Transcutaneous oximetry values in chronic ulcer patients during Hyperbaric treatment at 1.4 ATA compared to 2 ATA.

Chronic wounds have a significant impact on a patient's quality of life. Different pathologies, such as poor blood supply and tissue breakdown, may lead to inadequate oxygenation of the wound. Hyperbaric oxygen (HBO2) is a widely used treatment for an increasing number of medical practices. A new so-called "hyperbaric treatment" trend has emerged. The use of low-pressure, soft-sided, or inflatable chambers represents a growing trend in hyperbaric medicine. Used in professional settings as well as directly marketed to individuals for home use, they are promoted as equivalent to clinical hyperbaric treatments provided in medical centers. However, these chambers are pressurized to 1.3 atmospheres absolute (ATA) on either air or with an oxygen concentrator, both generate oxygen partial pressures well below those used in approved hyperbaric centers for UHMS-approved indications. A total of 130 consecutive patients with chronic ulcers where tested. TcPO2 was measured near the ulcer area while the patient was breathing 100% O2 at 1.4 ATA for five and 10 minutes. The average TcPO2 at 1.4 ATA after 10 minutes of O2 breathing was 161 mmHg (1-601 mmHg, standard deviation 137.91), compared to 333 mmHg in 2 ATA (1-914±232.56), p < 0.001. Each electrode tested was also statistically significant, both after five minutes of O2 breathing and after 10 minutes. We have not found evidence supporting the claim that 1.4 ATA treatment can benefit a chronic ulcer patient. The field of HBO2 is constantly evolving. We have discovered new ways to treat previously incurable ailments. Nevertheless, it is important to note that new horizons must be examined scientifically, supported by evidence-based data. The actual effect of 1.4 ATA on many ailments is yet to be determined.

Polyurethane Implants in Revisional Breast Augmentation: A Prospective 5-Year Study.

BACKGROUND: Revisional surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as to prevent implant displacement by bio-integrating with the pocket. OBJECTIVES: Our study aimed to assess the use of PU implants in breast revisional surgery and to provide an algorithm. METHODS: Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Postoperative outcomes were followed up. RESULTS: Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.5, with a BMI of 22.3 and a mean follow-up of 5 years. A majority (63%) represented secondary revisional cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed in retropectoral position and 47% prepectoral. Significantly more implants in secondary cases were changed from prepectoral to retropectoral (P = .005), and in tertiary changed from retropectoral to prepectoral (P = .002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revisional surgery in our series had a 1.9% acute complication rate, 4.5% longer-term reoperation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture. CONCLUSIONS: This is the first study to provide data on outcomes of revisional breast augmentation surgery with PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revisional surgery.

Broken Dermal Filler Cannula in Post-Radiated Décolleté.

We present a case of 72-year-old that arrived at our emergency department following breaking of a dermal cannula used to inject a poly-L-lactic acid (PLLA) to the décolleté by an aesthetic practitioner. She had a history of previous radiation to the breast after a lumpectomy. The cannula was removed using fluoroscopy guidance. This case emphasizes several key messages. First is the extreme caution needed when using a cannula to inject dermal fillers in a previously radiated area. Second, the importance of properly trained practitioners. Last, one should consider the use of bio-stimulants in a previously cancerous area. Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Yoav Yechezkel] Last name [Pikkel], Author 1 Given name: [Assaf Aviram] Last name [Zeltzer] Also, kindly confirm the details in the metadata are correct.confirmedPlease check and confirm the organization division and organization name is correctly identified for the affiliation 2.yesLevel of Evidence V 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 .

Using an Elastomeric Skin Protectant to Manage Donor Site Wounds of Split-thickness Skin Grafts: A Case Series.

ABSTRACT: Split-thickness skin grafting (STSG) is a common surgical procedure to manage acute and chronic wounds. A plethora of dressings exists to treat STSG donor site wounds (DSWs). Recently, a new elastomeric skin protectant was adopted (Cavilon Advanced Skin Protectant; 3M) in the treatment of incontinence-associated dermatitis. In this report, the authors assess the effects of this elastomeric skin protectant as an alternative wound dressing for STSG donor sites.The authors report a single-center prospective case series that was performed to establish a treatment protocol. Nine consecutive patients with different indications for treatment with an STSG from May to September 2018 were included. Collected data included general patient information, comorbidities, complications, blood loss, pain during dressing change, and the duration of DSW healing.This case series showed promising results in terms of duration of DSW healing when applying the elastomeric skin protectant. The authors also observed less blood loss and less pain during dressing changes. No infections were seen during the trial.

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed. METHODS: The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed. RESULTS: A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen. CONCLUSION: The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum.

ABSTRACT: During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.

The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction.

