Three Simple Steps for Refining Transcutaneous Lower Blepharoplasty for Aging Eyelids: The Indispensability of Micro-Autologous Fat Transplantation.

BACKGROUND: Lower blepharoplasty has been used for rejuvenating lower eyelids, and diverse modifications have been used to treat conjunct deformities at the tear trough/lid-cheek junction. Strategies for recontouring prominent tear trough/lid-cheek junctions, including orbital fat manipulation, have been reported with good results in the literature. Micro-autologous fat transplantation (MAFT) is a previously unevaluated, potentially advantageous approach to blending the prominent tear trough/lid-cheek junction. OBJECTIVES: We determined the long-term results after 3-step transcutaneous lower blepharoplasty with MAFT for patients with aging eyelids and prominent tear trough/lid-cheek junctions. METHODS: We evaluated 205 patients with aging lower eyelids who underwent transcutaneous lower blepharoplasty with MAFT between October 2010 and September 2016. The 3-step procedure involved a subciliary elliptical skin excision, resection of 3 orbital fat compartments, and MAFT for the tear trough/lid-cheek junction employing a MAFT-GUN under intravenous anesthesia. RESULTS: The mean patient age was 52 years (range, 34-78 years). The mean operating time was 61 minutes. The mean fat volumes delivered to the tear trough/lid-cheek junctions were 2.80 mL and 2.76 mL for the left and right sides, respectively. The average weights of the 3 resected orbital fat compartments were 0.58 g for the left side and 0.56 g for the right side. Patients showed significant improvement and maintenance at an average follow-up of 60.2 months (range, 18-90 months). CONCLUSIONS: Three-step transcutaneous lower blepharoplasty with MAFT is an effective, reliable, and promising method with high patient satisfaction and minimal risk of complications. Long-term results demonstrated its utility for aging lower eyelid treatment.

Educational video-assisted versus conventional informed consent for trauma-related debridement surgery: a parallel group randomized controlled trial.

BACKGROUND: We investigated whether, in the emergency department (ED), educational video-assisted informed consent is superior to the conventional consent process, to inform trauma patients undergoing surgery about the procedure, benefits, risks, alternatives, and postoperative care. METHODS: We conducted a prospective randomized controlled trial, with superiority study design. All trauma patients scheduled to receive trauma-related debridement surgery in the ED of Kaohsiung Medical University Hospital were included. Patients were assigned to one of two education protocols. Participants in the intervention group watched an educational video illustrating informed consent information, whereas those in the control group read an informed consent document. The primary outcome was knowledge scores and the secondary outcome was assessment of patient satisfaction. A multivariable regression model, with predefined covariates, was used to analyze differences in knowledge scores and patient satisfaction levels between the groups. RESULTS: A total of 142 patients were enrolled, with 70 and 72 assigned to the intervention and control groups, respectively. Mean knowledge scores were higher in the intervention (72.57 ± 16.21 (SD)) than in the control (61.67 ± 18.39) group. By multivariate analysis, the intervention group had significantly greater differences in knowledge scores (coefficient: 7.646, 95% CI: 3.381-11.911). Age, injury severity score, and baseline knowledge score significantly affected the differences in knowledge scores. Significant improvements were observed in patients' perception of statements addressing comprehension of the information provided, helpfulness of the supplied information for decision making, and satisfaction with the informed consent process. Multivariate analysis showed significant correlations between video education and patient satisfaction. CONCLUSIONS: Both the educational approach and severity of injury may have an impact on patient understanding during the informed consent process in an emergency environment. Video-assisted informed consent may improve the understanding of surgery and satisfaction with the informed consent process for trauma patients in the ED. Institutions should develop structured methods and other strategies to better inform trauma patients, facilitate treatment decisions, and improve patient satisfaction. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

Micro-Autologous Fat Transplantation for Treating a Gummy Smile.

BACKGROUND: A gummy smile is treated using many techniques, including botulinum toxin injection and various surgical interventions. Micro-autologous fat transplantation (MAFT) is a potentially advantageous alternative approach that has not been previously evaluated. OBJECTIVES: This study sought to determine the long-term results of MAFT in patients with a gummy smile. METHODS: Seven patients with gummy smiles were evaluated for MAFT treatment between October 2015 and April 2017. Centrifuged purified fat was micro-transplanted into the nasolabial groove, ergotrid, and upper lip areas using the MAFT-GUN while the patients were under total intravenous anesthesia. RESULTS: The mean age of the 7 patients was 31 years (range, 23-40 years). The mean operating time for MAFT was 52 minutes (range, 40-72 minutes), and the mean volume of fat delivered to the nasolabial groove, ergotrid, and upper lip was 16.1 mL. The mean decreases of gingival display in the right canine incisor, left canine incisor, right canine, and left canine teeth were 4.9, 4.6, 3.8, and 4.4 mm, respectively. The smiles of the 7 patients showed significant improvement at an average follow-up time of 12.9 months. CONCLUSIONS: Gummy smile treatment using MAFT is an effective, reliable, and relatively simple method, with high patient satisfaction and minimal risk of complications.

