Evaluation of a Novel Objective Method for The Assessment of Nasal Symmetry Among Patients with Unilateral Cleft Lip.

OBJECTIVE: This is a cross sectional study aimed to asses novel semi objectve compter assisted method to asses the symmetry amog unilateral cleft lip patients. DESIGN: using Standard inferior view nose photos that were uploaded to Digimizer© Version 4.6.1 (2005-2016 MedCalc Software) Image Analysis, symmetry percentage was calculated and compared between cleft and non-cleft neonates. This method was compared to two subjective methods of rating symmetry. SETTING: This a cross sectional pilot study performed in the Univresity Medical Center using standard inferior views of unilateral cleft patients which were compared to non-cleft neonates. PATIENTS: Photographs of 71 neonates with unilateral complete and incomplete cleft lip and 30 neonates without facial cleft, which were born at the university medical center, Beer Sheba, Israel, were analyzed in a standard manner to determine nasal symmetry. MAIN MEASURES: the novel method proposed produced a nominal value for percentage of symmetry. RESULTS: Using Pearson's correlation test we found intra-rater reliability of 91.2% (p < 0.001) and Inter-rater reliability of 82.9% (p < 0.001). The analysis correlated with the surgeons subjective scores in both the numerical ranking method at 73% (p < 0.001) and 72.6% (p < 0.001) and the Ordinal ranking method at 87.6% (p < 0.001) and 77.7% (p < 0.001). The ability of the method to discriminate healthy from Cleft Lip patients overall was 92.3% With high sensitivity and specificity. CONCLUSIONS: This method accurately distinguishes healthy patients from cleft lip patients. We have achieved High levels of inter and intra-rater reliability. Significant correlations were found between our semiobjective method and the subjective scores.

Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes.

In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.

Novel Biomarkers and Therapeutic Targets for Melanoma.

Malignant melanoma is one of the most common cancers in the world. In the disease's early stages, treatment involves surgery, in advanced stages however, treatment options were once scarce. There has been a paradigm shift in advanced melanoma treatment with the introduction of immunotherapy and targeted therapies. Understanding the molecular pathways and their pathologic counterparts helped identifying specific biomarkers that lead to the development of specific targeted therapies. In this review we briefly present some of these markers and their relevance to melanoma treatment.

Accelerated Wound Border Closure Using a Microemulsion Containing Non-Inhibitory Recombinant α1-Antitrypsin.

Wound healing requires a non-compromising combination of inflammatory and anti-inflammatory processes. Human α1-antitrypsin (hAAT), a circulating glycoprotein that rises during acute-phase responses and during healthy pregnancies, is tissue-protective and tolerance-inducing; although anti-inflammatory, hAAT enhances revascularization. hAAT blocks tissue-degrading enzymes, including neutrophil elastase; it is, therefore, unclear how wound healing might improve under hAAT-rich conditions. Here, wound healing was examined in the presence of recombinant hAAT (hAATWT) and protease-inhibition-lacking hAAT (hAATCP). The impact of both hAAT forms was determined by an epithelial cell gap closure assay, and by excisional skin injuries via a microemulsion optimized for open wounds. Neutrophilic infiltration was examined after 8 h. According to results, both hAAT forms accelerated epithelial gap closure and excisional wound closure, particularly at early time points. Unlike dexamethasone-treated wounds, both resulted in closed borders at the 8-h time point. In untreated and hAATCP-treated wounds, leukocytic infiltrates were widespread, in hAATWT-treated wounds compartmentalized and in dexamethasone-treated wounds, scarce. Both hAAT forms decreased interleukin-1ß and increased VEGF gene expression. In conclusion hAAT improves epithelial cell migration and outcomes of in vivo wounds irrespective of protease inhibition. While both forms of hAAT allow neutrophils to infiltrate, only native hAAT created discrete neutrophilic tissue clusters.

Copper Ions Ameliorated Thermal Burn-Induced Damage in ex vivo Human Skin Organ Culture.

