Patient Weight and Chemoprophylaxis in Abdominoplasty: Does It Result in More Bleeding Events?

BACKGROUND: Bariatric surgery has gained popularity in recent decades as an effective treatment for obesity. Abdominoplasty is one of the most often performed aesthetic procedures all over the world. In post-bariatric patients undergoing abdominoplasty, the diameter size and number of the abdominal wall perforators increase proportionally with increased body weight. Postoperative complications that may occur are haematoma, and venous thromboembolism (VTE). In plastic surgery procedures VTE prophylaxis grades vary due to the lack of consensus and clear guidelines. The aim of this study was to explore the frequency of postoperative bleeding and VTE in patients undergoing abdominoplasty and to explore the risk factors associated with major bleeding. METHODS: A retrospective single-centre study of adult patients who were operated on by abdominoplasty between 2011 and 2020. Chemoprophylaxis including low molecular weight heparin (LMHW) was recommended when the operating time exceeded 2 h. RESULTS: A total of 102 patients were included. There were no patients with VTE. Eight patients were re-operated for major haematoma. The weight loss (peak weight to weight before the abdominoplasty) was 14.4 kg larger in the re-operation group (p = 0.03). Eighty-eight percent in the re-operation group and 67% in the other group were treated with LMWH (p = 0.43). Multivariable logistic regression showed that with each decrease from the peak in BMI kg/m2 the risk of re-operation for major haematoma was increased by 22% (p = 0.02). CONCLUSION: Abdominoplasty in patients after massive weight loss has a higher risk of postoperative bleeding. Having a clear protocol for chemoprophylaxis should be considered. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

miRNome and Proteome Profiling of Human Keratinocytes and Adipose Derived Stem Cells Proposed miRNA-Mediated Regulations of Epidermal Growth Factor and Interleukin 1-Alpha.

Wound healing is regulated by complex crosstalk between keratinocytes and other cell types, including stem cells. In this study, a 7-day direct co-culture model of human keratinocytes and adipose-derived stem cells (ADSCs) was proposed to study the interaction between the two cell types, in order to identify regulators of ADSCs differentiation toward the epidermal lineage. As major mediators of cell communication, miRNome and proteome profiles in cell lysates of cultured human keratinocytes and ADSCs were explored through experimental and computational analyses. GeneChip® miRNA microarray, identified 378 differentially expressed miRNAs; of these, 114 miRNAs were upregulated and 264 miRNAs were downregulated in keratinocytes. According to miRNA target prediction databases and the Expression Atlas database, 109 skin-related genes were obtained. Pathway enrichment analysis revealed 14 pathways including vesicle-mediated transport, signaling by interleukin, and others. Proteome profiling showed a significant upregulation of the epidermal growth factor (EGF) and Interleukin 1-alpha (IL-1α) compared to ADSCs. Integrated analysis through cross-matching the differentially expressed miRNA and proteins suggested two potential pathways for regulations of epidermal differentiation; the first is EGF-based through the downregulation of miR-485-5p and miR-6765-5p and/or the upregulation of miR-4459. The second is mediated by IL-1α overexpression through four isomers of miR-30-5p and miR-181a-5p.

A Systematic Review of Keratinocyte Secretions: A Regenerative Perspective.

Cell regenerative therapy is a modern solution for difficult-to-heal wounds. Keratinocytes, the most common cell type in the skin, are difficult to obtain without the creation of another wound. Stem cell differentiation towards keratinocytes is a challenging process, and it is difficult to reproduce in chemically defined media. Nevertheless, a co-culture of keratinocytes with stem cells usually achieves efficient differentiation. This systematic review aims to identify the secretions of normal human keratinocytes reported in the literature and correlate them with the differentiation process. An online search revealed 338 references, of which 100 met the selection criteria. A total of 80 different keratinocyte secretions were reported, which can be grouped mainly into cytokines, growth factors, and antimicrobial peptides. The growth-factor group mostly affects stem cell differentiation into keratinocytes, especially epidermal growth factor and members of the transforming growth factor family. Nevertheless, the reported secretions reflected the nature of the involved studies, as most of them focused on keratinocyte interaction with inflammation. This review highlights the secretory function of keratinocytes, as well as the need for intense investigation to characterize these secretions and evaluate their regenerative capacities.

