Can Local Infiltration Influence Postoperative Recovery in Upper Blepharoplasty? A Case Series Study on Two Different Infiltration Methods.

Upper blepharoplasty is a common aesthetic surgery procedure which is frequently performed wide awake, under local anesthesia. However, advancements concerning the patients' perception during and after the procedure are still needed. This study aimed to evaluate the efficacy of a new method for local anesthetic infiltration in the upper eyelid comparing it to the traditional needle injections.A prospective, randomized, and clinical trial was conducted on 20 patients who underwent upper eyelid blepharoplasty in local anesthesia. After randomization, one eyelid was infiltrated using a Nanosoft technology needle, while on the contralateral side traditional needle injections were performed. Preoperative demographics, Fitzpatrick, and SNAP test were recorded. Postoperative patients visual analog scale (VAS) scores for both infiltration methods and ecchymosis and edema were recorded.Our results showed that the mean VAS scores for perceived pain were significantly lower on the eye infiltrated with Nanosoft technology (p < 0.05). Furthermore, the rate of postoperative ecchymosis and edema were also significantly lower with Nanosoft technology (p = 0.0012 and 0 = 0.0197, respectively). All 20 patients were satisfied with outcomes, and there were no major complications or need for a revision.Our case series study suggests that Nanosoft technology may be a more effective and efficient method for the local anesthetic infiltration in upper eyelid blepharoplasty in reducing discomfort and downtime for the patient.

Do Sex-Specific Factors Influence the Surgical Treatment of Facial Skin Cancer?

Facial skin cancer (FSC) is prone to incomplete excision due to the sophisticated anatomy and the aesthetic importance of the face. In this study, we sought to investigate to what extent sex-specific differences and other operation-, patient-, and cancer-specific factors influence the re-resection rate in FSC surgery, in order to provide personalized treatment strategies to patients. In this retrospective study, patients (>18 years) undergoing surgical excision of an FSC were enrolled. Each patient's demographic data, cancer location, the surgical team, primary and secondary surgeries were analyzed. Overall, 469 patients (819 surgeries) were included. The mean age was 69 ± 15 years. No significant association between sex-specific factors (surgeon's sex (OR: 1.09, 95% CI: 0.76-1.56) or patient's sex (OR: 0.85, 95% CI: 0.62-1.17), surgeon-patient sex concordance and discordance) and the likelihood of secondary surgery were found. However, healing by secondary intention (OR: 4.28; 95% CI: 1.94-9.45) and cancer location showed an increased re-resection rate. In conclusion, FSC surgery is a safe method unaffected by sex-specific factors, which had no impact on the re-resection rate. However, in further analysis, the likelihood of a re-resection was influenced by other factors such as healing by secondary intention and cancer location. This knowledge might be useful to provide an algorithm for personalized treatment strategies in the future.

Long-term Complications of Gluteal Augmentation Using Aquafilling Filler: A Case Report.

The interest in gluteal augmentation using minimally invasive techniques has been increasing rapidly. Despite the fact that Aquafilling filler was described as biocompatible with human tissues, the number of associated complications has been rising. We present an exceptional case of a 35-year-old female patient, who suffered major long-term complications in association with Aquafilling filler injections in the gluteal region. The patient was referred to our center with signs of recurrent inflammation and severe pain focusing on the left lower extremity. A computed tomography (CT) scan showed multiple, communicating abscess formations all the way from the gluteal region to the lower leg. Therefore, an operative debridement was accomplished in the operating theater. Finally, this report emphasizes the severity of possible long-term complications when using Aquafilling filler especially in larger areas. Furthermore, the oncogenicity as well as toxicity of polyacrylamide, the core material of Aquafilling filler, remains uncertain, which is why further research is urgently required.

Conchal Excision Techniques in Otoplasty: A Literature Review.