INTRODUCTION: The zone of stasis is formed around the coagulation zone following skin burning and is characterized by its unique potential for salvation. The cells in this zone may die or survive depending on the severity of the burn and therefore are target for the local treatments of burns. Their low survival rate is consistent with decreased tissue perfusion, hypotension, infection, and/or edema, resulting in a significant increase in the wound size following burning. Copper is an essential trace mineral needed for the normal function of almost all body tissues, including the skin. OBJECTIVE: The aim of the work was to study the effect copper ions have on skin burn pathophysiology. METHODS: Skin obtained from healthy patients undergoing abdominoplasty surgery was cut into 8 × 8 mm squares, and round 0.8-mm diameter burn wounds were inflicted on the skin explants. The burned and control intact skin samples were cultured up to 27 days after wounding. Immediately following injury and then again every 48 h, saline only or containing 0.02 or 1 µM copper ions was added onto the skin explant burn wounds. RESULTS: We found that exposing the wounded sites immediately after burn infliction to 0.02 or 1 µM copper ions reduced the deterioration of the zone of stasis and the increase in wound size. The presence of the copper ions prevented the dramatic increase of pro-inflammatory cytokines (interleukin (IL)-6 and IL-8) and transforming growth factor beta-1 that followed skin burning. We also detected re-epithelialization of the skin tissue and a greater amount of collagen fibers upon copper treatment. CONCLUSION: The deterioration of the zone of stasis and the increase in wound size following burning may be prevented or reduced by using copper ion-based therapeutic interventions.

Comparing the Antimicrobial Effect of Silver Ion-Coated Silicone and Gentamicin-Irrigated Silicone Sheets from Breast Implant Material.

BACKGROUND: Post-operative infection is a significant complication of breast implant surgery that may require extensive use of antibiotics and surgical interventions. Here, we developed a biomaterial coating that is chemically bonded to silicone implants which delivers antimicrobial ions over time. METHODS: After coating the silicone implants with a "mediator" polymer (γ-PGA), the implants were impregnated with silver (Ag) ions. Antimicrobial effects of these implants were assayed with modified Kirby-Bauer disk diffusion method. The silicone disks were transferred to a plate with fresh bacteria. Control was intended to simulate an intra-operative wash. RESULTS: The Ag-γ-PGA coated silicone demonstrated antimicrobial effects against the most common etiological agents of breast implant infections, including Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli and Klebsiella pneumoniae. There was no effect of inhibition of bacterial growth around the control silicone or the silicone coated only with γ-PGA. The zone of inhibition was generally larger around the Ag-γ-PGA coated silicone as compared to the silicone irrigated with gentamicin, and continued antibacterial effect was also observed at 48 hours in the Ag-γ-PGA coated silicone for all bacteria groups with the exception of P. aeruginosa. Gentamicin-irrigated silicone did not inhibit bacterial growth at 48 hours. CONCLUSION: The observed antibacterial performance of the Ag-γ-PGA coating as compared to simulated intra-operative antibiotic wash is promising and should be further evaluated to develop the next generation of implants with diminished risk for post-operative implant infections.

Recent Changes and Innovations in Melanoma Treatment: A Review.

BACKGROUND: Malignant melanoma is one of the most extensively studied diseases in the last few decades. The outcome of these studies and the treatment changes that followed have dramatically altered the landscape of not only melanoma therapy, but all solid tumors. In this review we presented the recent advances of surgical and adjuvant management of patients with cutaneous malignant melanoma. This review focuses on stage III melanoma since this stage of disease requires surgical treatment as well as adjuvant therapy.

Rapid enzymatic burn debridement: A review of the paediatric clinical trial experience.

NexoBrid (NXB) has been proven to be an effective selective enzymatic debridement agent in adults. This manuscript presents the combined clinical trial experience with NXB in children. Hundred and ten children aged 0.5 to 18 years suffering from deep thermal burns of up to 67% total body surface area were treated with NXB in three clinical trials. Seventy-seven children were treated with NXB in a phase I/II study, where 92.7% of the areas treated achieved complete eschar removal within 0.9 days from admission. Thirty-three children (17 NXB, 16 standard of care [SOC]) participated in a phase III randomized controlled trial. All wounds treated with NXB achieved complete eschar removal. Time to complete eschar removal (from informed consent) was 0.9 days for NXB vs 6.5 days for SOC (P < .001). The incidence of surgical excision was 7.9% for NXB vs 73.3% for SOC (P < .001). Seventeen of these children participated in a phase III-b follow-up study (9 NXB and 8 SOC). The average long-term modified Vancouver Scar Scale scores were 3.4 for NXB-treated wounds vs 4.4 for SOC-treated wounds (NS). There were no significant treatment-related adverse events. Additional studies are needed to strengthen these results.

Prevalence of Monovalent Copper Over Divalent in Killing Escherichia coli and Staphylococcus aureus.