Assessment of Freestyle Local Facial Perforator Flaps for Coverage of Facial Defects.

OBJECTIVE: To assess local freestyle facial perforator flaps in the reconstruction of small to medium-sized facial defects. MATERIALS AND METHODS: In a case series, local freestyle perforator flaps were used in Suez Canal University Hospital to reconstruct 28 facial defects in 26 patients between 2017 and 2019. Adequate perforators were identified near those defects and flaps were designed as propeller or VY advancement. Four scales from the FACE-Q (satisfaction with facial appearance, satisfaction with the outcome, psychological function, and appearance-related psychosocial distress) and 2 scales from the SCAR-Q (Appearance scale and Symptom scale) were used as well as the observer part of the Patient and Observer Scar Assessment Scale. The mean follow up period was 10 months. RESULTS: Complete reconstruction was achieved in all cases with a high rate of patient satisfaction which was assessed by FACE-Q and SCAR-Q. Moreover, observer assessment by Patient and Observer Scar Assessment Scale score showed high patient satisfaction with the scars with a mean (SD) 15.5 (3.4) and there was a positive correlation between subjective and objective: results (r2 from 0.27 to 0.41, P < 0.01). Regarding complications, bulkiness occurred in 2 flaps, congestion in 2 flaps, dehiscence in 1 flap, and tip necrosis in 5 flaps. Accordingly, secondary intervention in the form of medicinal leech therapy was used in 3 flaps, delayed closure for the dehisced flap and debulking for 1 flap. CONCLUSIONS: Local freestyle perforator flap reconstruction is one of the recommended techniques for small to medium-sized facial defects which gives a high aesthetic outcome and patient satisfaction.

Scarring at Donor Sites after Split-Thickness Skin Graft: A Prospective, Longitudinal, Randomized Trial.

OBJECTIVE: To investigate if previous findings on the association between dressing treatments and subjective opinion on final donor site scar outcome using the Patient and Observer Scar Assessment Scale (POSAS) can be confirmed objectively. The previous study showed that patients dressed with hydrofiber covered with film were more satisfied with their donor site scars than patients receiving porcine xenograft or polyurethane foam dressings. METHODS: Scar outcome measurements were assessed by a blinded observer using POSAS and the Cutometer dual MPA 580 device to measure the viscoelasticity of skin. RESULTS: A total of 17 participants were included in this study, five of whom were treated with hydrofiber, six with polyurethane foam, and another six with porcine xenograft. There were no significant differences among groups in any of the POSAS items or in the viscoelasticity measurements made with the Cutometer. CONCLUSIONS: The investigators could not confirm previous associations between dressing treatment and long-term donor site scars. No associations between donor sites' healing times and final scarring were found. Hypopigmentation was reported in 15 of 17 donor sites evaluated.

Children aged 0-16 admitted to Swedish intensive care units and paediatric intensive care units showed low mortality rates.

AIM: This study described the basic characteristics of children aged 0-16 years who were treated in intensive care units (ICUs) and paediatric ICUs (PICUs), compared their outcomes and examined any causes of death. METHODS: This was a retrospective cohort study of admissions to 74 ICUs and three PICUs in Sweden that were recorded in the Swedish Intensive Care Registry from January 1, 2008 to December 31, 2012. RESULTS: We retrieved data on 12 756 children who were admitted 17 003 times. The case mix differed between the ICUs, which were mainly admissions for injuries, accidents and observation, and PICUs, which were mainly admissions for malformations, genetic abnormalities and respiratory problems (p < 0.001). The median stays in the ICUs and PICUs were 1.4 and 3.5 days (p < 0.001), respectively. The respective crude mortality rates were 1.1% and 2.0, and the Paediatric Index of Mortality version 2 standardised mortality ratios were 0.43 and 0.50. None of these differences were significant. Most deaths were within 24 hours: About 57% in the ICUs, mainly from brain anomalies, and 13% in the PICUs, mainly from circulatory problems. CONCLUSION: Sweden had a low mortality rate in both ICUs and PICUs and the children admitted to these two types of unit differed.

