The evidence for natural therapeutics as potential anti-scarring agents in burn-related scarring.

Though survival rate following severe thermal injuries has improved, the incidence and treatment of scarring have not improved at the same speed. This review discusses the formation of scars and in particular the formation of hypertrophic scars. Further, though there is as yet no gold standard treatment for the prevention or treatment of scarring, a brief overview is included. A number of natural therapeutics have shown beneficial effects both in vivo and in vitro with the potential of becoming clinical therapeutics in the future. These natural therapeutics include both plant-based products such as resveratrol, quercetin and epigallocatechin gallate as examples and includes the non-plant-based therapeutic honey. The review also includes potential mechanism of action for the therapeutics, any recorded adverse events and current administration of the therapeutics used. This review discusses a number of potential 'treatments' that may reduce or even prevent scarring particularly hypertrophic scarring, which is associated with thermal injuries without compromising wound repair.

Role of reconstructive surgery in the management of head and neck cancer: a national outcomes analysis of 11,841 reconstructions.

BACKGROUND: The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis. METHODS: An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003-2013 national activity. RESULTS: The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site (n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision (n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm (n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days (P < 0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66-3.38; P < 0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed. CONCLUSIONS: Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes.

The growth factors involved in flexor tendon repair and adhesion formation.

Flexor tendon injuries remain a significant clinical problem, owing to the formation of adhesions or tendon rupture. A number of strategies have been tried to improve outcomes, but as yet none are routinely used in clinical practice. Understanding the role that growth factors play in tendon repair should enable a more targeted approach to be developed to improve the results of flexor tendon repair. This review describes the main growth factors in tendon wound healing, and the role they play in both repair and adhesion formation.

Survival of a pedicled latissimus dorsi flap in breast reconstruction without a thoracodorsal pedicle.

The latissimus dorsi flap, first performed by Tansini in 1892, was popularised for use by Olivari in 1976. The successful transfer of a latissimus dorsi flap during breast reconstruction has previously been thought to be dependent on having an intact thoracodorsal pedicle to ensure flap survival. It is well documented that the flap may also survive on the serratus branch in thoracodorsal pedicle division. We report a case of a 52-year-old female patient who underwent successful delayed breast reconstruction with a latissimus dorsi flap following previous mastectomy and axillary node clearance. Intraoperatively, the thoracodorsal pedicle and serratus branch were found to have been previously divided. On postoperative computer tomographic angiography the thoracodorsal pedicle was shown to be divided together with the serratus branch. The flap was seen to be supplied by the lateral thoracic artery. To our knowledge survival of a pedicled latissimus dorsi flap in breast reconstruction with a vascular supply from this vessel following thoracodorsal pedicle division has not previously been described. Previous thoracodorsal pedicle and serratus branch division may not be an absolute contraindication for the use of the latissimus dorsi flap in breast reconstruction, depending on the results of preoperative Doppler or computer tomographic angiography studies.

Asymmetric implants for breast asymmetry.

The indications, advantages, and disadvantages of round and anatomical implants have previously been described. The principles of biodimensional implant selection have been developed by several authors, where the objective choice of breast prosthesis for augmentation is based on the patient's breast tissues. This process has largely been applied to anatomical implant selection. We report a case of breast asymmetry, where we have applied the same concepts in the selection of implants based on tissue dimension. This resulted in an anatomical implant being used to augment the left breast, and a round implant on the right. To our knowledge a round implant and an anatomical implant have not previously been employed in the same patient to correct breast asymmetry. This resulted in excellent postoperative symmetry.

Sitting on a gold mine: optimal autologous reconstruction of a significant cosmetic contour defect of the buttock using a deep inferior epigastric artery perforator free flap.

The options for reconstruction of soft tissue defects of the buttock include custom prosthetic implants and autologous tissue transfer: fat transfer, local flaps, pedicled flaps and free flaps. Optimal reconstruction involves replacement of like-with-like tissue, sufficient padding and adequate contouring. We report a case of a female patient presenting with a significant cosmetic contour defect of her left buttock following previous excision of a malignant fibrous histiocytoma. The patient had autologous buttock reconstruction using a deep inferior epigastric artery perforator free flap with an excellent result. To our knowledge a deep inferior epigastric artery perforator free flap has not previously been described to reconstruct the buttock.

The mechanics of flexor tendon adhesions.

