A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes.

BACKGROUND: Despite simultaneous microvascular breast reconstruction (MBR) and vascularized lymph node transfer (VLNT) gaining wide popularity as a potential treatment for breast cancer related lymphedema (BCRL), there is a lack of evidence supporting the procedure. There are few reports in the literature, and no study has compared simple deep inferior epigastric artery perforator (DIEP) to simultaneous DIEP flap and VLNT. PATIENTS AND METHODS: A retrospective analysis of our series of DIEP flaps was conducted. Patients presenting with BCRL who had delayed MBR and simultaneous VLNT were selected. Thirty-two patients were included and compared with a control group of delayed MBR with DIEP flap alone. Clinical evaluation, circumference reduction rate, and LYMQOL questionnaire were used to compare preoperative and postoperative findings in the study group. A digital version of BREAST Q questionnaire was administered to all patients. RESULTS: Thirty-two patients were enrolled in the study group, with a mean follow-up of 42.5 ± 25.7 months and mean age of 54.1 ± 7.8 years. The mean circumference reduction rate was 46.1 ± 52.3, 39 ± 42.3, 47.5 ± 53.5, 39.2 ± 52.4, 33.6 ± 50.1 at the deltoid insertion, above the elbow, below the elbow, at the mid-forearm and wrist respectively. Postoperative LYMQOL scores significantly improved (function 1.21, appearance 1.15, symptoms 1.34, mood 1.33, overall QOLscore 8.6) from preoperative baseline (p < .001). There was no significant difference in term of outcomes and complications rate of the donor site between the study and control groups. CONCLUSIONS: Simultaneous DIEPandVLNT improves the HRQOL of patients with lymphedema. Coupling VLNT with abdominal flap does not increase the morbidity of donor site.

Defining the Aesthetic Range of Normal Symmetry for Lip and Nose Features in 5-Year-Old Children Using the Computer-Based Program SymNose.

OBJECTIVE: To provide a normal comparison group against which to judge symmetry results after cleft surgery and to introduce the thin lip correction (TLC) feature in SymNose. A lip-aspect ratio algorithm has been added to the latest version of SymNose to compensate for the higher degree of overlap in thicker lips when compared to thin lips. DESIGN: Retrospective analysis of symmetry in healthy participants, using the computer-based program SymNose on both anteroposterior (AP) and base view images. Photographs of 91 noncleft children were traced twice by 3 independent investigators experienced with SymNose. PARTICIPANTS: Five-year-old healthy participants from a local state school in Tavistock (West Devon, United Kingdom). MAIN OUTCOME MEASURE: Asymmetry expressed as the perimeter mismatch percentage for nose and lip features on AP view images and for nose features on base view images. RESULTS: The perimeter mismatch reference range for the nose (AP view) was 2.65% to 30.91%, for the lip 2.13% to 15.44%, for the nose (base view) 1.69% to 14.84%, for the nostrils 4.68% to 26.6%, and for the width-height ratio 1.15% to 1.80%. The perimeter mismatch percentage for the lip without TLC was significantly higher compared to the perimeter mismatch percentage with TLC (P < .001). CONCLUSION: This article provides a noncleft reference range for all perimeters drawn from SymNose against which to compare results after cleft surgery at 5 years of age. Furthermore, it shows the importance of correcting for variance in lip volume per child.

Use of the Sphenoid Flap in Repair of the Wide Cleft Palate.

OBJECTIVE: In wide palatal defects, closure of the nasal layer can prove a considerable challenge. Mobilizing nasal flaps posteriorly usually facilitates soft palate closure. However, the defect is often too wide within the hard palate; hence, bilateral vomerine flaps are frequently required. Despite this, there is often a small defect in the nasal layer at the posterior septum (typically equating to the hard-soft palate junction), which has to be left to heal by secondary intention with the resulting increased risk of fistula formation and the potential deleterious long-term effect on speech due to cicatricial migration of the reconstructed levator sling anteriorly. We describe our experience in the use of the sphenoid flap to obtain tension-free primary closure of the nasal layer. METHODS: A retrospective multi-center study assessing all sphenoid flap procedures undertaken at both Birmingham Children's Hospital and Great Ormond Street Hospital. Key demographic and medical data was collected pre-, peri-, and postoperatively across the 2 sites. RESULTS: A total of 66 patients underwent the use of a sphenoid flap to aid closure of the nasal layer. The average age at time of repair was 9.7 months. More than half (55%, n = 36) were isolated cleft palates, and 35% (n = 23) were BCLPs. Forty-two percent of all patients had Robin sequence. The average cleft width was 14.4 mm. The overall fistula rate was 25.8% (n = 17). CONCLUSIONS: We describe the operative technique, indications, and our experience in the use of the sphenoid flap in wide cleft palate repair.