Skin regeneration in three dimensions, current status, challenges and opportunities.

Skin regeneration is a life-saving need for many patients, whom list is stretched from burn victims to motor-car accidents. Spraying cells, either keratinocytes or stem cells, were associated with variable results and, in many cases, unfavorable outcomes. As the spatial configuration of the skin is distinctive, many trials investigated the bio-printing or the construction of three dimensional skin models where different layers of the skin were preserved. Although some of these models showed the histological configuration of the skin, their acceptance by the wound was questionable as a consequence of delayed vascularization. In this mini-review, different models for three dimensional regeneration of the skin will be discussed with their main points of strength and challenges as well as their possible opportunities.

Evaluation of Glandular Liposculpture as a Single Treatment for Grades I and II Gynaecomastia.

BACKGROUND: Gynaecomastia is a benign enlargement of the male breast, of which the psychological burden on the patient can be considerable, with the increased risk of disorders such as depression, anxiety, and social phobia. Minimal scarring can be achieved by liposuction alone, though it is known to have a limited effect on the dense glandular and fibroconnective tissues. We know of few studies published on "liposuction alone", so we designed this study to evaluate the outcome of combining liposuction with glandular liposculpturing through two axillary incisions as a single treatment for the management of grades I and II gynaecomastia. METHODS: We made a retrospective analysis of 18 patients with grade I or II gynaecomastia who were operated on by combined liposuction and glandular liposculpturing using a fat disruptor cannula, without glandular excision, during the period 2014-2016. Patient satisfaction was assessed using the Breast Evaluation Questionnaire (BEQ), which is a 5-point Likert scale (1 = very dissatisfied; 2 = dissatisfied; 3 = neither; 4 = satisfied; 5 = very satisfied). The post-operative aesthetic appearance of the chest was evaluated by five independent observers on a scale from 1 to 5 (5 = considerable improvement). RESULTS: The patient mean (SD) overall satisfaction score was 4.7 (0.7), in which 92% of the responders were "satisfied" to "very satisfied". The mean (SD) BEQ for all questions answered increased from 2.1 (0.2) "dissatisfied" preoperatively to 4.1 (0.2) "satisfied" post-operatively. The observers' mean (SD) rate for the improvement in the shape of the front chest wall was 4.1 (0.7). No haematomas were recorded, one patient developed a wound infection, and two patients complained of remnants of tissue. The median (IQR) body mass index was 27.4 (26.7-29.4), 11 patients had gynaecomastia grade I, and 7 patients grade II. The median (IQR) volume of aspirated fat was 700 ml (650-800), operating time was 67 (65-75) minutes, 14 patients had general anaesthesia, and hospital charges were US$ 538 (481-594). CONCLUSIONS: Combined liposuction and liposculpturing using the fat disruptor cannula resulted in satisfied patients and acceptable outcomes according to the observers' ratings. It could be a useful alternative with an outcome that corresponds to that of more expensive methods. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Scarring At Donor Sites After Split-Thickness Skin Graft: A Prospective, Longitudinal, Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate scarring at split-thickness skin graft donor sites 8 years after surgery. METHODS: At surgery, 67 patients were randomized to hydrofiber, polyurethane foam, or porcine xenograft treatment. Scars were evaluated with the Patient and Observer Scar Assessment Scale. RESULTS: Results showed significant differences in observed scar outcomes at donor sites, leaving the polyurethane foam-treated and the porcine xenograft-treated patients with the least satisfying scars. Multivariable regression analysis showed that the group treated with the xenografts had worse scores for overall opinion of the scar than did the other groups (P = .03), the most important factor being pigmentation. There was no correlation between duration of healing time and quality of the scar. CONCLUSIONS: There were significant differences among the groups, with the hydrofiber group being the most satisfied with the appearance of their scar.