BACKGROUND: Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. OBJECTIVES: The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. METHODS: The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the "hug flap" (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. RESULTS: There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). CONCLUSIONS: Although all breast-enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry.

A Rare Case of KID Syndrome: The Use of Hydrosurgery and Strategies for Antiseptic Wound Care.

A 14-year-old girl with a history of keratitis-ichthyosis-deafness (KID) syndrome, a rare autosomal dominant condition, was referred to the Department of Plastic Surgery at Brussels University Hospital in June 2016 for progressively worsening inguinoperineal ulceration exacerbated by overapplication of combination drug treclinax (tretinoin and erythromycin). On assessment, a large area of purulent papillomatous hyperkeratosis with follicular plugging, likely superimposed bacterial colonization, and deep ulceration were noted requiring thorough debridement.A first procedure was performed in June 2016 with hydrosurgical debridement (Versajet IITM; Smith & Nephew, Forth Worth, Texas). During the procedure, significant blood loss was noted, and topical adrenaline, blood transfusion, and a short ICU stay were required for monitoring during which the patient remained hemodynamically stable. The wound was primarily dressed with an antimicrobial barrier silver dressing; meropenem, ceftazidime, and fluconazole were started to treat for Gram-negative, Gram-positive, and anaerobic bacilli, as well as Pseudomonas aeruginosa and fungal infections in situ. A further three debridements were required 6, 12, and 26 days after the initial procedure. The patient was discharged 36 days after admission without any antibiotics and with an outpatient wound care plan.Not only was this case rare, but it also reflected the importance of a careful approach when tackling KID syndrome's cutaneous manifestations. Multiple debridements, thorough wound care, and appropriate antibiotic therapy may be required to achieve local healing and a satisfactory result. Hydrosurgical debridement offered a precise and well-controlled method for treating a large ulcerating hyperkeratotic urogenital lesion in this pediatric patient.

Deep inferior epigastric artery perforator flap harvest after full abdominoplasty.

Abdominal scars are no longer a contra-indication for abdominal perforator flap harvesting. Few research data exists about the regeneration potential of the abdominal wall's perforator system. Therefore, previous abdominoplasty with umbilical transposition is an absolute contra-indication for a DIEaP-flap (deep inferior epigastric artery perforator flap). A 50-year-old patient required a breast reconstruction of the right breast, 10 years after an abdominoplasty with undermining of the superior abdomen and umbilical transposition. The patient was scheduled for a free lumbar artery perforator (LaP) flap. The preoperative computed tomography-angiography mapping showed nice lumbar perforators and to our surprise a good-sized DIEa perforator in the peri-umbilical region. The DIEa perforator on the right hemi-abdomen, consisting of two veins and one artery, was pulsatile and found suitable in size. A classical flap harvest and transfer was further performed. This case report is the first in which a dominant perforator is found in the area of undermining after a full abdominoplasty with umbilical repositioning. Further investigations regarding the nature and timing of re-permeation or regeneration of perforators after abdominoplasty are to be done. Nevertheless, we are convinced that with appropriate perforator mapping and a suitable plan B, previous abdominoplasty is no longer an absolute but a relative contra-indication for performing DIEaP-flap.

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass.

BACKGROUND AND OBJECTIVES: Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery. METHODS: A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed. RESULTS: Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully. CONCLUSIONS: MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.

A Review of Lymphedema for the Hand and Upper-Extremity Surgeon.

Secondary lymphedema of the upper limb is frequently seen in Western countries after cancer treatment (most often breast in women). It is a chronic disease that affects quality of life and functioning. In its extreme form, it may be debilitating. A review is given of the pathology, nonsurgical treatment, and surgical treatment with a protocol.

Percutaneous Purse-String Suture: An Innovative Percutaneous Technique for Inframammary Fold Creation and Improved Breast Projection in Reconstructive Surgery.

BACKGROUND: Lipofilling for breast reconstruction has become increasingly common. Creation of a well-defined inframammary fold (IMF) is integral to achieving symmetrical aesthetic results. This has traditionally been done under direct vision through an open incision. OBJECTIVES: The authors present their experience in reconstructive breast surgery with a novel percutaneous technique for IMF creation and improvement of projection without the need for large incisions. METHODS: From June 2011 to January 2015, 180 patients underwent a percutaneous purse-string suture (PPSS) to enhance their IMF and improve breast projection. After completion of lipofilling, a curved cannula is tunneled subcutaneously. The suture is placed into the cannula and passed around the circumference of the breast footprint. After the completion of two passes in different anatomic levels around the footprint, the suture is tightened at the breast's tail zone to achieve the desired IMF definition and breast projection. Surgical technique, results, and follow up are presented. RESULTS: The PPSS technique was combined either with lipofilling only or as part of flap breast reconstruction in 30 and 150 patients, respectively. The average follow-up time was 34 months (range, 11-48 months). PPSS was redone in 25 patients to further improve breast projection. One patient complained of postoperative pain. No other PPSS-related complication was reported. CONCLUSIONS: PPSS is an innovative technique designed to complement the emerging field of lipofilling for breast reconstruction. The technique is safe, easily reproduced, and provides excellent results. Breast IMF and projection are immediately improved without the need for open incisions.

