Autologous Stem Cell-derived Therapies for Androgenetic Alopecia: A Systematic Review of Randomized Control Trials on Efficacy, Safety, and Outcomes.

Background: Androgenic alopecia (AGA), a prevalent and extensively studied condition characterized by hair loss, presents a significant global issue for both men and women. Stem cell therapy has emerged as a promising therapeutic approach for AGA due to its regenerative and immunomodulatory properties. The primary objective of this systematic review was to assess the current literature on the efficacy and safety of cellular and acellular stem cell-derived therapies in the management of AGA. Methods: A computerized literature search was conducted in ClinicalTrials.gov, PubMed, and Cochrane Library in October 2023. The online screening process was performed by three independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. Results: The search yielded 53 articles from 2013 to 2023. Twelve randomized controlled trials were included. Stem cells and their derivatives were isolated from human adipose tissue, hair follicles, bone marrow, umbilical cord blood, and exfoliated deciduous teeth. These trials showed that stem cell-derived treatments can promote hair regeneration and density. Conclusions: Both cellular and acellular stem cell-based therapies are safe and effective in improving hair regeneration and density in AGA patients. Although the outcomes may be temporary in some cases, regenerative treatments may become useful adjuncts in combination with traditional methods of hair transplantation. Future research should focus on protocol optimization to enhance long-term patient outcomes.

Instructional Video of a Standardized Interprofessional Postsimulation Facilitator-guided Debriefing of a Fatality in Plastic Surgery.

Background: Postsimulation facilitator-guided debriefing (PSFGD) is the process of intentional discussion of thoughts, actions, and events that took place during simulation amongst the facilitator(s) and trainees. Despite the significance of delivering high-quality debriefings, there is a lack of evidence-based guidelines. Our study aimed to provide an instructional video demonstration of a PSFGD of a fatality. Methods: Fifty surgical interns participated in a burn simulation scenario in two groups. Group 1 (control, or "no exposure," n = 25) consisted of residents who received oral postsimulation debriefing from an independent faculty member who had no exposure to our instructional video on how to debrief effectively. Group 2 (intervention, or "exposure," n = 25) consisted of interns who were debriefed by the second faculty member who did watch our instructional video before the simulation and learned about "advocacy and inquiry" techniques. The outcome measures were the Debriefing Assessment for Simulation in Healthcare score and the postdebrief multiple-choice question (MCQ) quiz scores to assess debriefers' performance and interns' knowledge consolidation, respectively. Results: The "exposure" group presented statistically significantly higher values for the Debriefing Assessment for Simulation in Healthcare score (P < 0.001) and MCQ score (P < 0.001) compared with the "no exposure" group. Conclusions: Debriefers who followed the methodology as demonstrated in our instructional video were considered more competent, and the residents achieved higher MCQ scores. The quality of the debriefing ensures improved critical thinking and problem-solving skills. Safer practice and better patient outcomes are achieved by developing debriefing programs for educators.

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise. OBJECTIVE: This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies. METHODS: This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias. RESULTS: Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention. DISCUSSION: This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments. CONCLUSION: HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II 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 .

Rat Microvascular Model is Tolerant to Technical Errors.

BACKGROUND: Extensive studies have been conducted using the rat model to understand the potential technical errors that lead to anastomotic failure. However, current literature indicates that the rat model has excellent tolerance to diverse errors committed by microsurgeons. The error-investigating rat model is often created by one or two experienced surgeons, and only one isolated technical error is examined. These biases may potentially cause limitations of the results from previous studies. Meanwhile, venous anastomoses have rarely been investigated in previous literature. Therefore, it is important to elucidate this topic with a more comprehensive study design. METHODS: Ninety-four arterial and 94 venous anastomoses on Sprague-Dawley rat femoral vessels that were performed by 47 microsurgeons who participated in the microsurgery course at the Columbia University and the University of Thessaloniki were evaluated. In total, 10 technical errors were examined: (1) disruption of suture line, (2) back-wall stitch, (3) oblique stitch, (4) wide bite, (5) partial thickness bite, (6) unequal suture distance, (7) tear in vessel wall, (8) excessively tight suture, (9) suture threads in lumen, and (10) large edge overlap. The frequency of each error committed, and the 30-minute postoperative patency was also recorded. The underlying causal relationship between these errors, potential interaction, and the short-term anastomosis patency was analyzed statistically. RESULTS: Only the back-wall stitch was found to have a significant causal effect on arterial anastomosis failure (p < 0.001). Back-wall stitch, wide bite, and partial thickness bite significantly impact venous anastomosis patency (p < 0.001). No other statistically significant result was found. CONCLUSION: Overall, the rat model is highly resilient to various technical errors despite these mistakes being often considered clinically unacceptable. Therefore, researchers need to consider the resilience of the rat model when designing and analyzing future studies. In addition, microsurgery instructors should focus on individual stitch quality rather than the final patency.