Immediate nipple reconstruction in combination with implant reconstruction using dermal sling.

The inferior de-epithelialized dermal flap with implant is increasingly used for immediate breast reconstruction. We have adapted the technique to provide concurrent immediate nipple reconstruction by recruiting the triangle of skin above the excised nipple as a modified C-V flap. The safety and efficacy of this technique has been assessed in 15 patients, of which eight were bilateral and seven were unilateral cases. We suggest that this is a safe, reliable, and original technique for immediate nipple reconstruction in patients undergoing immediate breast reconstruction with an inferior dermal sling and implant.

Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review.

OBJECTIVES: Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist. DESIGN: A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist. PATIENTS, PARTICIPANTS: The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CL/P RCTs during the study period. MAIN OUTCOME MEASURES: The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale. RESULTS: The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score (P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased. CONCLUSION: This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.

Revised estimates of mortality from the Birmingham Burn Centre, 2001-2010: a continuing analysis over 65 years.

OBJECTIVE: The Birmingham Burn Centre has continued to publish mortality data over the last 65 years. It is one of the longest running cross-sectional cohort studies in the world. We present the latest data from the study, with a comparison to previous results. BACKGROUND: Results from the previous decade failed to show any improvement in mortality despite perceived advances in burn care. The aim of this update was to establish current mortality statistics and ascertain whether improvement had now been made. METHODS: Data were collected for a 10-year period on all burn-injured patients admitted to the Birmingham Burn Centre (Birmingham Children's Hospital, Selly Oak Hospital, and Queen Elizabeth Hospital Birmingham). Patients' age, percentage of burn, date of injury, and outcome were recorded and analyzed with both probit and logistic regression analyses. RESULTS: A total of 4577 patients were included in the analysis, with a mean total body surface area (TBSA) burn of 7.2% and a mean age of 22 years. Comparison of probit model results with previous results demonstrates improvement in predicted mortality and lethal area (LA50) of burns. Logistic regression produces similar results to the probit analysis. Trend analysis proved a statistically significant improvement in mortality. CONCLUSIONS: The last decade of burn care at Birmingham Burn Centre demonstrates an improvement in predicted mortality and LA50. This reflects our structured, multidisciplinary approach to burn-injured patients, early surgical excision and wound closure, and general advances in the intensive care of patients.

A systematic review of 2-strand versus multistrand core suture techniques and functional outcome after digital flexor tendon repair.

PURPOSE: To determine published evidence to evaluate the hypothesis that multistrand techniques result in a poorer outcome than 2-strand techniques for digital flexor tendon repairs. METHODS: A systematic review was undertaken to compare outcomes and rupture rates between 2-strand and multistrand core sutures in digital flexor zones 2 to 5. Outcome was measured by the American Society for Surgery of the Hand criteria, original or modified Strickland criteria, or Buck-Gramcko criteria. RESULTS: A total of 1,878 patients (2,585 digits; 3,749 tendons) were included from the selected studies. Thirty-three studies reported 2-strand repairs and 15 reported multistrand repairs. Of the total tendon injuries, 59% were flexor digitorum profundus, 38% were flexor digitorum superficialis, and 2% were flexor pollicis longus. The pooled rupture rate was 3.9 per 100 digits. No significant difference was detected between 2-strand and multistrand repairs for outcomes by all measures or rupture rate. CONCLUSIONS: Because of the wide variation in reporting of outcomes and study design on which this analysis was based, we cannot definitively confirm our hypothesis. We present the standards for outcomes as well as rupture rate for digital flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Parameter estimation of a model describing the human fingers.

The goal of this paper is twofold: firstly, to provide a novel mathematical model that describes the kinematic chain of motion of the human fingers based on Lagrangian mechanics with four degrees of freedom and secondly, to estimate the model parameters using data from able-bodied individuals. In the literature there are a variety of mathematical models that have been developed to describe the motion of the human finger. These models offer little to no information on the underlying mechanisms or corresponding equations of motion. Furthermore, these models do not provide information as to how they scale with different anthropometries. The data used here is generated using an experimental procedure that considers the free response motion of each finger segment with data captured via a motion capture system. The angular data collected are then filtered and fitted to a linear second-order differential approximation of the equations of motion. The results of the study show that the free response motion of the segments is underdamped across flexion/extension and ad/abduction.