The vascularized groin lymph node flap (VGLN): Anatomical study and flap planning using multi-detector CT scanner. The golden triangle for flap harvesting.

INTRODUCTION: A growing number of surgeons perform lymph node transfers for the treatment of lymphedema. When harvesting a vascularized lymph node groin flap (VGLNF) one of the major concerns is the potential risk of iatrogenic lymphedema of the donor-site. This article helps understanding of the lymph node distribution of the groin in order to minimize this risk. MATERIALS AND METHODS: Fifty consecutive patients undergoing abdominal mapping by multi-detector CT scanner were included and 100 groins analyzed. The groin was divided in three zones (of which zone II is the safe zone) and lymph nodes were counted and mapped with their distances to anatomic landmarks. Further node units were plotted and counted. RESULTS: The average age was 48 years. A mean number of nodes of 6.5/groin was found. In zone II, which is our zone of interest a mean of 3.1 nodes were counted with a mean size of 7.8 mm. In three patients no nodes were found in zone II. In five patients nodes were seen in zone II but were not sufficient in size or number to be considered a lymph node unit. On average the lymph node unit in zone II was found to be 48.3 mm from the pubic tubercle when projected on a line from the pubic tubercle to the anterior superior iliac spine, 16.0 mm caudal to this line, and 20.4 mm above the groin crease. On average the lymph node unit was a mean of 41.7 mm lateral to the SCIV-SIEV confluence. CONCLUSION: This study provides increased understanding of the lymphatic anatomy in zone II of the groin flap and suggests a refined technique for designing the VGLNF. As with any flap there is a degree of individual patient variability. However, having information on the most common anatomy and flap design is of great value.

Superior epigastric artery perforator flap: anatomy, clinical applications, and review of literature.

INTRODUCTION: To reduce donor site morbidity in anterior chest wall reconstruction, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction. MATERIALS AND METHODS: We combined our anatomical and clinical experience with superior epigastric artery perforator (SEAP) flap with a PubMed search of the English language literature for articles published on "SEAP flap". Reference lists of the articles found were then checked for other related articles of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps. RESULTS: The four best perforators were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The territory of the SEAPs depends on the location of the perforator. Controversy exists in the current literature concerning preferable SEAP flap orientation. Although tip necrosis is the major complication, this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus. CONCLUSION: The SEAP flap provides a useful approach for reconstruction of defects of the anterior chest, or of the abdominal wall. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity.

Biomaterials in the clinical treatment of lymphedema-a systematic review.

OBJECTIVE: Lymphedema is a chronic condition caused by impaired lymphatic fluid drainage, resulting in progressive edema. The current mainstay of lymphedema therapy consists of conservative therapy and surgical therapy. In this systematic review, we investigated the novel role of biomaterials in clinical lymphedema therapy and assessed their objective outcomes and the complication rate associated with their use. METHODS: Studies were identified through systematic review using the Embase and PubMed/MEDLINE databases. Only original articles reporting the use of biomaterials for clinical lymphedema therapy were included. The primary outcome measure was the objective reduction in limb volume after biomaterial use. The secondary outcome measure was the assessment of biomaterial safety. RESULTS: A total of 354 articles were identified in the first search, of which 10 met our inclusion criteria. These articles described the use of two biomaterials, nanofibrillar collagen scaffolds (NCSs) and silicone tubes (STs), for the treatment of lymphedema. NCS implantation showed an average excess limb volume reduction of 1% to 10.7% and clear evidence of lymphangiogenesis on imaging. No complications were 7documented after NCS implantation. ST implantation showed an average limb volume reduction of 700 to 887 mL and limb circumference reduction of 3.1 to 8 cm in patients with advanced stage lymphedema. Of 177 patients treated with ST implantation, only 11 (6.2%) developed local inflammation. CONCLUSIONS: Both NCS and ST implantation showed promising limb volume reduction; however, with the scarce literature available, additional research is needed to determine their effectiveness. Both demonstrated good safety profiles, with no complications after NCS implantation and a complication rate equivalent to other similar implants for ST implantation.

Augmentation blepharoplasty: a review of 500 consecutive patients.