Prominent ears are a common congenital deformity of the head and neck. Correcting concha hypertrophy is an important step in otoplasty. Despite the risk of postoperative deformity due to the sharp edges created by excision, removing a section of cartilage is sometimes the only method to obtain a satisfying and long-lasting result. Multiple conchal excision techniques have been reported in the literature, with significant differences in approach, outcome evaluation, and complication classification. The objective was to review cartilage excision-based otoplasty procedures to offer plastic surgeons' insights into current data on outcomes and complications of conchal excision techniques. Methods: We conducted a literature search through the MEDLINE, EMBASE, Scopus, and Cochrane databases. Prospective and retrospective studies on otoplasty, including revision surgeries and conchal excision techniques involving concha cartilage resection, were included. Articles with no outcomes data, review articles, case reports, expert opinion or comment, and nonclinical studies were excluded. Results: There were a total of four manuscripts that fulfilled our criteria. Three out of four authors preferred posterior access that separates the skin excision from the cartilage excision. Following resection, cartilage edges can be approximated by placing cartilage sutures, or they can be allowed to collapse spontaneously. Although only two authors employed a systematic classification for complications, all the articles reviewed indicated a low complication rate and excellent postoperative cosmetic outcomes. Conclusion: Although the techniques and principles stated in the literature varied to some extent, the outcomes of all studies reviewed were comparable.

Social Profiloplasty: A Practical Assessment and Injection Guide.

The trend of aesthetic medical procedures continues growing every year since decades all over the globe, especially considering minimal invasive treatments since the results are immediate and the downtime minimal. Hence, treatments with hyaluronic acid fillers have become extremely popular and routinely used in common practice. However, numerous areas of treatment were identified and described in the last years clinical training and consciousness of possibly complication remain still under represented. In the following article, we present four key treatment areas for optimal overall facial rejuvenation of what the authors define the social profile. Of each area an assessment, anatomical considerations, danger zones, and the preferred personal technique of the authors are described.

Bilateral Finger Morton Neuroma after Primary Fingertip Amputation.

Morton's neuroma (MN) is a painful, proliferative fibrosis of perineural tissue caused by pressure or recurrent irritation that was previously thought to affect only the common interdigital nerve of the foot. We present a case of a bilateral MN of both the ulnar and radial proper digital nerves of the fifth finger in a 30-year-old patient, following multiple surgeries on the aforementioned finger. The patient was referred to our center by a peripheral hospital after traumatic fingertip amputation distal the DIP joint, where the fingertip was initially simply sutured. Because of progressive neuropathic pain, he underwent two revision surgeries, in which the distal phalanx was removed, two neuromas were excised, and the nerve stumps were shortened, but both were unsuccessful. A final, more extensive revision surgery was then carried out, in which two club-like enlargements were excised and the nerve stumps coadapted to form a loop. Histopathological examination of the excised specimen revealed perineural fibrosis in the context of a Morton's neuroma. This is, to our knowledge, the first documented case of a bilateral MN of the hand, which may have resulted from an inadequate primary finger and nerve shortening, resulting in high pressure from the surrounding soft tissue. Finally, this report emphasizes the significance of optimal treatment for finger amputation injuries, as well as the fact that for neuromas, simple nerve resection should be avoided whenever possible, because of the high recurrence rates.

Traumatic upper extremity injuries: Analysis of correlation of mangled extremity severity score and disabilities of the arm, shoulder and hand score.

BACKGROUND: The Mangled Extremity Severity Score is a decision-making tool for limb amputation after trauma. The Disabilities of the Arm, Shoulder and Hand questionnaire was developed to quantify posttraumatic functional deficits of the upper extremity. This study aims to determine the correlation between these two assessments. METHODS: In this study, a retrospective review of all patients with upper extremity injuries who had been treated with vascular reconstruction at two centres between 2005 and 2014 was performed. The respective Mangled Extremity Severity Score was calculated for each participant. Patients were recalled for follow-up examination and assessment of the Disabilities of the Arm, Shoulder and Hand Score. RESULTS: In this study, 14 patients met the inclusion criteria. The mean total Mangled Extremity Severity Score was 5.9 and the mean total Disabilities of the Arm, Shoulder and Hand Score was 30 points. There was no statistically significant correlation between these assessments (Spearman's rank correlation coefficient: 0.49, p=0.075). CONCLUSION: The Disabilities of the Arm, Shoulder and Hand Score did not correlate significantly with the Mangled Extremity Severity Score.

