A Systematic Review of Pressure Injuries Associated with Urethrocutaneous Fistula.

OBJECTIVE: To review the literature about combined urologic and reconstructive management of pressure injuries (PIs) with urethral fistulas. DATA SOURCES: Authors searched the PubMed, MEDLINE, EMBASE, and Cochrane databases using the following keywords: "Perineum" or "Perineal" and "Pressure Ulcers" or '' Pressure Injury'' and "Urethral Fistula." STUDY SELECTION: The search yielded a total of 95 articles. Study selection followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement, and the study was designed according to the PICOS (Population, Intervention, Comparison, Outcomes, Study) guidelines. Congress abstracts, letters to the editor, and editorial comments were excluded. After screening, a total of 9 studies (30 patients) were included in the review. DATA EXTRACTION: Included patients received treatment for a perineal or ischial PI associated with a urinary fistula. The outcomes were recovery, complications, treatment failure, recurrence, and illness-related death. DATA SYNTHESIS: Pressure injuries were mainly ischiatic (50%) and perineal (43%). Forty-six percent of patients had spinal cord injuries, and at least 40% reported voiding dysfunction. Sixteen percent had previous ischiectomy. Flaps such as posterior thigh flap, biceps femoris flap, and inferiorly based transverse rectus abdominal muscle flap had 88% to 100% success rates when used with urinary diversion techniques. Suprapubic cystostomy, the simplest method of urinary diversion, was successful in 47% of cases when performed alone and in 100% when combined with a pedicled omental flap or a transverse rectus abdominal muscle flap. CONCLUSIONS: Prevention and wound care are essential for PI management, but when combined with a urinary fistula, surgical management is unavoidable. Urinary diversion is essential before undergoing any type of ulcer reconstruction. Urethral reconstruction showed favorable results, further strengthened when combined with a musculocutaneous flap.

Clinical and pathological features associated with high-risk, multiple, and recurrent basal cell carcinomas: a retrospective cohort analysis from the Levantine coast of the Mediterranean Sea.

Basal cell carcinoma (BCC) data coming from the Levantine coast of the Mediterranean Sea are limited. The study aimed to primarily analyze the demographic, clinical, pathological, and prognostic characteristics of BCC in this region of the world and secondarily identify features associated with high-risk, recurrent, or multiple BCCs. Patients with at least one diagnosis of BCC registered in the pathology department between January 2015 and December 2019 were included in this analytical retrospective single-center cohort study. Patients with basal cell nevus syndrome were excluded. Patients' characteristics and pathological features were collected through file check for a first analysis. Risk factors and evolution were sought through a phone call interview for the second analysis. The first analysis included 506 BCCs corresponding to 365 patients with a mean age of 65 ± 15 years, twenty-two (6%) were less than 40 years old, 180 (49.3%) were women, and 85 (23.3%) had two or more BCCs. The second analysis included 279 BCCs corresponding to 205 patients. Periorificial and infiltrative BCCs were more frequent in men. Periorificial tumors were more frequently nodular or infiltrative and were associated with recurrence. Tumors with perineural involvement were histologically never nodular nor superficial. Recurrence was more frequent in BCCs having periorificial location, a size larger than 2 cm, or an infiltrative subtype. Multiple BCCs were more frequent in patients with light skin type or familial history of skin cancer. High-risk BCCs were more common in patients with low sun exposure.

Auricular pseudocysts: a systematic review of the literature.

BACKGROUND: Auricular pseudocysts are benign fluid accumulations of the ear of uncertain etiology. Little is known about the optimal modality to successfully treat these lesions. No systematic review addressing auricular pseudocysts have been published to date. OBJECTIVES: The aim of this study is to summarize all the published data regarding diagnostic and therapeutic challenges of auricular pseudocysts. METHODS: On May 28, 2020, a systematic search of Medline, Embase, and Cochrane databases was conducted. All the studies describing treatment of auricular pseudocysts, procedure description, outcome, and follow-up period were included in this review. RESULTS: After full-text article review, 74 articles were included, representing a total of 1,011 lesions. The commonly used treatments for auricular pseudocysts were deroofing (493 lesions), aspiration (284 lesions), incision and drainage (171 lesions), intralesional steroids (53 lesions), and observation (10 lesions). The highest cure rate was found with the deroofing procedure (97.2%) followed by incision and drainage (95.9%). The mean follow-up period was 6.7 months. CONCLUSION: Surgical procedures (anterior deroofing or incision and drainage) showed the highest cure rates and should be considered as first-line treatment for auricular pseudocysts. Future adequately designed randomized controlled trials are warranted to compare the efficacy of the techniques described.

Breast Implant-associated Double Capsules: What Do We Know So Far? A Systematic Review of the Literature.