Reliability, accuracy, and minimal detectable difference of a mixed concept marker set for finger kinematic evaluation.

The study of finger biomechanics requires special tools for accurately recording finger joint data. A marker set to evaluate finger postures during activities of daily living is needed to understand finger biomechanics in order to improve prosthesis design and clinical interventions. The purpose of this study was to evaluate the reliability of a proposed hand marker set (the Warwick marker set) to capture finger kinematics using motion capture. The marker set consisted of the application of two and three marker clusters to the fingers of twelve participants who participated in the tests across two sessions. Calibration markers were applied using a custom palpation technique. Each participant performed a series of range of motion movements and held a set of objects. Intra and inter-session reliability was calculated as well as Standard Error of Measurement (SEM) and Minimal Detectable Difference (MDD). The findings showed varying levels of intra- and inter-session reliability, ranging from poor to excellent. The SEM and MDD values were lower for the intra-session range of motion and grasp evaluation. The reduced reliability can potentially be attributed to skin artifacts, differences in marker placement, and the inherent kinematic variability of finger motion. The proposed marker set shows potential to assess finger postures and analyse activities of daily living, primarily within the context of single session tests.

Ten-year audit of melanoma in a central England population.

The incidence of melanoma in the North Staffordshire region has more than doubled over the last 10 years, and nearly tripled in the "thin" melanoma group (≤ 1 mm). A retrospective audit was performed to investigate the overall management of melanoma, with a focus on thin melanomas. A total of 507 patients was identified between 1999 and 2009. The incidence of melanoma is increasing in the older age groups (> 50 years), although the thin melanomas were diagnosed at a significantly younger age than the cohort as a whole (p < 0.001). The anatomical distribution was similar in both groups. More females were affected by thin melanomas (65%) compared with all melanomas (55%). This audit provides a unique insight into the incidence and characteristics of melanoma in a Central England population. The incidence of melanoma is increasing, but more so in the thin group. Thick (> 4 mm) and intermediate (1.01-4 mm) melanomas are increasing at a slower rate.

Monitoring the Effect of Transdermal Drug Delivery Patches on the Skin Using Terahertz Sensing.

Water content of the skin is an important parameter for controlling the penetration rate of chemicals through the skin barrier; therefore, for transdermal patches designed for drug delivery to be successful, the effects of the patches on the water content of the skin must be understood. Terahertz (THz) spectroscopy is a technique which is being increasingly investigated for biomedical applications due to its high sensitivity to water content and non-ionizing nature. In this study, we used THz measurements of the skin (in vivo) to observe the effect of partially and fully occlusive skin patches on the THz response of the skin after the patches had been applied for 24 h. We were able to observe an increase in the water content of the skin following the application of the patches and to identify that the skin remained hyper-hydrated for four hours after the removal of the fully occlusive patches. Herein, we show that THz spectroscopy has potential for increasing the understanding of how transdermal patches affect the skin, how long the skin takes to recover following patch removal, and what implications these factors might have for how transdermal drug patches are designed and used.

Bioresponsive dextrin-rhEGF conjugates: in vitro evaluation in models relevant to its proposed use as a treatment for chronic wounds.

We recently developed a bioresponsive dextrin-recombinant human epidermal growth factor (rhEGF) conjugate as a polymer therapeutic with potential for use in the promotion of tissue repair. The aim of these studies was to use patient-derived wound fluid and fibroblasts to evaluate its potential for further development as a treatment for chronic wounds, such as venous leg ulceration, a growing clinical challenge in the aging population. First, the levels of EGF (ELISA assay), alpha-amylase and elastase (enzyme assays) were measured in patient-derived acute and chronic wound fluid. EGF was detected in acute, but not in chronic wound fluid. alpha-Amylase concentrations were higher in acute (188 IU/L), compared to chronic wound fluid (52 IU/L), but both were in the range of human serum levels. Although elastase was present in chronic wound fluid (2.1 +/- 1.2 RFU/min), none was detected in acute wound fluid. Dextrin-rhEGF incubation in chronic wound fluid led to endogenous alpha-amylase-mediated release of rhEGF (ELISA) that was maximal at 48 h. When the migration of HaCaT keratinocytes and of human fibroblasts (isolated from patient-matched, normal skin and chronic dermal wounds) was studied in vitro using the scratch wound assay, enhanced cell migration was observed in response to both free rhEGF and alpha-amylase-activated dextrin-rhEGF conjugate compared to controls. In addition, fibroblasts displayed increased proliferation (normal dermal fibroblasts approximately 160%; chronic wound fibroblasts approximately 140%) following incubation (72 h) with dextrin-rhEGF that had been exposed to physiological levels of alpha-amylase (93 IU/L). These results suggest further preclinical in vivo evaluation of dextrin-rhEGF is warranted to determine whether conjugate pharmacokinetics and rhEGF liberation into such a complex and aggressive environment can still lead to bioactivity.

