Hyperbaric Oxygen Therapy in Upper Limb Crush Injury: Why and When?

Introduction In 2016, the European Committee for Hyperbaric Medicine strongly recommended hyperbaric oxygen therapy (HBOT) adjunctive to surgery in post-traumatic crush injuries, initiating as rapidly as possible. For the last 30 years, HBOT has been used in crush injury, but in most cases as a last resort, after skin flaps necrosis or wound bed infection, diminishing its potential benefits as a complementary treatment. It is, therefore, essential to understand how HBOT modulates the outcome of crush injury, and when to use it, since this can be a significant and underused therapeutic weapon that may alter the natural course of these patients. Methods Nineteen (n=19) adult patients with upper limb crush injuries underwent adjunctive HBOT, after the initial surgical approach. The measured outcomes included trauma-related acute complications (tissue necrosis and local infection), and late complications (pseudarthrosis and late deep infection). Results Only six (n=6) patients started HBOT in the first 24 hours. Four (n=4) patients presented acute complications; in half of those cases (n=2), HBOT was initiated more than 24 hours post-injury. Late complications were observed in three patients, none of which had initiated HBOT in the first 24 hours post-injury. Conclusions Either lack of awareness or logistic difficulties, preclude initiating timely HBOT, limiting its potential benefits. It is important to alert all practitioners to the right timing to initiate HBOT in order to improve these patients' outcomes.

Impact of polyurethane versus acellular dermal matrix coating on prepectoral reconstruction outcomes: Interface does matter.

BACKGROUND: Interfaces continue to be used in prepectoral breast reconstruction to refine breast appearance, but more clinical data are required to assess their effectiveness. This study compares the rates of capsular contracture, breast esthetics, and patient satisfaction between two commonly used interface materials, acellular dermal matrix (ADM) and polyurethane (PU) foam. METHODS: A cross-sectional assessment was conducted on all patients who underwent prepectoral direct-to-implant reconstruction with an interface material between June 2018 and June 2022. We compared capsular contracture rates (assessed in-person), esthetic outcomes (evaluated by a three-member panel using a specially designed scale), and patient satisfaction (measured using the Breast-Q questionnaire) among the members of the interface groups. RESULTS: Among the 79 reconstructed breasts (20 bilateral cases), 35 were reconstructed using ADM and 44 using PU implants. The ADM group had a significantly higher frequency of Baker III/IV capsular contracture compared with the PU group (14.3% vs. 0%, p = 0.014) and lower ratings from the panel in terms of capsular contracture (median 3.7 vs. 4.0, p < 0.001). PU reconstructions scored worse in implant visibility (median 2.3 vs. 3.3, p < 0.001) and rippling (median 3.0 vs. 3.7, p < 0.001). However, after appropriate adjustment for confounders, no significant differences in overall appearance and patient satisfaction were found. CONCLUSIONS: ADM reconstructions are prone to capsular contracture with all their related esthetic issues, but PU implants have certain cosmetic flaws, such as implant visibility and malposition. Since each technique has its own limitations, neither the experienced surgeons nor patients exhibited a clear preference for either approach.

Heterotopic ossification - A rare donor site complication after iliac crest free flap.

Iliac crest free flap is still essential as a source of vascularized bone tissue, having a definite role in osseous reconstruction of the face and other small bone defects. Some of its drawbacks include laborious dissection and donor site morbidity. We report a case of a patient that presented to our follow-up consultation ten years after iliac crest free flap harvest with new complaints of pain, gait disturbance and swelling in the right hip. Imaging exams revealed a heterotopic bone formation and helped with the diagnosis of heterotopic ossification (HO) of the right iliacus bone. Surgical intervention was needed for debridement of the heterotopic bone, with resolution of the symptoms. To our knowledge, this is the first report of HO after iliac crest free flap harvest. This rare condition adds to an already well-known number of donor zone complications of this flap. Plastic surgeons should be aware of this complication, as it can cause disability many years after the original surgery.

Primary care doctor's perception about the scope of plastic surgeons: A national survey.

BACKGROUND: Plastic surgery is characterized by a broad spectrum of aesthetic and reconstructive surgical expertise that is not defined by an anatomic area. The authors sought to identify primary care doctors' perceptions of different fields of plastic surgery. METHODS: A short, anonymous, web-based survey was administered to primary care doctors in Portugal. Respondents were asked to choose the specialist they perceived to be an expert for 29 specific clinical areas, including 20 that are the core of plastic surgery practice. Specialists for selection included the following choices: dermatologist, general surgeon, maxillofacial surgeon, vascular surgeon, neurosurgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. RESULTS: A total of 430 complete answers to the survey were collected. Out of the 20 clinical cases related to plastic surgery, only nine were attributed to plastic surgery in the majority of the answers: thumb reimplantation (64,2%), abdominoplasty (93%), breast reduction (94%), otoplasty (62,3%), skin graft for a burn (97,7%), breast reconstruction (94,9%), complex open wound (57,2%), facial reanimation (36,7%) and first web space contracture of the hand (78,6%). CONCLUSIONS: There is a clear underestimation of the role of plastic surgery in a wide range of conditions, which may lead to the downsizing of plastic surgery departments in the national health system. It is of utmost importance to educate primary care doctors so that patients are referred correctly and in a timely manner.