INTRODUCTION: A double capsule is a recently described rare occurrence following breast implant placement in which an inner capsule envelope totally or partially adheres to the implant surface while a distinct outer capsule adheres to surrounding tissues, with an intercapsular space developing between the two. The objective of this study is to review all available literature related to formation of double capsules and propose a treatment algorithm. METHODS AND MATERIALS: A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. Articles reporting management of breast implant-associated double capsules were included in this review. RESULTS: A total of 9 studies (68 implants) were included in the review. 94.1% of double capsules occurred with textured Biocell shaped and round implants independently from implant pocket (p value=0.64). In all cases, double capsules were diagnosed fortuitously intra-operatively for another surgical indication. Capsular contracture was present in 50% of double capsules patients and was the most common indication for secondary breast surgery, 81.5% of which being clinically evident (p value<0.001). Treatment consisted in 84.4% in an inner capsulectomy with smooth implants exchange, and management of the outer capsule as per the capsular contracture algorithm. CONCLUSION: Double capsule formation is caused by delamination of a tight adhering capsule to a textured implant surface into two layers and continuous micro-shearing forces, and the probable contribution of bacterial biofilm. The only treatment reported so far includes inner with or without outer capsulectomy with smooth implant exchange. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An unusual tell sign of botulinum toxin injection in patients with facial flushing: incorporating a new questionnaire in the evaluation of botulinum toxin patients.

Lately it has been established that intra-dermal botulinum toxin is also effective in treating many dermatological conditions including refractory erythematous-telangiectatic rosacea, post - menopausal facial flushing and other similar conditions.However, the desired effect of treating the reddening in patients suffering from facial flushing can become an undesirable and embarrassing side effect when these same patients present to the clinic for esthetic concerns such as upper face rhytids. In this case, intramuscular botulinum toxin injections used for wrinkles treatment will also secondarily treat the facial reddening in their localized skin diffusion zones and result in embarrassing white patches all over the face. The patchy appearance following botulinum toxin injections for esthetic purposes could be bothersome for some patients and could be a tell-tale sign of botulinum toxin injections.

Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study.

BACKGROUND: Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty. METHODS: Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups. RESULTS: Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg; p = 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p < 0.0001). CONCLUSIONS: Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Acquired ungual fibrokeratoma: a systematic review of the literature.

BACKGROUND: Acquired ungual fibrokeratomas (AUFKs) are benign recurrent fibrokeratotic tumors of the nail unit of uncertain etiology. Little is known about the optimal modality to successfully treat these lesions. No systematic review addressing ungual fibrokeratomas has been published to date. OBJECTIVES: The aim of this study is to summarize all the published data regarding diagnostic and therapeutic challenges of AUFKs. METHODS: On August 9, 2019, a systematic search of Medline and Cochrane databases was conducted. All the studies describing the treatment of ungual fibrokeratomas, procedure description, pathological findings, outcome, and follow-up period were included in this review. RESULTS: After full-text article review, 103 articles were included, representing a total of 78 lesions. The commonly used treatments for fibrokeratomas were complete tumor resection (90.5%), shave excision (8.3%), and cryotherapy (1.2%). Complete surgical excision yielded the highest cure rate among all treatment modalities (90.8%) compared to partial surgical excision (28.6%) and cryotherapy (0%). The mean follow-up period was 12.1 months (1-144). CONCLUSION: Complete surgical removal preserving the matrix showed the highest cure rates and should be considered as first-line treatment for AUFKs. Future adequately designed randomized control trials are warranted to compare different treatment modalities.

Nontuberculous Mycobacterial Infections After Cosmetic Procedures: A Systematic Review and Management Algorithm.

BACKGROUND: Nontuberculous mycobacterium (NTM) infection following cosmetic procedures usually results from inadequate sterile techniques and contamination from nonsterile water. These infections are difficult to diagnose and treat. OBJECTIVE: This study aimed to describe the characteristics of NTM infections acquired after an aesthetic procedure, identify high-risk patients and high-risk cosmetic procedures, and provide a diagnostic and management algorithm for NTM infections occurring after cosmetic procedures. METHODS: On December 20, 2017 an online search of the Medline database was done. All articles describing NTM infection in cosmetic procedures were included in this review. RESULTS: In total, 92 patients with a mean age of 38.35 years were included in this review. Cosmetic procedures performed in the Dominican Republic were the most common source of infection and were noted in 33 patients. The procedure that resulted in the highest proportion of the infections was mesotherapy (34%). In most of the cases, the diagnosis was missed at the initial presentation and a short course of inadequate antibiotics was unsuccessful. CONCLUSION: Nontuberculous mycobacterium infections are hard to diagnose and difficult to treat, sometimes leading to severe irreversible sequalae. Aesthetic practitioners should know when to suspect and how to prevent, diagnose, and treat NTM infections.

