How to spot cocaine-induced pseudovasculitis.

The prevalence of cocaine-induced pseudovasculitis (CIP) causing cutaneous destruction is increasing, and plastic surgeons need to be aware of this condition because they are a part of the multidisciplinary treatment team. Differentiation of CIP from a true autoimmune vasculitis can be exceedingly challenging, and misdiagnosis with ensuing treatment may be fatal. This article is a succinct review of CIP, guided by a clinical case of 30% total body surface area skin necrosis, to familiarize the reader with this syndrome. Diagnostic aids include history of cocaine use, localized disease manifestation to skin or mucosa, discordance of antineutrophil cytoplasmic antibody and target antibody patterns typical for true vasculitis, and testing for antihuman neutrophil elastase and levamisole. Treatment is primarily supportive, and wound care, with regard to dressings and surgery, is a cross between to that of burns and meningococcemia patients.

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow.

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Clinical Application of Mathematical Long Bone Ratios to Calculate Appropriate Donor Limb Lengths in Bilateral Upper Limb Transplantation.

Background: Limited methods exist to aid in deciding the appropriate donor limb lengths in bilateral upper limb amputees qualifying for vascularized composite allotransplantation. We hypothesized mathematical equations could be created using long bone length ratios, and applied to radiographs, to approximate the patient's limb length prior to amputation. Methods: A data set of 30 skeletons' unilateral upper limb long bones measured using osteometric board and calipers was used. Anatomic segment ratios were calculated based on humerus length after multivariate linear regression analysis. For clinical application testing, 5 cadavers' upper limbs were radiographed. Radiographic bone lengths were then measured along the long axis of each long bone. These measured radiographic lengths were then compared with the predicted bone lengths, generated from the skeleton data set ratios, for each cadaver. Results: The chi-square goodness-of-fit test showed excellent fit (P < .01) between the predicted and radiographically measured lengths for the 5 cadavers, and interobserver measurements showed no statistical difference. Depending on the cadaver, percent error in total limb length predicted to measure ranged from 0.9% to 2.7%. The variables to multiply an individual humerus length to calculate a given anatomic segment thus proved to be effective. Conclusions: If a bilateral upper limb amputee has 1 intact humerus, ratios to the humerus length can be reliably applied to calculate the preamputation limb length based on the patient's radiographic humerus length. These formulas are indicated for finding the appropriate limb lengths, and smaller anatomic segments, for donor-recipient matching in upper limb transplantation.

Complements c3 and c5 individually and in combination increase early wound strength in a rat model of experimental wound healing.

Background. Complements C3 and C5 have independently been shown to augment and increase wound healing and strength. Our goal was to investigate the combinatorial effect of complements C3 and C5 on wound healing. Methods. Each rat served as its own control where topical collagen was applied to one incision and 100 nM of C3 and C5 in collagen vehicle was applied to the other incision (n = 6). To compare between systemic effects, a sham group of rats (n = 6) was treated with collagen alone on one wound and saline on the other. At day 3, the tissue was examined for maximal breaking strength (MBS) and sectioned for histological examination. Results. There was a statistically significant 88% increase in MBS with the topical application of C3C5 when compared to sham wounds (n < 0.05). This was correlated with increased fibroblast and collagen deposition in the treated wounds. Furthermore, there appeared to be an additive hemostatic effect with the C3C5 combination. Conclusions. The combination of complements C3 and C5 as a topical application drug to skin wounds significantly increased wound healing maximum breaking strength as early as 3 days.

Topical application of complement C3 in collagen formulation increases early wound healing.

BACKGROUND: The complement system is composed of bactericidal and hemolytic proteins that increase capillary leakage and inflammatory cell migration. The role of complement C3 to augment wound healing has not yet been studied. METHODS: We examined the effects of topical complement C3 formulation at two concentrations (10 and 100 nM) on the rat surgical skin incision model. Skin was examined for maximal breaking strength and sectioned for histological examination. Fibronectin and collagen I content were measured using western blot analysis. RESULTS: There was a statistically significant 74% increase in maximum wound strength with the topical application of 100 nM of C3 at day 3 (850 ± 138 g) when compared to the control rats (490 ± 57 g). Histological correlation was seen with an increased inflammatory cell and fibroblast infiltration in treated wounds as compared to control rats as early as 3 days post-wounding. Western blots revealed increased fibronectin and collagen I levels in C3 treated wounds. CONCLUSIONS: Topical application of complement C3 in collagen formulation to skin wounds significantly increases wound healing as early as 3 days after wounding. This is correlated with increased inflammatory cell recruitment and the subsequent early fibroblast migration and increased collagen deposition and organization in wounds.