Stylomandibular False Ankylosis: An Unusual Complication After Vascularized Iliac Crest Flap for Mandibular Reconstruction.

Stylomandibular fusion is a poorly documented and rare complication of maxillofacial surgical procedures. This case report describes a patient presenting with stylomandibular false ankylosis following mandibular reconstruction. A 59-year-old female patient underwent segmental mandibular resection and reconstruction for a defect resulting from ameloblastoma surgery using an iliac crest free flap. A styloid fracture was detected postoperatively, and the patient was managed conservatively. In the third postoperative year, the patient presented with marked limitation of oral gape. A diagnosis of stylomandibular false ankylosis was made, and the patient underwent an ostectomy of the aberrant bone, with improved mouth opening. The abnormal union between the styloid process and the mandible is a previously unreported complication in the use of iliac crest free flaps. This case report emphasizes the importance of being vigilant for stylomandibular false ankylosis, especially when there is a restriction of oral aperture postoperatively following reconstructive procedures involving bone flaps.

Comparing Polyurethane and Acellular Dermal Matrix Implant Cover in Prepectoral Breast Reconstruction: Short-term Complications.

Implant covering with an interface material is the standard in prepectoral breast reconstruction. Acellular dermal matrix (ADM) is frequently used, but it is expensive and associated with complications. Alternatively, we have been using integrated devices consisting of a silicone implant coated with polyurethane (PU) foam. We aimed to compare both techniques in terms of acute complications. Methods: The authors retrospectively reviewed patients undergoing prepectoral direct-to-implant reconstruction from June 2018 to January 2022. Two cohorts were defined based on the interface material used: ADM versus PU. Total drainage volume, time to drain removal, and acute complications (hematoma, seroma, infection, and explantation) were analyzed. Results: Forty-four breast reconstructions were performed in 35 patients (10 bilateral); implants were covered with ADM in 23 cases and with PU foam in 21. Median total drainage volume (500 versus 515 cc for ADM and PU, respectively) and time to drain removal (9 versus 8 days) were not affected by the interface material used, but seromas and infections occurred exclusively in the ADM cohort (seromas in four of 23 of cases, P = 0.109; infections in three of 23 cases, P = 0.234). Overall complications occurred more often in cases reconstructed with ADM, but the difference was nonsignificant (P = 0.245). Conclusions: The use of interface materials is generally considered a prerequisite for state-of-the-art prepectoral breast reconstruction for a variety of reasons, including the prevention of capsular contracture. In this study, PU coating tended to be associated with fewer short-term complications than ADM, including seroma and infection.

Predictors of Prognosis in Patients with Type B Aortic Dissection.

INTRODUCTION: Type B aortic dissection (TBAD) affects mostly men with an estimated annual incidence between 2.9 and 4.0 per 100,000, and it appears to be increasing. DISSECT classification was published in 2013 aiming to reunite clinical and anatomical characteristics of interest to clinicians involved in TBAD management. In Portugal, the incidence of the condition, as well as its characteristics and outcomes, are not well documented. The aim of this paper is to describe the reality of a tertiary institution with a referral area of about 0,6 million habitants. METHODS: It is a retrospective study that included all patients with TBAD admitted from March of 2006 to 2016. The patients were categorized according to their demographic and clinical characteristics. For each patient, the computerized tomography scan that enable the TBAD diagnosis was classified using DISSECT classification. Overall mortality rates and aorta-related mortality rates were estimated using Kaplan-Meier method. Cox regression was used to study determinants of mortality. RESULTS: We included 35 patients, estimating a TBAD incidence of approximately 0.6 per 100,000 person-year. The majority were men (83%) with a mean age of 60±12 years-old; 71% were hypertensive, 56% were ex-smokers or active smokers and 13% had diabetes. As to DISSECT classification, 76% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum trans-aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental extent), 26% presented with Complications, being rupture and branch vessel malperfusion the most frequent, and 28% had partial Thrombosis of false lumen (versus 66% with permeability of false lumen). Eight patients underwent surgery (24%), 6 of them in acute phase and 2 of them in subacute phase. At 12 months, overall survival of whole series was 73,1%±8,3% and survival free from aortic-related mortality was 83±6,7% (Figure 1 A and B). The presence of complications was identified as an independent risk factor of overall mortality but not to aortic-related mortality. CONCLUSION: The incidence of TBAD verified was lower than what has been described in literature. DISSECT classification can be easily applied to TBAD cases. The presence of complications predicts higher mortality. Further studies are needed to characterize TBAD in Portugal.