Quilting Sutures in Rhytidectomy: A Systematic Review of the Literature.

BACKGROUND: Different technical variations exist for the utilization of quilting sutures (QS) in rhytidectomy. No systematic review or meta-analysis of the studies describing the use of QS in facelifts has been published to date to the authors' knowledge. OBJECTIVES: The objective of this study was to summarize all the published data regarding the utilization of QS in rhytidectomy, compare QS techniques, and evaluate their effect on postoperative complications. METHODS: On April 1, 2019, a systematic search of the Medline, Embase, and Cochrane databases was conducted. All the studies describing the usage of QS in facelifts were included in this review. Studies reporting hematoma rate in a QS group and a control group were included in the meta-analysis part of this study. RESULTS: The initial search of the databases yielded 93 results. Four trials were included in the systematic review and 2 were included in the meta-analysis. The total number of included patients with QS was 527. Two studies employed internal QS and the remaining studies utilized external QS. The meta-analysis found a lower rate of hematoma in the QS group (relative risk, 0.02; 95% confidence interval = 0.00-0.13; P < 0.0001). CONCLUSIONS: QS can be applied either internally or externally and are very effective in reducing hematomas after facelifts. QS could be a great asset in facelifts but should be utilized with caution because additional work is needed to confirm their safety and efficacy.

The Impact of Upper Face Botulinum Toxin Injections on Eyebrow Height and Forehead Lines: A Randomized Controlled Trial and an Algorithmic Approach to Forehead Injection.

No previous study has objectively evaluated the effect of different forehead injection patterns on the eyebrow height and forehead lines. The patients were divided into three groups. Botulinum toxin was injected into both the lateral and medial eyebrow depressors in all groups. The frontalis was injected using either a V-pattern (group 1), a middle horizontal pattern (group 2), or a high horizontal pattern (group 3). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Validated photonumeric scales were used to assess the forehead lines. Fifteen patients (30 eyebrows) were included in each group. In all of the groups, 2 weeks after injection, the brow was lower at all the measured positions, with the exception of the lateral brow edge, which was higher in the three injection patterns. No difference was found when comparing group 1 to groups 2 and 3. The middle forehead injection pattern lowered the eyebrow more than the upper forehead injection pattern. The three techniques improved the forehead lines at rest and with contraction. The forehead lines with contraction were more improved in group 1 compared with both groups 2 and 3. Each forehead injection pattern yielded different results on forehead lines and eyebrow position. Upper forehead injections were less effective on forehead lines but prevented eyebrow ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, II.

A Systematic Review of Zosteriform Rash in Breast Cancer Patients: An Objective Proof of Flap Reinnervation and a Management Algorithm.

BACKGROUND: Zosteriform rash in cancer patients provides objective clues to the process of reinnervation of the reconstructed breast. This rash should also raise suspicion for metastasis, which can be confused with herpes zoster. OBJECTIVES: The aims of this study were to explain the reconstruction flap sensory reinnervation mechanism based on the clinical findings and provide a diagnostic and management algorithm of zosteriform rash in breast cancer patients. METHODS: On November 15, 2017, we conducted a search of published articles in MEDLINE and Cochrane databases. All the articles describing a zosteriform rash in a patient with a history of breast cancer were included in this review. RESULTS: Eleven articles from the literature and 1 case from our practice were selected for inclusion in this systematic review. Five patients had a breast reconstruction with a flap. The flap skin was affected by the rash in 4 of these patients, providing an objective proof of the reinnervation of the reconstructed breast. In 6 patients, the presentation was typical, and the diagnosis of herpes zoster was made without additional diagnostic testing. In 4 cases, the eruption was atypical, and a biopsy was done to confirm the diagnosis of a cancer metastasis. In 2 patients, the rash was multidermatomal, and a polymerase chain reaction was done to confirm the diagnosis of disseminated herpes zoster. CONCLUSIONS: Zoster reactivation in breast reconstructed patients is an objective proof of the reinnervation of the skin flap. Moreover, zosteriform rash in cancer patients should raise suspicion for metastasis, which can be confused with herpes zoster.

Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and Neck Rejuvenation and a Crossover Clinical Trial.

