deformities. In group 2, one patient showed unilateral excess volume on the medial breast pole and another developed a postoperative hematoma that reabsorbed within 4 weeks. CONCLUSIONS: In many patients, the occurrence of double-contour deformities is linked to the difference in thickness between the area above and below the natural breast fold. The rotated abdominal fat flap increases the thickness of the lower pole in the area between the old and new IMF, which lacked volume, thus treating double-contour deformities in many patients. The same technique can be used to avoid the risk of these deformities when performing primary augmentation in patients with a short distance from the nipple to the inframammary fold or tight breasts.

Zygomatic Implants through a Face-Lift Approach: Analysis of 30 Years' Experience.

BACKGROUND: The use of zygomatic implants has been mostly replaced by fat grafting in rhytidectomy procedures. Furthermore, surgeons using implants prefer the intraoral approach. The authors aimed to describe and emphasize the usefulness of the preauricular approach as the best approach for this operation and underline the value of cheek implants as an alternative and/or as an adjunct to fat grafting during face-lift procedures for midfacial rejuvenation. METHODS: A retrospective study of 350 patients who underwent face-lift procedures with silicone malar implant placement through a preauricular approach was conducted. Postoperative photographs of all patients were examined by two physicians for postoperative volume adequacy, naturalness of appearance, and improvement in asymmetry. Patient satisfaction was evaluated using a questionnaire with an ordinal scale. RESULTS: The large majority of patients [338 of 350 (96.5 percent)] were completely satisfied or satisfied with the aesthetic outcome. The complication rate was very low and comparable to data reported in current literature. CONCLUSIONS: The application of cheek implants proved to be a great tool for midfacial volume rejuvenation with or without associated fat grafting. This conclusion was drawn from the answers reported in the questionnaires completed by the two examiners. The main challenge in this operation was the choice of the type, shape, and size of the implant. The preauricular approach should be given preference during this procedure because, compared to the other approaches, it is easier, faster, and more comfortable for both the patient and the surgeon. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Properly Diluted Fat (PDF): An Easy and Safe Approach to Periocular Fat Grafting.

BACKGROUND: The main challenge of periocular fat grafting is the risk of contour irregularities, especially in the lower eyelid. Injection of diluted fat can decrease the likelihood of poor contour. OBJECTIVES: The authors developed a simple method of periocular fat grafting in which the fat was harvested through unconventional cannulas and diluted before the injection to avoid the risk of contour irregularities. METHODS: A retrospective study was conducted on 200 patients who underwent fat grafting to the periocular region. Lipoaspirate was obtained through a 0.5-mm multiple-hole cannula and then was centrifuged. A solution of 70% fat was prepared (ie, properly diluted fat [PDF]) with saline and infranatant fluid as the diluent. The recipient site was tunnelized with a 1.2-mm cannula, and PDF was transferred utilizing a 1.2-mm cannula containing a single 1-mm hole. Aesthetic improvement was ascertained from pre- and postoperative photographs evaluated by 3 examiners. RESULTS: A total of 164 (82%) patients received follow-up 6 months postoperatively, and 83 of these patients (41.5%) returned for monitoring 1 year postoperatively. Nearly all patients had improvement in periocular contour, but variable loss of volume was observed by 1 year. Patients who presented initially with scleral show often had noticeable improvement. At 1 year, only 3 patients experienced contour irregularities comprising soft bulges, similar to fat hernias. Two patients showed fat accumulation after substantial weight gain later than 1 year postoperatively. CONCLUSIONS: Preparation and periocular delivery of PDF by the described techniques yield good contour with a low risk of visible masses occurrence.

Lateral Skin-Platysma Displacement: A New Approach to Neck Rejuvenation Through a Lateral Approach.

Lateral skin-platysma displacement is a new technique for neck rejuvenation based on composite platysma-cutaneous flaps repositioned laterally through cable sutures. This technique skews the anatomy of the muscle, displacing it in a more lateral position and decreases the risk of paramedian bands recurrence. Traction applied to the midbody of the myocutaneous flaps is more effective in treating anterior excess skin than traction applied to the lateral platysma borders. The advantages of Lateral skin-platysma displacement are limited neck undermining, absence of submental scar, shorter operating time, faster patient recovery, satisfactory results, and an easier approach to submandibular gland reduction.

Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows.

BACKGROUND: The height of the eyebrow is less crucial aesthetically than is the relationship between the lateral and medial portions of the brow. Although various surgical procedures are effective in raising the brow, the authors maintain that transcutaneous brow shaping (TBS) is the only technique that enables precise shaping of the brow and correction of minor asymmetries. OBJECTIVES: The authors described their experiences with direct TBS alone or in conjunction with blepharoplasty and facelift. METHODS: A total of 212 patients underwent TBS performed by the senior author (M.P.C). All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results. RESULTS: There were no major complications. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS. CONCLUSIONS: A misconception of transcutaneous browlift procedures is that they yield visible scars. TBS requires accurate planning, preservation of subcutaneous volume, limited undermining, preoperative application of botulinum toxin, and perioperative administration of local vasodilators. When these requirements are fulfilled, the authors have found that TBS does not yield a visible scar and is the easiest, most precise, and most reliable procedure for brow shaping. LEVEL OF EVIDENCE: 4.

Treatment of Anterior Neck Aging without a Submental Approach: Lateral Skin-Platysma Displacement, a New and Proven Technique for Platysma Bands and Skin Laxity.