Reporting disclosures to the reader in plastic surgery journal publications.

BACKGROUND: With the associations between investigators and funding sources becoming increasingly complicated, conflicts of interest may arise that could potentially cause biases in the reporting of results. OBJECTIVE: To determine the number of published plastic surgery articles that lack reporting of disclosures. METHODS: An online review of four major North American plastic surgery journal publications from January 1, 2007 to December 31, 2007, was performed. For identification and to provide anonymity, journals were assigned a letter from A to D. RESULTS: Of the 1759 articles reviewed, 726 (41%) were included. Disclosure was not reported in 368 (51%) articles: Journal A (n=10, 3%), Journal B (n=153, 85%), Journal C (n=193, 93%) and Journal D (n=12, 32%). Journals differed significantly in their reporting of disclosure (P<0.01). CONCLUSION: In the plastic surgery journals reviewed, the lack of documentation of disclosures was frequent. To ensure identification of bias in plastic surgery publications, a section dedicated to disclosure statements is recommended for each published article.

HISTORIQUE: Puisque les associations entre les chercheurs et les sources de financement deviennent de plus en plus complexes, des conflits d'intérêts risquent de biaiser la transmission des résultats. OBJECTIF: Déterminer le nombre d'articles de chirurgie plastique publiés qui ne transmettent pas les divulgations de conflits d'intérêts. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse virtuelle des publications de quatre grandes revues nord-américaines de chirurgie plastique entre le 1er janvier 2007 et le 31 décembre 2007. Afin de les identifier tout en conservant leur anonymat, les revues étaient désignées par les lettres A à D. RÉSULTATS: Des 1 759 articles examinés, 726 (41 %) ont été inclus. Dans 368 articles (51 %), la divulgation n'était pas indiquée : revue A (n=10, 3 %), revue B (n=153, 85 %), revue C (n=193, 93 %) et revue D (n=12, 32 %). La transmission des divulgations de conflits d'intérêts différait considérablement selon les revues (P<0,01). CONCLUSION: Dans les revues de chirurgie plastique examinées, on constatait fréquemment l'absence de divulgation. Afin d'assurer la divulgation des conflits d'intérêts dans les publications de chirurgie plastique, il est recommandé de prévoir une rubrique consacrée aux énoncés de divulgation dans chaque article publié.

Accelerated wound healing with topical application of complement C5.

BACKGROUND: Delayed-healing traumatic, surgical, and chronic wounds can be detrimental to patients and the health care system. The authors set out to investigate the effects of complement C5, a naturally occurring chemotactic cytokine, on wounds. METHODS: The authors examined the effects of complement C5 on the rat paired skin incision model. Each rat served as its own control where topical collagen was applied to one incision and 100 nM of C5 in collagen vehicle was applied to the other incision. Rats were killed on days 3 (n = 6), 7 (n = 6), and 28 (n = 5) after wounding. RESULTS: There was a statistically significant, 65 percent increase in maximum wound breaking strength with the topical application of C5 at day 3 (p < 0.01). The increase persisted to 14 percent at 7 days after wounding (p < 0.05). When compared with the sham group, the C5-treated wound strength increased by 83 percent at day 3 and 64 percent at day 7. There was no change in breaking strength at 28 days. Western blot analysis demonstrated a significant increase in collagen and fibronectin content in the C5-treated wounds. CONCLUSIONS: Topical application of C5 to skin wounds significantly increases wound healing maximum breaking strength as early as 3 days and up to 7 days after wounding. C5 accelerated wound healing by at least 4 days in the first week of wounding. This was correlated with an increase in vascular permeability, increased inflammatory cell recruitment, subsequent fibroblast migration, and increased collagen deposition.

The effects of topical collagen treatment on wound breaking strength and scar cosmesis in rats.