This study opens the investigation series focused on antimicrobial effects of copper (Cu) compared to silver (Ag), which is currently used to treat wound infection in burn victims as well as in chronic wounds. Noticeably, in its ionized state, Cu is more commonly present as Cu2+ rather than as Cu+, while electronic configuration similarity of Cu+ and Ag+ indicates that actually it may be the active state. To test this hypothesis, effect of Cu+ and Cu2+, using Ag+ ions and metallic copper as controls on Escherichia coli and Staphylococcus aureus bacteria, was examined under anaerobic conditions. Cu+ was produced by two different methods, and its effect on microorganism growth was tested using a syringe and Petri dish methods. It was found that the presence of Cu+ causes a dramatic depletion in the viability of both microorganisms. Metallic copper did not have any effect on the viability, whereas Cu2+ and Ag+ ions had much lower activity than Cu+ ions. Minimal inhibitory concentration of Cu+ for E. coli was twice lower than that of Cu2+. The obtained results show that Cu+ proves to be a potent antimicrobial agent.

Effect of Botulinum Toxin A on Muscle Healing and its Implications in Aesthetic and Reconstructive Surgery.

BACKGROUND: Muscle activity contributes to the enhancement of facial aging deformity, blepharospasm, cerebral palsy spasticity, trismus, torticollis, and other conditions. Myotomy of the involved muscles in order to reduce the deformity has variable success rates due to muscle healing and regeneration of activity. OBJECTIVES: The goal of this study was to investigate whether blocking striated muscle activity with Botulinum toxin (BtxA) during the healing time after myotomy alters the healing process and reduces long-term muscle activity. METHODS: Eighteen Sprague Dawley rats where divided into 3 groups: group A (n = 7) underwent myotomy of their Latisimus Dorsi muscle; group B (n = 7) underwent myotomy and injection of BtxA into their severed muscle; group C (n = 4) injection of BtxA only. Muscle strength was tested periodically using a grip test. RESULTS: Starting at week 16 and until the termination of study at week 22, group B (Myotomy + BtxA) showed significant reduction in muscle power compared to the two control groups. CONCLUSIONS: Addition of BtxA injection into a muscle immediately after myotomy may interfere with muscle healing and contribute to a more successful long-term result.

Bromelain-based enzymatic debridement of chronic wounds: A preliminary report.

Sharp debridement is currently considered most effective for debridement of chronic wounds; however, some patients do not have access to or cannot be treated by surgical methods. This study was designed to provide a first impression of the safety and efficacy of bromelain-based enzymatic debridement of chronic wounds. Two consecutive single-arm studies assessing the enzymatic debridement efficacy of a concentrate of proteolytic enzymes enriched in bromelain in chronic wounds was conducted in 2 medical centres. Patients were treated with up to 11 consecutive 4-hour enzymatic debridement sessions and then treated until wound closure. Twenty-four patients with chronic wounds of different aetiologies were enrolled. All wounds achieved an average of 68% ± 30% debridement in an average of 3.5 ± 2.8 enzymatic debridement 4-hour sessions. Seventeen responding wounds (venous, diabetic, pressure, and post-traumatic aetiologies) achieved an average 85% ± 12% debridement in 3.2 ± 2.5 applications. Seven non-responding wounds (arterial and post-surgical aetiologies) achieved an average 26% ± 13% debridement in 4.3 ± 3.5 applications. No treatment-related serious adverse events were observed, and the only adverse event attributed to the enzymatic debridement was pain. These preliminary results indicate the potential safety and efficacy of bromelain-based enzymatic debridement in chronic wounds. Larger controlled studies are needed to further investigate this indication.

Bone Healing Promotion by Negatively Charged Polysterene Microspheres.

Bone healing under optimal conditions is fairly predictable. Yet when the healing process is disturbed by inadequate immobilization, inadequate blood supply, or scar tissue, little therapeutic alternatives to surgery exist.It appears that redistribution of electric charges along the bone during a callus consolidation promotes bone healing. It has been shown in the past that negatively charged polysterene spheres promote bone growth in animal models.In this preliminary report, we tested weather or not a commercial device of negatively charged polysterene spheres promotes bone healing in a porcine model.This preliminary study seems to suggest that the negatively charged polystyrene microspheres may have a potential in promoting bone healing, either alone or as an adjunct to other bone graft materials. These speculations should be further validated by large-scale studies in animal models and clinical trials.

Facial Reconstruction of a Mucormycosis Survivor by Free Rectus Abdominis Muscle Flap, Tissue Expansion, and Ocular Prosthesis.

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel.

BACKGROUND: Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES: The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS: A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS: Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS: DM is highly integrated into the daily medical practices of plastic surgeons in Israel.