Wound infection among children with moderate burns - An explorative review of the association between reported frequency and diagnosis.

INTRODUCTION: The Linkoping burn centre in Sweden has, even though being a high income country, reported high burn wound infections (BWI) frequencies in scalded children compared to similar populations in other parts of the world. AIM: The aim was to investigate possible explanations for differences in frequency of BWI among children with partial thickness burns treated at the Linköping burn centre in Sweden, and that reported in other studies. METHOD: In order to investigate what BWI criteria that were used in similar studies a literature search on PubMed Central was done along with a retrospective analysis of children previously diagnosed as infected to confirm or reject the high infection frequency reported earlier. RESULT: Of the 34 selected publications reporting on BWI frequency 16 (47%) did not define a criteria for the BWI diagnosis and almost a third did not report on wound culturing. Of those who did report the use a third do not mention any bacterial growth found is these cultures. The retrospective analysis on children at the centre did not show any decrease in infection frequency even with some disagreement on onset for the BWI. CONCLUSION: The reporting of criteria and diagnosis of burn wound infection is highly variable making it difficult to interpret results and come to conclusions. The high frequency of BWI at the centre might be a result of close monitoring due to study participation, use of clean instead of sterile routine at dressing changes or low thresholds for the diagnosis in respect to changes in infection markers.

Breast Reconstruction Using the Extended Latissimus Dorsi Myocutaneous Flap-A Long-term Follow-up Utilizing BREAST-Q.

Background: The latissimus dorsi (LD) flap is a commonly used method for breast reconstruction after mastectomy. In this study, we present a long-term follow-up and effects of refining surgery on patient satisfaction and quality of life after breast reconstruction with the extended LD flap, using the BREAST-Q questionnaire. Objectives: The aim of this study was to investigate the patient-reported long-term results after breast reconstruction with the extended LD myocutaneous flap. Methods: A retrospective cohort study of adult patients (n = 101) who were operated on using the extended LD flap for breast reconstruction at the Linköping University Hospital during 1997 to 2012 was made using data retrieved from medical records. The patients were asked to complete the BREAST-Q questionnaire at 2 different postoperative time points. Results: Eighty-three patients replied to the first questionnaire, and 56 patients also replied to the second. Mean follow-up was 11.7 years. Higher age and living together with someone correlated to higher BREAST-Q results, while postoperative infection, bilateral LD flaps, smoking, and prior breast surgery had a negative impact on the results. Overall BREAST-Q results increased over time. No independent effect of refining surgery could be shown. Conclusions: Patient satisfaction after breast reconstruction with the LD flap as measured with the BREAST-Q questionnaire is high and in line with other studies. The overall satisfaction with the reconstruction method seems to increase with time, but no further increase in satisfaction after refining surgery could be established.

Skin perfusion and oxygen saturation after mastectomy and radiation therapy in breast cancer patients.

The pathophysiological mechanism behind complications associated with postmastectomy radiotherapy (PMRT) and subsequent implant-based breast reconstruction are not completely understood. The aim of this study was to examine if there is a relationship between PMRT and microvascular perfusion and saturation in the skin after mastectomy and assess if there is impaired responsiveness to a topically applied vasodilator (Methyl nicotinate - MN). Skin microvascular perfusion and oxygenation >2 years after PMRT were measured using white light diffuse reflectance spectroscopy (DRS) and laser Doppler flowmetry (LDF) in the irradiated chest wall of 31 women with the contralateral breast as a control. In the non-irradiated breast, the perfusion after application of MN (median 0.84, 25th-75th centile 0.59-1.02 % RBC × mm/s) was higher compared to the irradiated chest wall (median 0.51, 25th-75th centile 0.21-0.68 % RBC × mm/s, p < 0.001). The same phenomenon was noted for saturation (median 91 %, 25th-75th centile 89-94 % compared to 89 % 25th-75th centile 77-93 %, p = 0.001). Eight of the women (26%) had a ≥10 % difference in skin oxygenation between the non-irradiated breast and the irradiated chest wall. These results indicate that late microvascular changes caused by radiotherapy of the chest wall significantly affect skin perfusion and oxygenation.