Three-phase video-assisted multidisciplinary team debriefing (VAMTD) in high-fidelity blast simulation through the "advocacy and inquiry" method.

INTRODUCTION: Video-assisted debriefing (VAD) combined with the "advocacy and inquiry" (A&I) technique, is a tool that allows video playback of selected segments of a simulation, thereby assisting the debriefers to structure the session. Currently, however, no consensus exists on how to optimally perform a team debriefing. In our study, we aim to demonstrate and describe the methodology of A&I debriefing in an instructional simulated blast scenario and assess the impact of VAD on residents' technical and non-technical skills (NTS). MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, we performed a study with 50 residents who were randomly assigned to two groups. Group 1 (control, or "no VAD", n=25) consisted of residents who received oral debriefing by one independent faculty member without the recorded video of the simulation. Group 2 (intervention, or "VAD", n=25) consisted of residents who received VAD from the second independent faculty member. These residents repeated the same simulation scenario one week after their debrief. Every resident was assessed on the primary and secondary survey, as well as the NTS, based on the integrated skills (IS) score. RESULTS: The "VAD" group presented significantly higher values for the IS score (p<0.001) compared to the "no VAD'' group. CONCLUSIONS: Our demonstration of three-phase VAD emphasizes important aspects of coherent simulation-based training: psychological safety, A&I, reflection, cognitive frames, pre-brief, main debrief, summary, and translation of new discoveries to real-life patient care. The unique audio-visual aspect of the VAD enhanced residents' performance in simulation.

Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes.

In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.

A Systematic Review of Pediatric Nonaccidental Burns: Protecting the Children Through Knowledge, Vigilance, and Prevention.

BACKGROUND: Inflicted burns on children are a particularly difficult medical and psychosocial issue. Pediatric nonaccidental burns (PNABs) are unfortunately relatively common. In our study, we aim to present the key findings on PNABs with the intention of raising awareness, improving early, and recognizing accurately by identifying red flags, developing triage tools, and establishing prevention strategies for this sensitive issue. METHODS: A computerized literature search was conducted on PubMed, Google Scholar, and Cochrane for articles published until November 2020. The online screening process was performed by 3 independent reviewers with the Covidence tool against set inclusion/exclusion criteria. The protocol was reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO). RESULTS: A total of 12 studies were included for analysis. Scald burns via forced immersion accounted for the majority of reported PNABs affecting both feet and hands. Complications included wound infection, sepsis, requiring systemic antibiotics, or intensive care. Abused children's parents had a history of mental illness, unemployment, substance abuse, incarceration, and/or low annual income. CONCLUSIONS: Scalds via forced immersion remain the most common mechanism of PNABs. All health care professionals must remain vigilant, be able to recognize subtle signs of abuse, triage patients appropriately, report to police and/or social services, and ensure no further harm is made to the child or children. Repeated abuse with burns can lead to death. Prevention and education are the cornerstones for addressing this social phenomenon.

Efficacy and Safety of Microsurgical Pharyngolaryngeal and Pharyngoesophageal Reconstruction: A Systematic Review of the Literature.

Restoration of function and complication management after pharyngolaryngectomy remains a challenging task. The aim of our study was to compare the functional and clinical outcomes of pharyngolaryngeal and pharyngoesophageal reconstruction using free flaps, namely jejunal (FJF), anterolateral thigh, and radial forearm, and describe a reconstructive approach for these defects following tumor resection. Methods: We performed a systematic literature review on PubMed (Medline), Embase and Cochrane Library over the last two decades for articles reporting the surgical reconstructive modalities available after total or partial pharyngeal and/or laryngeal resection using a structured search strategy and strict inclusion and elimination criteria. Results: Our search identified a total of 677 articles, 112 full texts were fully reviewed for eligibility, and 39 met the inclusion criteria. The use of both FJF and fasciocutaneous flaps is safe. The FJF has optimal swallowing outcomes and a low incidence of major recipient-site complications. Nevertheless, free fasciocutaneous flaps exhibit comparable functional results, while they seem linked with fewer cases of perioperative mortality and flap failure. However, none of the currently available techniques can combine all potential benefits. Conclusions: Despite these procedures being mainly palliative in nature, the advent of microvascular techniques and utilization of fasciocutaneous free flaps has allowed optimal restoration of function combined with a reduced rate of perioperative and longterm complications. Both FJF and fasciocutaneous flaps can be viable treatment options, depending on the expertise of the surgeon and patient selection, to ensure the best outcomes.