[DEMOGRAPHIC AND ANATOMIC CHARACTERISTICS AND SURGERY RESULTS IN CHILDREN WHO WERE TREATED IN SOROKA FOR CRANIOSYNOSTOSIS].

BACKGROUND: Craniosynostosis, the premature fusion of one or more of the cranial sutures, can occur as a part of a syndrome or as an isolated deformity. When not treated properly it may have major physical and social implications. STUDY HYPOTHESIS: We assumed that our center's results are similar to those reported in the literature, in terms of gender and anatomic characteristics, and different in terms of the number of syndromic cases. We also assume that only a few patients needed a second surgery and that this medical problem effects quality of life in term of cognitive impairment and aesthetic results. METHODS: A retrospective chart review was conducted of patients who were treated for craniosynostosis in Soroka University Medical Center between the years 1991-2005. RESULTS: A total of 63 patients were treated in Soroka during those years: 30 (47.6%) were females and 33 (50.8%) were males; 27 (42.9%) had coronal synostosis, 20 (31.8%) had sagital synostosis, 10 (15.8%) had metopic synostosis, 5 (7.9%) had lambdoid synostosis. A total of 5 (7.9%) cases were syndromic and the rest were isolated; 6 patients (9.5%) needed a second surgery for correction of the defect; 8 out of 30 patients (26.7%) 6 years or older at the present time suffer from attention deficit disorder. Parents' satisfaction from aesthetic results on a scale of 1-5 was 4.77 with SD of 0.504, while the doctors' score was 3.93 with SD 0.980 (p = 0.01). CONCLUSIONS: Craniosynostosis is a complex surgical problem, however with prompt treatment it may attain high levels of satisfaction among parents and patients. We found high rates 26.7% vs 10% (in the general population) of ADD in children affected by the disease.

[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Lymph Node Metastasis in Cutaneous Head and Neck Squamous Cell Carcinoma.

BACKGROUND: Cutaneous squamous cell carcinoma (CSCC), the second most common cancer in whites, may result in nodal metastasis in 4% of patients. In the last decade, sentinel lymph node biopsy (SLNB) became the common practice for treating patients with invasive skin cancers such as melanoma, although its use in patients with CSCC is still under debate. OBJECTIVE: To find the rate of cervical lymph node metastasis in the series of patients with CSCC of the head and neck and to identify those who may need SLNB. MATERIALS AND METHODS: A retrospective data collection on all patients diagnosed with CSCC of head and neck during the years 1998 to 2005. RESULTS: A total of 572 patients with 725 head and neck CSCC were included in the study group. During the follow-up period, 10 (1.3%) patients developed lymph node metastases and no patient developed distant metastases. The probability of lymph node metastasis within 6 years for T1 and T2 tumors was 1.09% and 5.46%, respectively (p = .0387). CONCLUSION: Because of the relatively low incidence of cervical lymph node metastases in patients with CSCC of the head and neck, SLNB for clinically N0 patients is not justified.

Double Back Cut in Post-mastectomy Breast Skin (Fish-Shaped Skin Paddle) in Delayed Pedicled TRAM Flap Breast Reconstruction.

Breast reconstruction has become standard of care for female patients with breast cancer. The transverse rectus abdominis musculo-cutaneous flap (TRAMf) is the most common method of immediate or delayed autologous breast reconstruction following mastectomy. We share our experience with modified, double back cut of post-mastectomy skin in delayed pedicled TRAMf breast reconstruction, resulting in fish-shaped skin paddle. This sort of back cut is a simple, reliable way to obtain a natural, esthetically pleasant breast mound with inconspicuous hidden scars.

Seborrhea-like dermatitis with psoriasiform elements caused by a mutation in ZNF750, encoding a putative C2H2 zinc finger protein.

We describe an Israeli Jewish Moroccan family presenting with autosomal dominant seborrhea-like dermatosis with psoriasiform elements, including enhanced keratinocyte proliferation, parakeratosis, follicular plugging, Pityrosporum ovale overgrowth and dermal CD4 lymphocyte infiltrate. We mapped the disease gene to a 0.5-cM region overlapping the PSORS2 locus (17q25) and identified a frameshift mutation in ZNF750, which encodes a putative C2H2 zinc finger protein. ZNF750 is normally expressed in keratinocytes but not in fibroblasts and is barely detectable in CD4 lymphocytes.

Total lip reconstruction with tendinofasciocutaneous radial forearm flap.

INTRODUCTION: Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. PATIENTS AND METHODS: This procedure was used in 5 patients with 80-100% lip defect resulting from Squamous cell carcinoma. Patients' age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. RESULTS: All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. CONCLUSION: We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.