Development and pilot testing of an informed consent video for patients with limb trauma prior to debridement surgery using a modified Delphi technique.

BACKGROUND: Ensuring adequate informed consent for surgery in a trauma setting is challenging. We developed and pilot tested an educational video containing information regarding the informed consent process for surgery in trauma patients and a knowledge measure instrument and evaluated whether the audiovisual presentation improved the patients' knowledge regarding their procedure and aftercare and their satisfaction with the informed consent process. METHODS: A modified Delphi technique in which a panel of experts participated in successive rounds of shared scoring of items to forecast outcomes was applied to reach a consensus among the experts. The resulting consensus was used to develop the video content and questions for measuring the understanding of the informed consent for debridement surgery in limb trauma patients. The expert panel included experienced patients. The participants in this pilot study were enrolled as a convenience sample of adult trauma patients scheduled to receive surgery. RESULTS: The modified Delphi technique comprised three rounds over a 4-month period. The items given higher scores by the experts in several categories were chosen for the subsequent rounds until consensus was reached. The experts reached a consensus on each item after the three-round process. The final knowledge measure comprising 10 questions was developed and validated. Thirty eligible trauma patients presenting to the Emergency Department (ED) were approached and completed the questionnaires in this pilot study. The participants exhibited significantly higher mean knowledge and satisfaction scores after watching the educational video than before watching the video. CONCLUSIONS: Our process is promising for developing procedure-specific informed consent and audiovisual aids in medical and surgical specialties. The educational video was developed using a scientific method that integrated the opinions of different stakeholders, particularly patients. This video is a useful tool for improving the knowledge and satisfaction of trauma patients in the ED. The modified Delphi technique is an effective method for collecting experts' opinions and reaching a consensus on the content of educational materials for informed consent. Institutions should prioritize patient-centered health care and develop a structured informed consent process to improve the quality of care. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

Fat Grafting for Recontouring Sunken Upper Eyelids With Multiple Folds in Asians-Novel Mechanism for Neoformation of Double Eyelid Crease.

BACKGROUND: This study reviewed the mini invasive technique, microautologous fat transplantation (MAFT), as a strategy in simultaneously treating sunken upper eyelids with multiple folds and recreating a double eyelid crease in Asian people. METHODS: The MAFT was performed with the assistance of a patented medical device, the MAFT-GUN, on 34 patients who had sunken upper eyelids and multiple folds. Each delivered fat parcel was accurately and consistently maintained at 1/240 mL during placement. Follow-up was regularly performed with photography for comparison. RESULTS: Fifty-eight sunken upper eyelids with multiple folds were reconstructed. In addition to the ameliorative recontouring of hollowness, a natural eyelid crease was created postoperatively. Temporary swelling and bruising were noted several days after surgery without morbidities, such as fibrosis or nodulation. All of the patients were satisfied with the 1-time MAFT procedure. CONCLUSIONS: Fat grafting for sunken upper eyelids with multiple folds has been reported in the literature. However, temporal effects and complications, such as nodulation and irregularity, have often occurred. A new method, MAFT, demonstrated its reliability as a modality for sunken upper eyelids with multiple folds in Asians. Moreover, MAFT might serve as an alternative for neoformation of double eyelids in these candidates.

Microautologous Fat Transplantation for Primary Augmentation Rhinoplasty: Long-Term Monitoring of 198 Asian Patients.

BACKGROUND: Numerous techniques and materials are available for increasing the dorsal height and length of the nose. Microautologous fat transplantation (MAFT) may be an appropriate strategy for augmentation rhinoplasty. OBJECTIVES: The authors sought to determine the long-term results of MAFT with the so-called one-third maneuver in Asian patients who underwent augmentation rhinoplasty. METHODS: A total of 198 patients who underwent primary augmentation rhinoplasty with MAFT were evaluated in a retrospective study. Fat was harvested by liposuction and was processed and refined by centrifugation. Minute parcels of purified fat were transplanted to the nasal dorsum with a MAFT-Gun. Patient satisfaction was scored with a 5-point Likert scale, and aesthetic outcomes were validated with pre- and postoperative photographs. RESULTS: The mean age of the patients was 45.5 years. The mean operating time for MAFT was 25 minutes, and patients underwent 1-3 MAFT sessions. The mean volume of fat delivered per session was 3.4 mL (range, 2.0-5.5 mL). Patients received follow-up for an average of 19 months (range, 6-42 months). Overall, 125 of 198 patients (63.1%) indicated that they were satisfied with the results of 1-3 sessions of MAFT. There were no major complications. CONCLUSIONS: The results of this study support MAFT as an appropriate fat-transfer strategy for Asian patients undergoing primary augmentation rhinoplasty. LEVEL OF EVIDENCE 4: Therapeutic.