BACKGROUND: Volume loss in the upper and lower eyelids and in the malar area is now considered a major component of periorbital aging. As classical resection blepharoplasty does not address this loss, filling procedures are becoming increasingly common. OBJECTIVES: The authors present their experience with periorbital fat grafting in conjunction with routine blepharoplasty to address periorbital aging. METHODS: Outcomes were retrospectively reviewed for 500 consecutive patients who underwent blepharoplasty in conjunction with the authors' periorbital augmentation technique from January 2008 to September 2011. The augmentation technique was a fine particle fat (microfat) grafting procedure that involved the use of small-diameter cannulae for transfer of autologous fat to the medial part of the upper eyelid, the orbitomalar groove, and the malar area. RESULTS: Clinical evaluation and review of patient photographs revealed favorable, natural-looking, and long-lasting improvement of the treated areas. Shortcomings of classical resection blepharoplasty, such as hollowing of the upper eyelids, incomplete blending of the eyelid-cheek junction, and persistent deflation of the midface, were avoided; the full and crisp aspect of the upper and lower eyelids seen at a younger age was regained; and the technique was not associated with the complications seen in an earlier patient series. No major complications occurred. Minor complications included bruising and swelling. CONCLUSIONS: Augmentation of the upper and lower eyelids through microfat grafting can be a useful alternative to existing blepharoplasty techniques. This study documents very natural and pleasing results that avoid the shortcomings of classical resection. Microfat grafting appears to be a valuable and safe alternative to complicated, difficult, and potentially dangerous eyelid and midface rejuvenation techniques.

Surgical treatment of breast cancer related lymphedema-the combined approach: a literature review.

Background and Objective: Breast cancer therapy is a common cause of lymphedema, a chronic condition resulting from impaired fluid drainage through the lymphatic system. The accumulation of fluid in the affected limb leads to swelling, inflammation, and fibrosis, causing irreversible changes. While conservative therapy is the initial treatment for lymphedema, it may prove ineffective for advanced-stage cases that require surgical intervention. Physiological approaches such as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) aim to restore lymphatic circulation, while reductive approaches such as excision of excess tissue and liposuction (LS) aim to eliminate fibrofatty tissue. In advanced stages of breast cancer-related lymphedema, a treatment that incorporates both physiological and reductive methods is advantageous. The timing of these approaches varies, and recent simultaneous procedures have been introduced to address both aspects in one surgery. Additionally, lymphedema treatment can be combined with breast reconstruction. Current imaging techniques provide a better assessment of the lymphedematous limb, aiding in the tailoring of a personalized combined approach within a single surgery. This study aims to review the combined approach for breast cancer-related lymphedema treatment and propose a new therapeutic algorithm based on recent literature. The research aims to optimize the management of breast cancer-related lymphedema and improve patient outcomes. Methods: PubMed/MEDLINE was used as the database to conduct a review of the currently available literature concerning combined surgical techniques for treating breast cancer related lymphedema (BCRL). Key Content and Findings: In our review, we discuss imaging methods for assessing lymphatic system anatomy and function in surgical preparation and decision-making. Simultaneously, we examine a range of combined surgical techniques for treating BCRL, encompassing the combined physiologic approach, breast reconstruction with physiologic surgery, and the combination of reductive and physiologic procedures. Our emphasis remains on key parameters, including patient demographics, lymphedema staging, procedure types, follow-up duration, and objective limb measurements. Conclusions: Surgical treatment of BCRL can include several surgical modalities that can be performed simultaneously. Current imaging techniques enable the tailoring of a personalized combined one-stage surgery for BCRL patients.

Evaluation of a novel anastomotic device in the animal model: A feasibility, safety, and efficacy study.

BACKGROUND: A novel device was designed to assist with microvascular arterial anastomoses. This study compares the safety and efficacy of the anastomosis-assisting device with manual suturing in an ovine model. METHODS: Arteries with a diameter ranging from 2 to 4 mm were transected and anastomosed at four locations. A comparison was done between manual anastomoses and anastomoses performed with a novel anastomotic device in seven sheep. All the device-assisted anastomoses were performed by a single surgeon. At day 45 ± 7, anastomotic sites were dissected to determine patency, and samples were obtained for pathology. RESULTS: Thirteen of 13 (100%) samples from the Vesseal™ group demonstrated patency both on the day the anastomoses were performed and after the 45-day follow-up period. All four additional anastomoses performed using the Vesseal™ were found patent. In the hand-suturing group, six of six (100%) samples demonstrated patency on the day of the anastomoses and five of six (83%) were patent after the follow-up period. No thromboses or adverse events were observed in the anastomoses in either group. No difference in histopathology of the anastomoses was observed between the groups. CONCLUSIONS: The anastomosis-assisting device is a safe and efficacious alternative to hand suturing. The patency rates of device-assisted anastomoses were greater than those of manual suturing and pose no additional risk, as demonstrated by clinical observation, histopathology, and macroscopic evaluation. The Vesseal™ anastomosis-assisting device may be a viable alternative to manual suturing, with an ergonomic and intuitive design, short learning curve, and consistent results.