Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. METHODS: We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p < 0.05. RESULTS: There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p > 0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p < 0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p > 0.05). CONCLUSIONS: Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.

Factors Affecting Postoperative Complications of Suction-Curettage by Arthroscopic Shaver for Bromhidrosis.

BACKGROUND: Suction-curettage by arthroscopic shaver is the most effective treatment for bromhidrosis; however, postoperative complications require wound management and exhibit a high risk of hypertrophic scarring. We investigated factors affecting postoperative complications. METHODS: We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage by arthroscopic shaver between 2011 and 2019. Cases followed for less than 1 year were excluded. Complications of hematoma or seroma, epidermis decortication, skin necrosis, and infection were recorded. Multinomial logistic analysis was used to calculate odds ratios and corresponding 95% confidence intervals for the complication of the surgery, adjusting for relevant statistically significant variables. RESULTS: Complications occurred in 52 axillae (12.1%). Epidermis decortication occurred in 24 axillae (5.6%), with a significant difference for age (P < 0.001). Hematoma occurred in 10 axillae (2.3%) with a significant difference in tumescent infiltration use (P = 0.039). Skin necrosis occurred in 16 axillae (3.7%) with a significant difference for age (P = 0.001). Infection occurred in 2 axillae (0.5%). Severe scarring occurred in 15 axillae (3.5%), with complications related to more severe skin scarring (P < 0.05). CONCLUSION: Older age was a risk factor for complications. Use of tumescent infiltration resulted in good postoperative pain control and less hematoma. Patients with complications presented with more severe skin scarring, but none experienced limited range of motion after massage.

Psychometric Properties of the Traditional Chinese Version of the Venous Leg Ulcer Quality of Life Questionnaire.

OBJECTIVE: Symptoms and treatment of venous leg ulcers (VLUs) adversely impact patients' quality of life (QoL). There is no QoL tool that considers the linguistic and cultural specificities of patients with VLU in Taiwan. This study aimed to evaluate the psychometric properties of the traditional Chinese version of the Venous Leg Ulcer Quality of Life Questionnaire (VLU-QoL). METHODS: The processes of translation and cultural adaptation of the VLU-QoL from English to traditional Chinese included forward translation, back translation, linguistic modification, and expert review. Using a sample of 167 patients with VLU from a hospital in southern Taiwan, the psychometric properties analyzed were internal consistency, test-retest reliability, content validity, convergent validity, and criterion-related. RESULTS: The traditional Chinese version of the VLU-QoL demonstrated good overall internal consistency (Cronbach α = .95) and overall test-retest reliability coefficient (r = 0.98). Confirmatory factor analysis was used to assess the convergent validity of the scale; results showed that the Activity, Psychology, and Symptom Distress constructs had acceptable fit and a structure similar to that of the original scale. The scale had its criterion-related validity verified using the Taiwanese version of the 36-item Short-Form Health Survey, demonstrating a good correlation coefficient r that ranged from -0.7 to -0.2 (P < .001). CONCLUSIONS: The Chinese version of the VLU-QoL is valid and reliable for assessing the QoL in patients with VLU, delivering a tool that nurses can use to deliver timely and appropriate care to improve patients' QoL.

Prophylactic Antibiotics for Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Comparison between Three Different Duration Approaches.

There is no consensus on the duration of prophylactic antibiotic use for autologous breast reconstruction after mastectomy. We attempted to standardize the use of prophylactic antibiotics after mastectomy using a deep inferior epigastric perforator flap for the breast reconstruction procedure. Methods: This retrospective case series included 108 patients who underwent immediate breast reconstruction with a deep inferior epigastric perforator flap at the Ditmanson Medical Foundation Chia-Yi Christian Hospital between 2012 and 2019. Patients were divided into three groups based on the duration of prophylactic antibiotic administration (1, 3, and >7 days) for patients with drains. Data were analyzed between January and April 2021. Results: The prevalence of surgical site infection in the breast was 0.93% (1/108), and in the abdomen it was 0%. The patient groups did not differ by age, body mass index, smoking status, or neoadjuvant chemotherapy. Only one patient experienced surgical site infection in the breast after half-deep necrosis of the inferior epigastric perforator flap. There were no significant differences in surgical site infection based on the duration of prophylactic antibiotic use. The operation time, methods of breast surgery, volume of fluid drainage in the first 3 days of the abdominal and breast drains, and day of removal of the abdominal and breast drains did not affect surgical site infection. Conclusion: Based on these data, we do not recommend extending prophylactic antibiotics beyond 24 hours in deep inferior epigastric perforator reconstruction.

Precisely Closed Reduction of Nasal Bone Fracture Assisted With Plain Film Measurements Under the Picture Archiving and Communication System.