The Detection of Wound Infection by Ion Mobility Chemical Analysis.

Surgical site infection represents a large burden of care in the National Health Service. Current methods for diagnosis include a subjective clinical assessment and wound swab culture that may take several days to return a result. Both techniques are potentially unreliable and result in delays in using targeted antibiotics. Volatile organic compounds (VOCs) are produced by micro-organisms such as those present in an infected wound. This study describes the use of a device to differentiate VOCs produced by an infected wound vs. colonised wound. Malodourous wound dressings were collected from patients, these were a mix of post-operative wounds and vascular leg ulcers. Wound microbiology swabs were taken and antibiotics commenced as clinically appropriate. A control group of soiled, but not malodorous wound dressings were collected from patients who had a split skin graft (SSG) donor site. The analyser used was a G.A.S. GC-IMS. The results from the samples had a sensitivity of 100% and a specificity of 88%, with a positive predictive value of 90%. An area under the curve (AUC) of 91% demonstrates an excellent ability to discriminate those with an infected wound from those without. VOC detection using GC-IMS has the potential to serve as a diagnostic tool for the differentiation of infected and non-infected wounds and facilitate the treatment of wound infections that is cost effective, non-invasive, acceptable to patients, portable, and reliable.

Fluidic Haptic Interface for Mechano-Tactile Feedback.

Notable advancements have been achieved in providing amputees with sensation through invasive and non-invasive haptic feedback systems such as mechano-, vibro-, electro-tactile and hybrid systems. Purely mechanical-driven feedback approaches, however, have been little explored. In this paper, we now created a haptic feedback system that does not require any external power source (such as batteries) or other electronic components (see Fig. 1 ). The system is low-cost, lightweight, adaptable and robust against external impact (such as water). Hence, it will be sustainable in many aspects. We have made use of latest multi-material 3D printing technology (Stratasys Objet500 Connex3) being able to fabricate a soft sensor and a mechano-tactile feedback actuator made of a rubber (TangoBlack Plus) and plastic (VeroClear) material. When forces are applied to the fingertip sensor, fluidic pressure inside the system acts on the membrane of the feedback actuator resulting in mechano-tactile sensation. Our [Formula: see text] feedback actuator is able to transmit a force range between 0.2 N (the median touch threshold) and 2.1 N (the maximum force transmitted by the feedback actuator at a 3 mm indentation) corresponding to force range exerted to the fingertip sensor of 1.2-18.49 N.

A self-healing hydrogel eye drop for the sustained delivery of decorin to prevent corneal scarring.

Scarring/Opacity on the surface of the eye and vascularisation following infectious diseases, inflammation and corneal trauma are often a leading cause of blindness. The 'gold standard' treatment to prevent corneal scarring is the application of amniotic membrane (AM) to the ocular surface in the acute stage of injury. Although clinically effective, the use of the AM is associated with biological variability and unpredictable responses. Potential health risks including disease transmission, significant ethical issues surrounding the tissue donation process and stringent regulations/storage conditions, preclude widespread use. Consequently, there is a demand for the development of a new, synthetic alternative, that is stable at room temperature, capable of protecting the wound and has the capacity to deliver anti-scarring and anti-inflammatory mediators. Here we have developed a micro-structured fluid gel eye drop, to deliver a potent anti-scarring molecule, decorin. We have compared the release of decorin from the formulated dressing to a typical gel film, demonstrating enhanced release for the fluid gel eye-drops. Therefore, we have investigated the effect of the fluid gel system in 2D human corneal fibroblast culture models, as well as shown the retention of the gellan fluid gel in an in vivo rat model. At the same time the efficacy of the fluid gel eye drop was studied in an organ culture model, whereby the fluid gel containing decorin, significantly (P < 0.05) increased re-epithelialisation within 4 days of treatment.