Empty toe: a unique type of closed degloving injury with dismal outcome.

Closed degloving injury is characterized by the development of soft tissue separated from underlying structure without outer skin disruption. "Empty toe" is one of the most unique types of closed degloving injuries. Only 4 such injuries have been reported previously. We demonstrate a case of this entity in a 20-year-old scooter passenger. She presented to our emergency department with apparent deformity of the left fifth toe with intact skin. Radiographic examination showed no skeletal fracture or dislocation, but the skin of the injured toe was detached from the underlying bony structure. Despite repositioning the phalangeal bone into the empty toe, the skin was nonviable, and surgical site gangrene developed thereafter. The fifth toe was eventually amputated. An empty toe implies that the injured site has experienced severe compressive and shearing force with potential neurovascular damage. Health care providers should be fully aware of the high risk of the probability of vascular insufficiency, and the viability would be associated with vascular capability.

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study.

BACKGROUND: To evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting. METHODS: A pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression. RESULTS: Structured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of "personal information overheard by others", being "seen by irrelevant persons", having "unintentionally heard inappropriate conversations from healthcare providers", and experiencing "providers' respect for my privacy". There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis. CONCLUSIONS: Significant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.

Radix Glycyrrhizae Preparata Induces Cell Cycle Arrest and Induced Caspase-Dependent Apoptosis in Glioblastoma Multiforme.

Glioblastoma multiforme (GBM) is a highly aggressive and devastating brain tumor characterized by poor prognosis and high rates of recurrence. Despite advances in multidisciplinary treatment, GBM constinues to have a poor overall survival. The Radix Glycyrrhizae Preparata (RGP) has been reported to possess anti-allergic, neuroprotective, antioxidative, and anti-inflammatory activities. However, it not clear what effect it may have on tumorigenesis in GBM. This study demonstrated that RGP reduced glioma cell viability and attenuated glioma cell locomotion in GBM8401 and U87MG cells. RGP treated cells had significant increase in the percentage of apoptotic cells and rise in the percentage of caspase-3 activity. In addition, the results of study's cell cycle analysis also showed that RGP arrested glioma cells at G2/M phase and Cell failure pass the G2 checkpoint by RGP treatment in GBM8401 Cells. Based on the above results, it seems to imply that RGP activated DNA damage checkpoint system and cell cycle regulators and induce apoptosis in established GBM cells. In conclusion, RGP can inhibit proliferation, cell locomotion, cell cycle progression and induce apoptosis in GBM cells in vitro.

Neck collar used in treatment of victims of urban motorcycle accidents: over- or underprotection?

BACKGROUND: Cervical collar brace protection of the cervical spine at the scene of the incident is the first priority for emergency medical technicians treating patients who have sustained trauma. However, there is still controversy between over- or underprotection. The objective of this study was to survey the cervical spine injury of lightweight motorcycle accident victims and further evaluate the neck collar protection policy. MATERIALS AND METHODS: We retrospectively reviewed patients who sustained lightweight motorcycle injuries, assumed to have been at a low velocity, with incidence of cervical spine damage, from a single medical center's trauma registration from 2008 to 2009. Patients were divided into 2 groups: those who were immobilized by cervical collar brace and those who were not. RESULTS: Of the 8633 motorcycle crash victims, 63 patients had cervical spine injury. The average of the injury severity score in these patients was 14.31 ± 8.25. There was no significant correlation of cervical spine injury between the patients who had had the neck collar applied and those who had not (χ(2), P = .896). The length of stay in intensive care unit was longer in the patients who had the neck collar applied, but the total hospital length of stay was not statistically different to the patients who did not have the neck collar applied. CONCLUSION: The incidence of cervical spinal injuries in the urban area lightweight motorcyclists is very low. Prehospital protocol for application of a cervical collar brace to people who have sustained a lightweight motorcycle accident in the urban area should be revised to avoid unnecessary restraint and possible complications.

Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration.

BACKGROUND: It is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans. METHODS: In this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex. RESULTS: In patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P < .001), and alanine aminotransferase (ALT) (P < .001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm(3), we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims. CONCLUSION: In patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

More becomes less: management strategy has definitely changed over the past decade of splenic injury--a nationwide population-based study.