Autologous Platelet-Rich Plasma Treatment for Androgenic Alopecia: A Systematic Review and Meta-Analysis of Clinical Trials.

BACKGROUND: Androgenic alopecia (AGA) is a common condition associated with hair loss in both men and women (female pattern hair loss), causing considerable psychological distress. Ongoing research focuses on novel safe, cost-effective, and efficient treatments with the best patient outcomes. Autologous platelet-rich plasma (PRP) has become increasingly popular in the treatment of AGA compared with hair transplantation techniques. The present study aims to evaluate the outcomes of PRP as a treatment for AGA/female pattern hair loss. METHODS: A computerized literature search was conducted on PubMed, clinicaltrials.gov , and Cochrane Library for articles published until November of 2020. The online screening process was performed by two independent reviewers with the Covidence tool against set inclusion/exclusion criteria. The protocol was reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health and Care Research. Meta-analyses were performed by using the random effects model with the RevMan software. RESULTS: The initial search yielded 49 randomized controlled clinical trials. Eleven randomized controlled clinical trials were included in the study based on a priori criteria. PRP injections significantly increased the number of hair follicles, hair thickness, and density compared with placebo interventions. Also, the patients reported high overall satisfaction with the PRP treatment. Only temporary minor side effects were noted, including localized pain, bleeding, and itching. CONCLUSIONS: Autologous PRP significantly improves alopecia in select patients. Future research should focus on optimizing PRP treatment protocols and minimizing possible adverse reactions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Congenital difference of the hand and foot: Pediatric macrodactyly.

BACKGROUND: Macrodactyly is a very rare congenital difference that affects hands and feet with significant developmental and psychological implications. Macrodactyly is attributed to a somatic mutation in PIK3CA, a component of the mTOR pathway-related overgrowth disorders. Other medical conditions have been associated with macrodactyly (e.g., neurofibromatosis and Proteus syndrome). A thorough investigation of the presence of these conditions should be undertaken by the multidisciplinary team. The aim of this study is to summarize the main clinical characteristics and associated conditions, with an emphasis on diagnosis and surgical treatment options. MATERIALS AND METHODS: We present several clinical cases after a retrospective chart review of macrodactyly cases and a comprehensive literature review. RESULTS: The indications for surgery include peripheral compressive neuropathies (e.g., carpal tunnel syndrome), grotesque enlargement interfering with function, psychosocial distress due to the deformity, and macrodystrophic lipomatosis with proximal upper limb involvement. The main surgical treatment options are categorized as follows: digit reduction (e.g., soft tissue debulking, skeletal shortening/ terminalization, Barsky procedure, and Tsuge technique), limitation of growth (digital nerve stripping and epiphysiodesis), and correction of deviation (wedge or angulation osteotomy, arthrodesis, Millesi procedure for thumb macrodactyly correction, toe-to-hand transfer, ray resection, and combination of bony reduction and soft tissue debulking). CONCLUSIONS: Macrodactyly correction requires surgical experience and an individualized approach. Treatment is primarily surgical; however, efforts are being made to delineate the root cause of macrodactyly and provide nonoperative management.

Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review.

BACKGROUND: The conventional way of treating burn victims with mainstream pain control modalities is costly and has many negative side effects. In this study, the authors aim to present the findings from the major clinical trials on three nonpharmacologic interventions-hypnosis, virtual/augmented reality, and yoga-as supplements to conventional pain regimens for burn management. METHODS: A computerized literature search was conducted of the PubMed and ClinicalTrials.gov databases in April of 2020. The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. RESULTS: The search yielded 254 articles from 1955 to 2020. Fifty-eight studies met the authors' inclusion criteria. Yoga reduced cognitive and somatic anxiety in burn survivors, and improved body image. Virtual reality is effective in pain reduction in both the pediatric and the adult burn population, and in faster burn wound reepithelialization. Hypnosis has similar results regarding reducing pain quality and anxiety in burn patients undergoing burn wound care and dressing changes but was not found to significantly accelerate the healing process. CONCLUSIONS: Nonpharmacologic interventions are not a substitute for conventional analgesics; however, they could help patients have better control over their pain, greater self-esteem, and less postburn traumatic experiences. Burn care centers should consider nonpharmacologic interventions to improve patient satisfaction and their participation in the treatment and rehabilitation process.