BACKGROUND: A high rate of recurrence of anterior platysma bands and anterior skin laxity was reported at the 1-year follow-up of 150 patients who underwent complete neck undermining and full-width platysma transection for neck rejuvenation. The authors propose a new technique-lateral skin-platysma displacement-to treat these two aesthetic problems using only a lateral approach to avoid "opening" the anterior neck. The authors' objective was to compare outcomes following full-width platysma transection technique and lateral skin-platysma displacement technique in terms of patient satisfaction, complications, and long-term effectiveness in the treatment of bands and anterior skin laxity. METHODS: A prospective study was carried out on 100 patients. All patients were operated on by the senior surgeon (M.P.C.). Patient questionnaires were used to assess their levels of satisfaction. RESULTS: Patient satisfaction was extremely high following both techniques. Successful correction of bands at 1 year was observed in 83.5 percent of the lateral skin-platysma displacement patients and 56 percent of the full platysma section patients. Regarding recurrent skin laxity, 68 percent of those who underwent lateral skin-platysma displacement did not show any obvious recurrence of excess skin at 1 year compared with 52 percent of the full platysma section group. Prolonged edema was the main complication and was considerably more frequent in the patients undergoing complete neck undermining. CONCLUSIONS: The 1-year patient satisfaction ratings were higher for those treated with the lateral skin-platysma displacement technique. The lateral skin-platysma displacement technique has proved to have a much shorter recovery and better outcomes in the correction of platysma bands and of the anterior neck skin laxity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complete Platysma Transection in Neck Rejuvenation: A Critical Appraisal.

BACKGROUND: The most common features of aging in the anterior neck are skin laxity and anterior platysma bands. Most neck correction techniques fail to obtain lasting correction of these despite promising early improvement. The authors use a major procedure to obtain the best results, combining full neck undermining with complete platysma transection and midline platysma approximation. Even using this technique, the authors have had concerns about the long-term results, and are aware of the lack of published studies of results using this technique. METHODS: A prospective study was conducted on 150 consecutive neck-lift patients operated on by the same senior surgeon (M.P.C.) between 2010 and 2014 to evaluate patient satisfaction and recurrence rates of anterior skin laxity and platysma bands. Patients were reviewed at 3 months (138 cases) and 1 year (96 cases). At both time points, patients completed questionnaires on level of satisfaction and eventual complaints regarding their surgical treatment, and were objectively evaluated for skin excess and recurrent bands. RESULTS: At 1 year, 76 percent of the patients were satisfied with the outcome using this technique, although satisfaction had been 100 percent at 3 months. However, only 52 percent showed no anterior neck skin excess and 55 percent had no recurrence of bands 1 year after surgery. CONCLUSIONS: Despite obtaining satisfactory results in most patients, this technique has several downsides: it is time consuming, there is the risk of iatrogenic deformities unless it is carried out precisely, the postoperative recovery is often very long, and there is a significant failure to maintain long-term correction. After 25 years' experience with these deficiencies, a reconsideration of the most appropriate procedure for correction of the anterior neck is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is considered the definitive standard for autologous breast reconstruction because of its ability to restore shape, its consistency, and its static and dynamic symmetry, but the degree of spontaneous sensory recovery is still widely discussed. To clarify the real need for sensitive nerve coaptation, return of sensibility in DIEP flaps was investigated using a pressure-specifying sensory device. METHODS: Thirty consecutive patients with breast cancer scheduled for modified radical mastectomy, axillary node dissection, and immediate reconstruction with cutaneous-adipose DIEP flaps without nerve repair were enrolled in the study. Sensibility for one and two points, static and moving, was tested preoperatively on the breasts and abdomen, and postoperatively at 6 and 12 months on the DIEP flaps. A t test was used for comparison of paired data and to investigate which factors affected sensory recovery. RESULTS: Preoperative healthy breast and abdomen pressure thresholds were lower for two-point than one-point discrimination and for moving discriminations compared with static ones at 6 and 12 months. Although they were significantly higher than those for contralateral healthy breasts (p < 0.05), pressure thresholds in DIEP flaps at 12 months were lower than at 6 months, showing a significant progressive sensory recovery (p < 0.05). At 12 months postoperatively, the best sensibility recovery was found at the inferior lateral quadrant, the worst at the superior medial quadrant. Age and flap weight were factors related to the performance of sensory recovery. CONCLUSIONS: DIEP flap transfer for immediate breast reconstruction undergoes satisfactory progressive spontaneous sensitive recovery at 6 and 12 months after surgery, and operative time spent dissecting sensitive perforator branches and their coaptation in recipient site could be spared.

Intense pulsed light photoepilation in hirsute women: the role of obesity.

Intense pulsed light (IPL) has shown diverse results in hair clearance related to treatment protocols or skin phototype. Hirsutism may be due to endocrine disease, as in polycystic ovary syndrome (PCOS) and congenital adrenal hyperplasia (CAH), both of which conditions may be associated with obesity. Obesity complicates the metabolic pattern, particularly in terms of insulin resistance, which may worsen the clinical condition of hirsutism. This study evaluated the role of obesity in photoepilation, comparing the clinical efficacy, long-term hair reduction and patient satisfaction in 40 hirsute women with PCOS or CAH, either obese (n = 20) or of normal weight (n = 20). The IPL settings were the same for both groups, but the number of sessions varied according to the clinical results. Obese patients showed a statistically significant severity of initial hirsutism if compared to the non-obese population and, for this reason, required more sessions to achieve hair reduction. The results were maintained at the 2-year follow-up examination, with a high satisfaction rate in both groups.