The mechanics of adhesions at a local tissue level have not been extensively studied. This study compared microstrains and macrostrains in adhesions of immobilized and mobilized partially lacerated flexor digitorum profundus tendons in a New Zealand White rabbit model. At 2 weeks, 50 digits were randomized to either gross tensile testing or micromechanical assessment, in which the movement of fluorescently labelled cell nuclei, acting as dynamic markers, was visualized using real-time confocal microscopy. The structural stiffness and load at failure of immobilized adhesions were 140% and 160% of that of mobilized adhesions, respectively, and both differences were statistically significant. Micromechanically, different patterns of loading and failure were observed. Mobilized adhesions exhibited over a three-fold higher local strain, which was less uniformly distributed. Confocal microscopy provided an accurate measure of local strain. For the first time, it has been possible to visualize, define, and quantify local adhesion tissue mechanics. Mobilization appears to favour the formation of sites expressing increased local strain responses or those predisposed to heterogeneity and localized failure.

The attachment of intrinsic and extrinsic, mobilized and immobilized adhesion cells to collagen and fibronectin.

This study investigated the attachment of intrinsic and extrinsic, mobilized and immobilized adhesion cells to the extracellular matrix. Five New Zealand White rabbit forepaws were dissected to isolate the flexor tendon core, tendon surface and synovial sheath, which were explanted separately. A further 10 animals were subjected to flexor tendon injuries, randomized to either mobilization or immobilization, and adhesions were explanted at 2 weeks. Cell groups were tested for attachment to collagen type-I or fibronectin and morphometric analysis was made. The attachment of intrinsic tendon cells and adhesion cells from mobilized tendons to both matrix proteins was statistically significantly greater than that of extrinsic tendon cells and adhesion cells from immobilized tendons. Adhesion cells from mobilized tendons were statistically significantly more elongated, which may correlate with the deposition of a more organized matrix. Because the synovial sheath cells were least attached to matrix proteins, selective treatments that reduce cell attachment may be used to exclude them, without inhibiting intrinsic tendon healing.

Concepts in aesthetic breast dimensions: analysis of the ideal breast.

BACKGROUND: This article identifies the key parameters that define the aesthetic ideal of the breast. Whilst much has previously been written on the aesthetic characteristics of the breast, thus far objective indices of beauty have not been identified. METHODS: In this observational study the breasts of 100 consecutive women in three quarter profile pose, having been chosen as topless models for the attractiveness of their breasts by editors of mass print media, were analysed to identify specific proportions common to all of them. Analysis of a series of less attractive breasts was subsequently carried out looking at divergence from the 'norms' identified in the first part of the study. RESULTS: We have identified 4 key features consistently found in all the models in the consecutive series: the proportion of the upper to the lower pole is a 45:55 ratio, the angulation of the nipple is upwards at a mean angle of 20° from the nipple meridian, the upper pole slope is linear or slightly concave, and the lower pole is convex. CONCLUSIONS: Deviation from this pattern yields a less attractive breast - the greater the deviation, the less attractive the breast. The importance of this template lies in its use as a guide for the design of aesthetic breast surgery as well as objective analysis of both good and bad results.

Shear-aggregated fibronectin with anti-adhesive properties.

Biomaterials based on proteins, such as fibronectin, have the potential to guide cell and tissue behaviour during healing as a function of their unique mechanical and bioactive properties. Fibronectin has been reported as a scaffold for attachment of fibroblasts and subsequent deposition of collagen. We have recently developed a derivative process of shear-aggregated fibronectin that prevents cell attachment without causing cell death. This has potential applications in clinical situations where adhesions form across gliding surfaces and cause loss of function, e.g. peritoneal or flexor tendon adhesions. This in vitro study tested this derivative fibronectin biomaterial and its effects on aggressive adhesion-forming cells, using rabbit flexor tendon synovial fibroblasts. We investigated degradation of the novel biomaterial, and attachment of fibroblasts to glass coated with the biomaterial, relative to fibroblast attachment to uncoated and fibronectin-coated glass. We assessed infiltration of the derivative fibronectin biomaterial by fibroblasts and cytotoxicity of the biomaterial to fibroblasts. The interaction between fibroblasts and the derivative fibronectin biomaterial was visualized using time-lapse photography. The derivative fibronectin biomaterial dissolved by 88% of its mass by 3 weeks. Fibroblast attachment to the novel biomaterial was significantly reduced at 6 h. After 24 h of exposure to the novel biomaterial, fibroblasts did not migrate into it, there was no cell death and no attachment was seen using time-lapse. This novel derivative fibronectin biomaterial combines inhibition of fibroblast attachment with barrier effects and has suitable mechanical properties for surgical use in preventing adhesions in vivo.

Self injection of lipase--an extreme case for regulation in non-surgical cosmetic procedures.

Mesotherapy or subcutaneous fat dissolution for cosmetic purposes has been described using phosphatidylcholine. A literature search found no reports of the use of lipase for mesotherapy. Substances for cosmetic mesotherapy are not licensed for use in the United Kingdom. We report a case of self injection using lipase obtained from the internet.