The Evolution and Interpretation of the Gustilo and Anderson Classification.

BACKGROUND: The Gustilo classification is the most established system for classifying open fractures. Despite this, the classification has changed in how it has been described and interpreted. We have traced how this classification has slowly evolved throughout the literature over the past 4 decades. METHODS: A systematic search of the literature was undertaken with the MEDLINE, Embase, and PubMed databases to source relevant articles that have evolved the interpretation of the Gustilo classification. The references from these articles were consecutively hand-searched to find other articles that describe the Gustilo classification. RESULTS: There was a total of 393 results from the Healthcare Databases Advanced Search (HDAS): 95 from MEDLINE, 49 from Embase, and 249 from PubMed. Fifty-six articles were initially selected; an additional 67 articles were retrieved through reference checking and further checking of relevant articles until no additional relevant articles could be found. CONCLUSIONS: The original Gustilo and Anderson classification initially was modified by Gustilo before subtle changes were made to the descriptors in the 1990s. Some authors have used the Gustilo classification to create alternative classifications, but these have not gained traction. Other contemporaneous literature has modified the Gustilo-IIIB subtypes to better stratify functional and reconstructive outcomes following vascular injury. The impact and longevity of such recent modifications are yet to be known.

Prospective comparative evaluation study of Laser Doppler Imaging and thermal imaging in the assessment of burn depth.

INTRODUCTION: The accurate assessment of burn depth is challenging but crucial for surgical excision and tissue preservation. Laser Doppler Imaging (LDI) has gained increasing acceptance as a tool to aid depth assessment but its adoption is hampered by high costs, long scan times and limited portability. Thermal imaging is touted as a suitable alternative however few comparison studies have been done. METHODS: Sixteen burn patients with 52 regions of interests were analysed. Burn depth was determined using four methods LDI, thermal imaging, photographic and real-time clinical evaluation at day 1 and day 3. LDI flux and Delta T values were used for the prediction of outcomes (wound closure in <21 days). Photographic clinical evaluation of burn depth was performed by 4 blinded burn surgeons. RESULTS: Accuracy of assessment methods were greater on post burn day 3 compared to day 0. Accuracies of LDI on post burn day 0 and 3 were 80.8% and 92.3% compared to 55.8% and 71.2% for thermal imaging and 62.5% and 71.6% for photographic clinical assessment. Real-time clinical examination had an accuracy of 88.5%. Thermal imaging scan times were significantly faster compared to LDI. DISCUSSION: LDI outperforms thermal imaging in terms of diagnostic accuracy of burn depth likely due to the susceptibility of thermal imaging to environmental factors.

Controlled release of dextrin-conjugated growth factors to support growth and differentiation of neural stem cells.

An essential aspect of stem cell in vitro culture and in vivo therapy is achieving sustained levels of growth factors to support stem cell survival and expansion, while maintaining their multipotency and differentiation potential. This study investigated the ability of dextrin (~74,000 g/mol; 27.8 mol% succinoylation) conjugated to epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF; or FGF-2) (3.9 and 6.7% w/w protein loading, respectively) to support the expansion and differentiation of stem cells in vitro via sustained, controllable growth factor release. Supplementation of mouse neural stem cells (mNSCs) with dextrin-growth factor conjugates led to greater and prolonged proliferation compared to unbound EGF/bFGF controls, with no detectable apoptosis after 7 days of treatment. Immunocytochemical detection of neural precursor (nestin) and differentiation (Olig2, MAP2, GFAP) markers verified that controlled release of dextrin-conjugated growth factors preserves stem cell properties of mNSCs for up to 7 days. These results show the potential of dextrin-growth factor conjugates for localized delivery of bioactive therapeutic agents to support stem cell expansion and differentiation, and as an adjunct to direct neuronal repair.

A role for vacuum-assisted closure in lower limb trauma: a proposed algorithm.

The British Association of Plastic Surgeons and British Orthopaedic Association estimate that 70% of Gustilo 3b tibial fractures require flap coverage. Prior to the introduction of vacuum-assisted closure (V.A.C.) in the late 1990s, options were limited for the treatment of such injuries in selected individuals with medical comorbidity or complex wounds. VAC has now become an important part of our algorithm for soft tissue reconstruction with excellent results, but its role has not yet been defined in common management pathways. The authors present 3 cases, all different in their mechanism of injury, type of injury, and subsequent management, but all had a successful outcome with VAC.