The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe.

BACKGROUND: The Mangled Extremity Severity Score (MESS) was constructed as an objective quantification criterion for limb trauma. A MESS of or greater than 7 was proposed as a cut-off point for primary limb amputation. Opinions concerning the predictive value of the MESS vary broadly in the literature. The aim of this study was to evaluate the applicability of the MESS in a contemporary civilian Central European cohort. METHODS: All patients treated for extremity injuries with arterial reconstruction at two centres between January 2005 and December 2014 were assessed. The MESS and the amputation rate were determined. RESULTS: Seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. The mean MESS was 4.97 (CI 4.4-5.6). Seventy-three per cent of all patients (52/71) had a MESS < 7 and 27% (19/71) of ≥7. Eight patients (11%) underwent secondary amputation. Patients with a MESS ≥ 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a MESS < 7 (7.7%; 4/52; p = 0.20). The area under the ROC curve was 0.57 (95% CI 0.41; 0.73). CONCLUSIONS: Based on these results, the MESS appears to be an inappropriate predictor for amputation in civilian settings in Central Europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft-tissue traumas.

The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes.

BACKGROUND: The compression/injury of the greater occipital nerve has been identified as a trigger of occipital headaches. Several compression points have been described, but the morphology of the myofascial unit between the greater occipital nerve and the obliquus capitis inferior muscle has not been studied yet. METHODS: Twenty fresh cadaveric heads were dissected, and the greater occipital nerve was tracked from its emergence to its passage around the obliquus capitis inferior. The intersection point between the greater occipital nerve and the obliquus capitis inferior, and the length and thickness of the obliquus capitis inferior, were measured. In addition, the nature of the interaction and whether the nerve passed through the muscle were also noted. RESULTS: All nerves passed either around the muscle loosely (type I), incorporated in the dense superficial muscle fascia (type II), or directly through a myofascial sleeve within the muscle (type III). The obliquus capitis inferior length was 5.60 ± 0.46 cm. The intersection point between the obliquus capitis inferior and the greater occipital nerve was 6.80 ± 0.68 cm caudal to the occiput and 3.56 ± 0.36 cm lateral to the midline. The thickness of the muscle at its intersection with the greater occipital nerve was 1.20 ± 0.25 cm. Loose, tight, and intramuscular connections were found in seven, 31, and two specimens, respectively. CONCLUSIONS: The obliquus capitis inferior remains relatively immobile during traumatic events, like whiplash injuries, placing strain as a tethering point on the greater occipital nerve. Better understanding of the anatomical relationship between the greater occipital nerve and the obliquus capitis inferior can be clinically useful in cases of posttraumatic occipital headaches for diagnostic and operative planning purposes.

Lessons Learned From Breast Implant Registries: A Systematic Review.

OBJECTIVE: Over several decades, numerous national and international registries on breast implants went online, aiming to collect prospective data to provide increased safety for patients and surgeons. We performed a review of all published data on breast implant registries to assess availability and quality of data and determine its usefulness and impact. MATERIALS AND METHODS: PubMed, Ovid, and Web of Science were searched to identify all articles containing breast implant registries in English language. The review was registered at PROSPERO (CRD42016041255) and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There was no limitation by publication date. RESULTS: Eight hundred ninety-five articles were identified; after removal of duplicates, 536 abstracts were screened on breast implant registries in plastic and reconstructive surgery. Unrelated articles, non-English articles, and not breast implant-related studies were excluded. Twenty breast implant registry-related articles met the inclusion criteria; 7 articles contained actual data on breast implants. Compared with international trends, only a minimal percentage of performed surgical breast augmentations is documented in registries, and the overall data quality and availability were low. CONCLUSIONS: Only a fraction of performed breast augmentations is documented properly in a registry. Currently, there are no published data based on a clinical quality registry. Sustained funding and reliable administrative governmental structures remain crucial to establish an adequate clinical quality registry for breast implants as currently launched in Australia to analyze outcomes and risk factors for an increased patient safety.