BACKGROUND: Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. MATERIALS AND METHODS: We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. RESULTS: 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X (2), P = 0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, P < 0.001, CI 1.017-1.049), with or without CT obtained (OR 0.347, P = 0.026, CI 0.158-0.889), and numbers of coexisting injuries (OR 1.346, P = 0.043, CI 1.010-1.842). CONCLUSION: Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality.

Application of microautologous fat transplantation in the correction of sunken upper eyelid.

BACKGROUND: Although fat grafting has been clinically applied by surgeons in esthetic and reconstructive surgery, it has widely evolved in processes such as harvesting, processing, and placement of fat, using the fat-grafting procedure, which dates back over 100 years. Surgeons frequently use fat grafting to recontour, augment, or fill soft-tissue defects, facial wrinkles, or skin problems such as depressions or scars. However, fat grafting has not been thoroughly understood and has not been conclusively standardized to ensure superior clinical results. METHODS: This study was intended to determine the role of microautologous fat transplantation (MAFT) under evidence-based medicine, particularly in accurate delivery of small fat parcels. The research method involved the conceptualization of MAFT and the development of an innovative surgical instrument for fat placement. Clinically, 168 patients with sunken upper eyelids with multiple folds underwent this procedure. RESULTS: The major findings suggested that MAFT exhibits promising clinical results and offers a superior guideline for fat placement. Details of the technique and theoretical implications are also discussed. CONCLUSIONS: The therapeutic effects of MAFT and the long-term clinical results of patients with sunken upper eyelids with multiple folds indicated satisfactory outcomes. Based on the results, MAFT offers an alternative option to surgeons for performing fat grafting and provides a more favorable option for the benefit and welfare of patients by reducing the potential complications.

Association of head, thoracic and abdominal trauma with delayed diagnosis of co-existing injuries in critical trauma patients.

BACKGROUND: Management of critically injured patients is usually complicated and challenging. A structured team approach with comprehensive survey is warranted. However, delayed diagnosis of co-existing injuries that are less severe or occult might still occur, despite a standard thorough approach coupled with advances in image intervention. Clinicians are easily distracted or occupied by the more obvious or threatening conditions. We hypothesised that the major area of injured body regions might contribute to this unwanted condition. METHODS: A retrospective study of all trauma patients admitted to our surgical intensive care units (ICU) was performed to survey the incidence of delayed diagnosis of injury (DDI) and the association between main body region injured and possibility of DDI. Demographic data and main body regions injured were compared and statistically analysed between patients with and without DDI. RESULTS: During the two-year study period, a total 976 trauma patients admitted to our surgical ICU were included in this study. The incidence of DDI was 12.1% (118/976). Patients with DDI had higher percentages of thoracic, abdominal, and pelvic injuries (30.5%, 16.1%, and 7.6% respectively) than the non-DDI group (14.7%, 7.5%, and 3.0% respectively) (p<0.001, 0.003, and 0.024 respectively). A logistic regression model demonstrated that head (odds ratio=1.99; 95%CI=1.20-3.31), thoracic (odds ratio=2.44; 95%CI=1.55-3.86), and abdominal injuries (odds ratio=2.38; 95%CI=1.28-4.42) were independently associated with increasing DDI in patients admitted to the surgical ICU. DISCUSSION: In conclusion, critical trauma patients admitted to the surgical ICU with these categories of injuries were more likely to have DDI. Clinicians should pay more attention to patients admitted due to injuries in these regions. More detailed and dedicated secondary and tertiary surveys should be given, with more frequent and careful re-evaluation.

Incidence, national trend, and outcome of nontraumatic subarachnoid haemorrhage in Taiwan: initial lower mortality, poor long-term outcome.

To investigate the longitudinal trend of nontraumatic subarachnoid haemorrhage (SAH), we analyzed the annual population-based incidence and mortality rate of nontraumatic subarachnoid hemorrhage in Taiwan. Logistic regression was used to identify independent predictors of mortality. The average incidence rate (IR) of nontraumatic SAH was 6.25 ± 0.88 per 100,000 per year. The prevalence of female patients was higher than in the male population (54.5% versus 45.5%). The average age of these patients was 55.78 ± 17.09 and females were older than males (58.50 ± 15.9 versus 52.45 ± 18.50, P < 0.001). Of these patients, 97.6% (611/626) were treated with surgical intervention with clipping procedure and 2.9% (18/626) with coiling. Total mortality of these patients was 13.4% (84/626). In adjusted analysis, age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.98-0.98; P < 0.001) and Charlson comorbidity index (OR, 0.709; 95% CI, 0.57-0.88; P = 0.002) remained independent predictors of the mortality. Patients with nontraumatic SAH had a much higher prevalence in older age groups and in females than in the general population. Patients with old age and more comorbidity have higher mortality. Aggressive management of patients might reduce the initial mortality; however, patient outcome still remains poor.