Long-term mortality after self-inflicted burns.

BACKGROUND: Those with self-inflicted burns are a small but consistent group among burn patients, with large injuries and conflicting findings regarding their in-hospital mortality. Overall, burn survivors have a shorter life expectancy, as compared with national controls, but long-term mortality after self-inflicted burns is understudied. The aim of this retrospective study was to investigate possible differences in long-term mortality among survivors after self-inflicted and accidental burns. METHODS: All adult patients with burns admitted at the Linköping Burn Centre and discharged alive between 2000 and 2017 were included, and end of follow up was April 26, 2021. Those with unknown survival status at that time were excluded. A Cox proportional hazards regression model, adjusted for age and sex, was used to analyse long term mortality. RESULTS: Among the 930 patients included in this study, 37 had self-inflicted burns. Overall, median follow up period was 8.8 years and crude mortality was 24.7%. After adjustment for age and sex, self-inflicted burns were independently associated with long-term mortality, Hazard Ratio= 2.08 (95% CI 1.13-3.83). Post hoc analysis showed that the effect was most pronounced during the first years after discharge although it was noticeable over the whole study period. CONCLUSION: Long-term risk of mortality after discharge from a burn centre was higher in patients with self-inflicted burns than in patients with accidental burns. The effect was noticeable over the whole study period although it was most pronounced during the first years after discharge.

The impact and validity of the Berlin criteria on burn-induced ARDS: Examining mortality rates, and inhalation injury influences. A single center observational cohort study.

BACKGROUND: As several recent studies have shown low mortality rates in burn injury induced ARDS early (≤7 days) after the burn, the Berlin criteria for the ARDS diagnosis in this setting may be disputed. Related to this issue, the present study investigated the incidence, trajectory and risk factors of early Acute Respiratory Distress Syndrome (ARDS) and outcome in burn patients, as per the Berlin criteria, along with the concurrent prevalence and influence of inhalation injury, and ventilator-acquired pneumonia (VAP). METHODS: Over a 2.5-year period, burn patients with Total Burn Surface Area (TBSA) exceeding 10% admitted to a national burn center were included. The subgroup of interest comprised patients with more than 48 h of ventilatory support. This group was assessed for ARDS, inhalation injury, and VAP. RESULTS: Out of 292 admissions, 62 sustained burns > 10% TBSA. Of these, 28 (45%) underwent ventilatory support for over 48 h, almost all, 24 out of 28, meeting the criteria for ARDS early, within 7 days post-injury and with a PaO2/FiO2 (PF) ratio nadir at day 5. The mortality rate for this early ARDS group was under 10%, regardless of PF ratios (mean TBSA% 34,8%). Patients with concurrent inhalation injury and early ARDS showed significantly lower PF ratios (p < 0.001), and higher SOFA scores (p = 0.004) but without impact on mortality. Organ failure, indicated by SOFA scores, peaked early (day 3) and declined in the first week, mirroring PF ratio trends (p < 0.001). CONCLUSIONS: The low mortality associated with early ARDS in burn patients in this study challenges the Berlin criteria's for the early ARDS diagnosis, which for its validity relies on that higher mortality is linked to worsening PF ratios. The finding suggests alternative mechanisms, leading to the early ARDS diagnosis, such as the significant impact of inhalation injury on early PF ratios and organ failure, as seen in this study. The concurrence of early organ failure with declining PF ratios, supports, as expected, the hypothesis of trauma-induced inflammation/multi-organ failure mechanisms contributing to early ARDS. The study highlights the complexity in differentiating between the contributions of inhalation injury to early ARDS and the related organ dysfunction early in the burn care trajectory. The Berlin criteria for the ARDS diagnosis may not be fully applicable in the burn care setting, where the low mortality significantly deviates from that described in the original Berlin ARDS criteria publication but is as expected when considering the actual not very extensive burn injury sizes/Baux scores as in the present study.

MicroRNA-155 mediates multiple gene regulations pertinent to the role of human adipose-derived mesenchymal stem cells in skin regeneration.