Thumb and first webspace reconstruction in nonsyndromic congenital mitten hand with symbrachydactyly.

INTRODUCTION: Nonsyndromic congenital mitten hand with thumb and index finger syndactyly is rare. Reconstruction of this condition is challenging, requiring repositioning of the thumb and creation of a wide and deep first webspace. The aim of this paper is to describe the characteristics of patients with this condition and also to describe our surgical technique. METHODS: We describe our technique in 16 consecutive children utilizing complete mobilization of the first metacarpal and thumb as an island flap on the neurovascular bundle, with a rotational osteotomy to reposition the thumb in pronation. In addition, a dorsal M flap was used to reconstruct the first webspace. Patients in this series also had varying degrees of symbrachydactyly with hypoplastic or aplastic phalanges of the central digits. RESULTS: There were 9 male and 7 female patients, with a mean age of 24.4 ± 22.4 months at the time of surgery. Mean follow-up was 19.1 ± 18.3 months. All reconstructions healed well. The mean thumb web distance in the affected hands was 4.2 cm (range 3.5 to 5). All reconstructed thumbs had a good opposition. Two children initially had mild hypertrophic scarring, which resolved with pressure gloves. No other complications were observed. CONCLUSION: One-stage reconstruction of the thumb and first webspace can be effectively achieved with our technique of complete mobilization of the thumb unit, rotational osteotomy, and a dorsal interdigitating M flap.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review.

BACKGROUND: Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects. METHODS: A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis. CONCLUSIONS: The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

An Unoperated Crouzon Family Treated with Monobloc Distraction: Challenges and Lessons.

Crouzon syndrome (CS) is a rare form of craniosynostosis characterized by bicoronal craniosynostosis and facial features including severe midface hypoplasia, exophthalmos, and hypertelorism. Most patients are diagnosed and treated in early childhood; however, there are a few reports of Crouzon patients treated as adults with monobloc facial advancement. To our knowledge, this is the first report of a family affected by CS treated sequentially with monobloc facial advancement using combined internal and external distraction osteogenesis (rigid external distraction). METHODS: We present a family from Jamaica (mother 47 years old, older daughter 17, and younger daughter 9) who were brought to our craniofacial clinic with stigmata of CS and no previous surgical intervention. Patients had bicoronal craniosynostosis and exorbitism, with varying severity, sequelae, and comorbidities. Here, we delineate our technique of monobloc distraction osteogenesis with advancement osteotomies using dual "push-pull" method, elevation of a split anteriorly based tunneled pericranial flap to seal off nasal cavity, and internal and external distraction. RESULTS: Our patients had favorable outcomes after reconstruction to reduce ocular symptoms and improve midface hypoplasia and aesthetic appearance. No intracranial injury, hardware/soft-tissue infection, hardware failure, or (new) loss of vision were encountered in 10 months follow-up. CONCLUSIONS: Dual "push-pull" monobloc distraction is safe and effective for a range of ages in CS; it allows good vector control, accommodates patient compliance, and allows early rigid external distraction device removal with sufficient time for consolidation. This surgery can be performed with highly satisfactory results.

Microsurgical techniques in the treatment of breast cancer-related lymphedema: a systematic review of efficacy and patient outcomes.

INTRODUCTION: Secondary lymphedema is the abnormal collection of lymphatic fluid within subcutaneous structures. Patients with lymphedema suffer a low quality of life. In our study, we aim to provide a systematic review of the current data on patient outcomes regarding breast cancer-related lymphedema (BCRL), and the most prevalent reconstructive techniques. METHODS: A PubMed (MEDLINE) and Scopus literature search was performed in September 2020. Studies were screened based on inclusion/exclusion criteria. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO), and it was reported in line with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). RESULTS: The search yielded 254 papers from 2010 to 2020. 67 were included in our study. Lymphaticovenous anastomosis (LVA)-a minimally invasive procedure diverting the lymph into the dermal venous drainage system-combined with postoperative bandaging and compression garments yields superior results with minimal donor site lymphedema morbidity. Vascularized lymph node transfer (VLNT)-another microsurgical technique, often combined with autologous free flap breast reconstruction-improves lymphedema and brachial plexus neuropathies, and reduces the risk of cellulitis. The combination of LVA and VLNT or with other methods maximizes their effectiveness. Vascularized lymph vessel transfer (VLVT) consists of harvesting certain lymph vessels, sparing the donor site's lymph nodes. CONCLUSION: Together with integrated lymphedema therapy, proper staging, and appropriate selection of procedure, safe and efficient surgical techniques can be beneficial to many patients with BCRL.