BACKGROUND: Microbotox consists of the injection of microdroplets of botulinum toxin into the dermis to improve the different lower face and neck aging components. No clinical trial has evaluated its effect on the different face and neck components and no study has compared it to the "Nefertiti lift" procedure. METHODS: In this crossover study, patients previously treated with the Nefertiti lift were injected using the microbotox technique. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. RESULTS: Twenty-five of the 30 patients previously treated with the Nefertiti technique were injected with a mean dose of 154 U using the microbotox technique. Platysmal bands with contraction, jowls, and neck volume reached a statistically significant improvement. The microbotox technique improved the jowls and the neck volume more than the Nefertiti technique, whereas the platysmal bands at rest and with contraction were more improved by the Nefertiti technique. One hundred percent of patients were satisfied with both techniques and rated themselves as improved. CONCLUSIONS: The microbotox technique is a useful, simple, and safe procedure for lower face and neck rejuvenation. It is mainly effective in treating neck and lower face soft-tissue ptosis, in contrast to the Nefertiti technique, which is more effective on platysmal bands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

"The Evolution of Eyebrow Morphology: The Westmore Model Revisited".

BACKGROUND: The most widely recognized eyebrow model was described by Westmore in 1974. With the rapidly changing concept of beauty, an accurate up-to-date model is needed. METHODS: The Westmore model was tested on fashion models that were randomly selected from the covers of the 1965-1975 (group 1) and 2006-2016 (group 2) Vogue magazine. The eyebrows of fashion models, which represent the beauty ideals of these decades, were objectively measured and compared. We proposed a modified eyebrow model more adapted to the modern standards of beauty, applied it to group 2, and objectively compared it to the Westmore model. This new model was validated on a group of randomly selected Caucasian women. RESULTS: Thirty women were included in each group. The medial edge of the eyebrow was better defined by the Westmore model in group 1 compared to group 2. The lateral edge of the eyebrow was better defined by the Westmore model in group 2. The peak of the eyebrow was not well defined by the Westmore model in both groups. The new model was more adapted than the Westmore model for both the medial edge and the peak of the eyebrow in group 2. It was also accurate in non-model Caucasian women. CONCLUSION: Eyebrow morphology has evolved since the description of the Westmore model. Our model represents a simple way to accurately predict the eyebrow landmarks according to the modern ideals of beauty.

Salvage of a cartilage framework exposure in total ear reconstruction using a retro-auricular fascia flap with double axial irrigation.

Cartilage framework exposure during total ear reconstruction requires an early salvage procedure and a secure coverage. We present a case that has been successfully covered by a retro-auricular fascia flap and a skin graft. Because we were dealing with a post-traumatic ear amputation with extensive scarring, the flap was designed to include both the retro-auricular artery and the occipital artery for an enhanced vascular security. This flap design may play a more important role especially in post-traumatic ear reconstruction.

The Impact of Botulinum Toxin on Brow Height and Morphology: A Randomized Controlled Trial.

BACKGROUND: Previous reports have objectively demonstrated the efficacy of botulinum toxin for brow elevation. No clinical trial has compared the variation of the eyebrow shape and height when the lateral eyebrow depressors are injected alone or in combination with the medial eyebrow depressors. METHODS: A prospective, randomized, controlled study was designed to evaluate and compare the effect of two different botulinum toxin injection techniques on brow shape and position. Patients were divided into two groups. AbobotulinumtoxinA was injected in the lateral eyebrow depressors alone (group 1) or in both the lateral and medial eyebrow depressors (group 2). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Patient satisfaction was also evaluated. RESULTS: Fifteen patients (30 eyebrows) were included in each group. The brow elevated by 0.6 to 2.1 mm at all positions in group 1. In group 2, the brow elevated from the medial limbus to the lateral edge of the brow (1 to 1.7 mm), with no changes at the level of the medial brow and canthus. When comparing the two injection techniques, the authors found a statistically significant difference in the change of eyebrow height at the level of the medial brow, medial canthus, and lateral brow edge. Ninety-seven percent of patients were satisfied with their results. CONCLUSION: Different eyebrow injection techniques yield different elevation patterns. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Effect of age and body mass index on the yield of stromal vascular fraction.

OBJECTIVE: The aim of this study was to determine the influence of age, body mass index, and site of liposuction on the cell yield of SVF. METHODS: A prospective study was performed on 58 patients. The average age was 39 years old, with BMI ≤ 25 or BMI ≥ 25. Fat tissue was harvested from the abdominal region, flanks, or thighs and SVF was isolated. RESULTS: The yield of viable SVF was evaluated by trypan blue, and the markers of stem cells were evaluated by flow cytometry. The cells were positive for stem cells markers, the age, sex of the patient had no impact on SVF cell yield with an average of 1.17 × 10^8. However, the BMI > 25 had resulted in higher cell numbers, and the harvest site had a significant impact on cell yield with abdomen being the site of interest. CONCLUSION: These data demonstrate that the age of the person does not affect the cell yield of SVF; nevertheless, the donor site and BMI might be important factors in affecting cell number.