Free thoracodorsal, perforator-scapular flap based on the angular artery (TDAP-Scap-aa): Clinical experiences and description of a novel technique for single flap reconstruction of extensive oromandibular defects.

PURPOSE: The reconstruction of oromandibular defects can be challenging, particularly when considerable amounts of bone and soft tissues are lost. In such cases, the use of a single flap may be unsatisfactory and a concomitant free flap is needed. Here we present a chimeric, thoracodorsal perforator-scapular free flap based on the angular artery of the subscapular system (TDAP-Scap-aa) as an alternative technique for single flap reconstruction of extensive oromandibular defects. MATERIALS AND METHODS: The authors studied patients who underwent reconstructions of extensive oromandibular defects with a TDAP-Scap-aa free flap. The operative technique and the clinical experiences are described. Postoperatively, surgical complications were classified with the Clavien-Dindo Classification. RESULTS: Five male patients (59.4 ± 8.8 years) were treated with the TDAP-Scap-aa. Average sizes for harvested hard and soft tissue components, which are both included in the flap and completely independently from each other, were 10.4 ± 1.5 cm of bone length, 2.6 ± 0.3 cm of bone height, 11.6 ± 4.8 cm of skin paddle length and 8.4 ± 1.7 cm of skin paddle width. The overall mean operation time (cut-suture) was 14.6 ± 0.9 h. The postoperative follow-up was 6 months. No complications requiring surgical treatment as well as donor site nerve damages were observed. CONCLUSIONS: In comparison to other double free flaps, the TDAP-Scap-aa offers several advantages such as higher amounts of hard and soft tissues without prolonged operation times, and provides satisfying aesthetic outcomes and little donor site morbidity due to the preservation of muscle and nerve structures. Therefore, the TDAP-Scap-aa constitutes a clinically reliable alternative in extensive oromandibular defect reconstruction.

Three-Dimensional Evaluation of Static and Dynamic Effects of Botulinum Toxin A on Glabellar Frown Lines.

BACKGROUND: The use of injectable solutions for aesthetic purposes has increased tremendously, but lacks objective support. We aimed at assessing static and dynamic effects of botulinum toxin A (BoNTA) on glabellar lines by use of an objective three-dimensional methodology. METHODS: We prospectively collected three-dimensional stereographic photographs of two different facial expressions (pretreatment, 30 and 90 days posttreatment) in 21 patients, receiving a total of 20 units of BoNTA in both corrugator supercilii muscles. The primary endpoint was the three-dimensional static and dynamic surface irregularity, and secondary endpoints were the glabellar line scale and overall patient satisfaction. Blinded retrospective data analysis and statistical evaluation were performed with p < 0.05 considered statistically significant. RESULTS: Static glabellar lines (neutral facial expression) were significantly reduced by - 17% and - 24% on day 30 and 90 posttreatment, respectively (vs. pretreatment; both p < 0.0001). Dynamic glabellar frown lines (firmest possible bilateral eye closure) demonstrated a reduction of surface irregularity by - 26% and - 21% on day 30 and 90 posttreatment, respectively (vs. pretreatment; both p < 0.0001). The subjective dynamic glabellar line scale documented a statistically significant improvement on day 30 posttreatment (mean ± SD: 1.5 ± 0.8; p < 0.05) versus pretreatment (2.8 ± 1.0). Polled patients confirmed a subjective wrinkle improvement 90 days posttreatment. CONCLUSION: The presented setup detected even subtle changes of BoNTA treatment for facial wrinkling and is a promising asset for scientific evaluations of clinical studies analyzing the outcome and duration of efficacy of injectable solutions on the face. 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 .

Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns.

BACKGROUND: Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. METHODS: We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. RESULTS: Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. CONCLUSION: More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. LEVEL OF EVIDENCE: Therapeutic, level IV.

Double Triangular Cartilage Excision Otoplasty.

BACKGROUND: Prominent ears have a negative impact on patients' psychosocial well-being. There are numerous surgical correction techniques described, but the majority have high complication and recurrence rates. In this article, the authors present a stitchless technique that takes advantage of different approaches to minimize complications and recurrences. METHODS: The authors prospectively studied patients who underwent a bilateral double triangular cartilage excision otoplasty in an outpatient setting. This prominent ear setback technique is based on a specific cartilage excision to mechanically collapse the ear without using any sutures through the cartilage. Postoperatively, surgical complications were classified according to the Clavien-Dindo classification. The patient-reported outcome was analyzed after completion of a questionnaire 6 months after surgery, and another clinical follow-up appointment was arranged 12 months after surgery. RESULTS: Sixty patients (120 ears) with an average age of 24 years were studied, and the overall complication rate was 6 percent. Three ears (2.5 percent) developed superficial cutaneous necrosis at the anterior concha, and one ear (1 percent) required an additional correction for unsatisfactory pinna rotation. Also, 2.5 percent of the patients experienced a grade I complication, and 1 percent of the patients experienced a grade IIIa complication according to the Clavien-Dindo classification. No wound infections, hematomas, or hypertrophic scars were observed, and the patient-reported outcome showed satisfaction with the results. CONCLUSIONS: The authors' findings show that the double triangular cartilage excision otoplasty is a safe procedure with low complication/recurrence rates. This stitchless technique should be included in each surgeon's repertoire as an alternative to previously published surgical techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Inhalation Injury in the Burned Patient.

Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.

Topical Antimicrobials in Burn Care: Part 1-Topical Antiseptics.

Burn wounds disrupt the body's primary defense against invasion and colonization by microorganisms. Topical antimicrobials are one component in burn wound care. These agents suppress microbial growth to advantage skin cells and wound healing. Topical antimicrobials can be divided into 2 superclasses: antiseptics and antibiotics. We review the 4 main classes of topical antiseptics (emulsifiers, acids, oxidizers, and heavy metals) and antiseptic-impregnated dressings in current clinical use and address the mechanisms, as well as the advantages and disadvantages of each antiseptic for burn wound management.

Risk factors for recurrence of pressure ulcers after defect reconstruction.

Patients suffering from pressure ulcers remain to be a challenging task for nursing staff and doctors in the daily clinical management, putting-notably in the case of recurrences-additional strain on the constantly reduced resources in public healthcare. We aimed to assess the risk factors for the recurrence of pressure ulcers at our institution, a tertiary referral center. In this retrospective analysis of patients admitted to our division we identified risk factors for pressure ulcer recurrence. The hospital patient database search included all patients with a diagnosis of pressure ulcers of the torso and lower extremity. One hundred sixty-three patients were diagnosed with pressure ulcers and 55 patients with 63 pressure ulcers met our inclusion criteria. The 17 recurrences (27%) had an average follow-up of 728 days. Most presented with lesions of the ischial tuberosity (n=24). Recurrence was statistically associated with defect size (p = 0.013, Cox regression analysis), and serum albumin levels (p = 0.045, Spearman correlation), but no association was found for body mass index, bacterial profile, comorbidities, localization, previous surgery, or time-to-admission for reconstruction (all p > 0.05). Supported by the recent literature we identified factors like defect size to be associated with pressure ulcer recurrence, but not with time-to admission for reconstruction or number of previous debridements. Whether laboratory values like serum albumin levels were the cause, the result or associated with pressure ulcer recurrence warrants further investigation.

The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality.

Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.