BACKGROUND: Topical application of collagen has been suggested to enhance wound healing; however, its long-term effect on wounds has not been studied in a rat model. HYPOTHESIS: Topical application of collagen type I will not facilitate incision healing or cosmesis in rats up to 28 days postwounding. METHODS: The effects of bovine collagen type I (6 mg/mL) on the rat surgical paired skin incision model were examined. Each rat served as its own control in which topical collagen was applied to one incision while normal saline (0.9%) was applied to the other incision. Rats were euthanized three (n=6), seven (n=6) and 28 (n=5) days after wounding. Tissue harvested from each time point was examined for maximal breaking strength, and for biochemical and histological analysis. RESULTS: There were no statistically significant differences (ie, P<0.05) in maximum wound breaking strength between the collagen- and saline-treated wounds at all time points. Histological analysis revealed a similar infiltration of inflammatory cells and fibroblasts in the wound edges of all incisions when matched with time of wounding. Western blot analysis revealed no differences in fibronectin or collagen I content in all wounds in each rat. CONCLUSIONS: The topical application of collagen did not facilitate wound healing from three to 28 days in the rat wound model.

HISTORIQUE: L'application topique de collagène améliorerait la guérison des plaies. Cependant, on n'a pas étudié son effet à long terme sur les plaies d'un modèle de rat. HYPOTHÈSE: L'application topique de collagène de type I ne facilitera pas la cicatrisation ou l'esthétique d'une incision chez les rats jusqu'à 28 jours après la formation de plaies. MÉTHODOLOGIE: Les auteurs ont examiné les effets du collagène bovin de type I (6 mg/mL) sur un modèle de double incision cutanée chez des rats. Chaque rat était son propre sujet témoin, car du collagène topique était appliqué sur une incision, et une solution physiologique normale (0,9 %), sur l'autre. Les rats étaient euthanasiés trois (n=6), sept (n=6) et 28 (n=5) jours après la création des plaies. Les auteurs ont prélevé des tissus à chacun de ces moments et les ont examinés pour établir leur résistance maximale à la rupture et pour procéder à une analyse biochimique et histologique. RÉSULTATS: Il n'y a pas de différence statistiquement significative (c'est-à-dire P<0,05) quant à la résistance maximale à la rupture des plaies traitées au collagène et de celles traitées au moyen d'une solution physiologique à l'un de ces trois moments. L'analyse histologique a révélé une infiltration similaire des cellules inflammatoires et des fibroblastes dans les lèvres de la plaie de chacune des incisions par rapport au moment de création de la plaie. Le transfert de Western n'a révélé aucune différence dans le contenu en fibronectine ou en collagène I des plaies de chaque rat. CONCLUSIONS: L'application topique de collagène ne facilite pas la cicatrisation des plaies au bout de trois à 28 jours dans un modèle de plaies chez les rats.

Level of evidence in plastic surgery research.

BACKGROUND: There has been a recent shift toward evidence-based medicine in the medical and surgical literature. The objective of this study was to determine the level of evidence of published plastic surgery articles. METHODS: A review of the following four major plastic surgery journal publications was performed to determine the level of evidence utilized in the published studies: Plastic and Reconstructive Surgery (PRS), Annals of Plastic Surgery (Annals), Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS), and American Journal of Aesthetic Surgery (Aesthetic) from January 1 to December 31, 2007. RESULTS: Of the 1759 articles reviewed, 726 (41 percent) were included (animal studies, cadaver studies, basic science studies, review articles, instructional course lectures, and correspondence were excluded). The articles were ranked according to their level [level I (highest evidence, e.g., randomized-controlled trials) to level IV (lowest evidence, e.g., case reports)]. The average level of evidence in each journal was as follows: PRS, 3.05; Aesthetic, 3.11; JPRAS, 3.35; and Annals, 3.31. The evidence differed significantly between journals (p < 0.05), except when JPRAS was compared with the Aesthetic journal. Only 2.2 percent of articles were level I evidence. CONCLUSIONS: The average level of evidence in four major plastic surgery journals was 3.2 (level III). In order for the plastic surgery profession to become a participant in higher-level evidence-based medicine, greater emphasis must be placed on prospective randomized blinded trials.

A nonlinear finite-element model of the newborn ear canal.

A three-dimensional nonlinear finite-element model of a 22-day-old newborn ear canal is presented. The geometry is based on a clinical x-ray CT scan. A nonlinear hyperelastic constitutive law is applied to model large deformations. The Young's modulus of the soft tissue is found to have a significant effect on the ear-canal volume change, which ranges from approximately 27% to 75% over the static-pressure range of +/-3kPa. The effects of Poisson's ratio and of the ratio C10: C01 in the hyperelastic model are found to be small. The volume changes do not reach a plateau at high pressures, which implies that the newborn ear-canal wall would not be rigid in tympanometric measurements. The displacements and volume changes calculated from the model are compared with available experimental data.