Introduction: The role of Adipose-derived mesenchymal stem cells (AD-MSCs) in skin wound healing remains to be fully characterized. This study aims to evaluate the regenerative potential of autologous AD-MSCs in a non-healing porcine wound model, in addition to elucidate key miRNA-mediated epigenetic regulations that underlie the regenerative potential of AD-MSCs in wounds. Methods: The regenerative potential of autologous AD-MSCs was evaluated in porcine model using histopathology and spatial frequency domain imaging. Then, the correlations between miRNAs and proteins of AD-MSCs were evaluated using an integration analysis in primary human AD-MSCs in comparison to primary human keratinocytes. Transfection study of AD-MSCs was conducted to validate the bioinformatics data. Results: Autologous porcine AD-MSCs improved wound epithelialization and skin properties in comparison to control wounds. We identified 26 proteins upregulated in human AD-MSCs, including growth and angiogenic factors, chemokines and inflammatory cytokines. Pathway enrichment analysis highlighted cell signalling-associated pathways and immunomodulatory pathways. miRNA-target modelling revealed regulations related to genes encoding for 16 upregulated proteins. miR-155-5p was predicted to regulate Fibroblast growth factor 2 and 7, C-C motif chemokine ligand 2 and Vascular cell adhesion molecule 1. Transfecting human AD-MSCs cell line with anti-miR-155 showed transient gene silencing of the four proteins at 24 h post-transfection. Discussion: This study proposes a positive miR-155-mediated gene regulation of key factors involved in wound healing. The study represents a promising approach for miRNA-based and cell-free regenerative treatment for difficult-to-heal wounds. The therapeutic potential of miR-155 and its identified targets should be further explored in-vivo.

Suprathel® or Mepilex® Ag for treatment of partial thickness burns in children: A case control study.

AIM: The study aim was to investigate if Suprathel® can be an adequate alternative to Mepilex® Ag for the treatment of partial-thickness scalds in children. METHODS: A retrospective study including 58 children admitted to The Burn Centre in Linköping, Sweden between year 2015 and 2022. Of the 58 children, 30 were dressed with Suprathel ® and 28 with Mepilex ® Ag. Outcomes investigated were healing time, burn wound infection (BWI), need for operations and number of dressing changes. RESULTS: We found no significant differences in any of the outcomes. In the Suprathel ® group 17 children and in the Mepilex ® Ag group 15 children were healed within 14 days. Ten children from each group received antibiotics for suspected BWI and two from each group underwent an operation with skin grafting. Each group had on median four dressing changes. CONCLUSIONS: Two different treatments were compared for children with partial-thickness scalds, and the data indicates that similar results are received with both dressings.

Flap Survival after Reconstructive Surgery for Pressure Ulcers: A Cohort Study.

Background: Pressure ulcers are troublesome for patients and require considerable resources to resolve. Previous studies have focused on recurrence, whereas there are few studies on flap survival. The aim was to describe the group and to analyze possible factors for flap survival. Method: A descriptive retrospective analysis of all operations between 2008 and 2020 was carried out. Flap survival at 40 days was assessed. A flap was classified as a failure if a reoperation with removal or replacement was planned before, or in connection with, the first return visit. Variables of patient demographics, details of the pressure ulcers, and surgical treatment and care were analyzed with multivariable logistic regression for their effect on flap survival. Results: A total of 111 flaps were included [78 (70%) with random blood supply and 33 (30%) with axial or perforator-based blood supply]; 54 (49%) of the flaps were fasciocutaneous. Body mass index was 25 (IQR 22-28). Flap survival rate was 90%. Variables associated with flap failure were higher body mass index, congenital spinal cord injury, type of blood supply to the flap, and the use of methylene blue to guide debridement of the wound. Conclusions: The findings show factors that can be modified to improve future results, including a normalized body mass index and use of methylene blue in surgery to outline wound edges and depth, as this has been shown to protect against flap failure. Our data suggest that random flaps, such as V-Y, are preferable to axial flaps in the studied group.