OBJECTIVES: To prevent aesthetic and functional deformities, precisely closed reduction is crucial in the management of nasal fractures. Plain film radiography (PF), ultrasonography (USG), and computed tomography can help confirm the diagnosis and classification of fractures and assist in performing closed reduction. However, no study in the literature reports on precisely closed reduction assisted with PF measurements under the picture archiving and communication system (PACS). METHODS: We retrospectively evaluated 153 patients with nasal bone fracture between January 2013 and December 2017. Surgeons conducted precisely closed reduction assisted with PF measurement of the distance between the fracture site and nasal tip under PACS on 34 patients (group A). Another group on 119 patients were reduced under surgeon's experience (group B). RESULTS: No significant differences in age, gender, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and reduction outcome were observed between group A and group B (P > .05). The operative time of the group A was significantly lower (12.50 ± 4.64 minutes) compared to group B (23.78 ± 11.20 minutes; P < .001). After adjusted age, gender, and AO classification, patients in group A scored 10.46 minutes less on the operative time than those in group B (P < .001). In addition, the severity of nasal bone fracture (AO classification, ß = 3.37, P = .002) was positive associated with the operative time. CONCLUSIONS: In this study, closed reduction in nasal bone fracture assisted with PF measurements under PACS was performed precisely, thereby effectively decreasing operative time and the occurrence of complications. This procedure requires neither the use of new instruments or C-arm nor USG or navigation experience. Moreover, reduction can be easily performed using this method, and it requires short operative time, helps achieve great reduction, less radiation exposures, and is cost-effective.

Multi-Staged Surgeries for Coexisting Facial Asymmetry and Strabismus in Parry-Romberg Syndrome.

ABSTRACT: Parry-Romberg syndrome (PRS) is a rare disorder resulting in disfiguring facial asymmetry. Ocular manifestations can result in complex strabismus. There were limited reports on the treatment of PRS with coexisting strabismus. We present a multistaged surgical approach to manage the facial asymmetry and strabismus.

Lipofundin mediates major inhibition of intravenous propofol on phorbol myristate acetate and Escherichia coli-induced neutrophil extracellular traps.

BACKGROUND: Neutrophil extracellular traps (NETs) consist of chromatin DNA networks that are studded with cytosolic and granular antimicrobial proteins to trap or kill an infected microorganism. A lipid emulsion, the solvent of pure propofol for intravenous application, is given to clinical patients who require intravenous feeding of fatty acids and fat for energy. Intravenous propofol is widely used to sedate critically ill patients. Both intravenous propofol and its lipid emulsion have immunomodulatory activity. However, the role of lipid emulsion of intravenous propofol on NET induction remains unclear. METHODS: In this study, neutrophils were stimulated with phorbol myristate acetate (PMA) or Escherichia coli (E. coli) in the absence or presence of intravenous propofol (Propofol-Lipuro®), its solvent lipid emulsion (Lipofundin) or pure propofol, and NETs were stained with SYTOX Green for visualization and quantification. Total HOCl was determined by measuring the taurine-chloramine complex, and intracellular HOCl was evaluated with BioTracker™ TP-HOCl 1 dye. RESULTS: PMA-induced NETs were not efficiently inhibited when Propofol-Lipuro® was added after PMA stimulation. Clinically relevant concentrations of Lipofundin exerted a significant reduction in PMA-induced NETs and total reactive oxidative species (ROS), which was comparable to that observed for Propofol-Lipuro®. Lipofundin transiently reduced intracellular HOCl production and the phosphorylation level of extracellular regulated kinase (p-ERK) but did not scavenge HOCl. Moreover, Lipofundin decreased E. coli-induced NETs in a ROS-independent pathway, similar to Propofol-Lipuro®. CONCLUSIONS: All data agree that Lipofundin, the major component of Propofol-Lipuro®, inhibits intracellular HOCl and p-ERK to suppress PMA-induced NET formation but reduces E.coli-induced NETs in a ROS-independent pathway.

Development and Pilot Usefulness Testing of an Interactive Computerized Patient Decision Aid for Intraocular Lens Selection Before Cataract Surgery.

PURPOSE: Modern cataract surgeries aim to treat impaired vision and also improve quality of life. An appropriate pre-operative selection of the intraocular lens is important to post-operative quality of life. Patients often have difficulty in choosing the best fit for individual needs. Patient decision aids (PDAs) are useful tools to assist patients in such decision-making process. However, most PDAs are paper-based and lack user interaction. This study is aimed to develop and evaluate an interactive computerized patient decision aid (cPDA) to help patients in the selection of an appropriate intraocular lens model before cataract surgery. MATERIALS AND METHODS: Patients and their families who were making the decision regarding intraocular lens selection before cataract surgeries were eligible to participate in this study. A cPDA was built on an interactive robot, to help the patients in the decision-making process. The usefulness of the cPDA was measured with the Decision Self-Efficacy (DSE) scale and Preparation for Decision Making (PrepDM) scale. RESULTS: A total of 50 participants (18 men and 32 women) were enrolled in the pilot test. The mean pre-cPDA DSE score was 46.5 ± 13.6, and the post-cPDA DSE score was 72.6 ±12.8. The average gain score on DSE was 26.1, and the standard deviation was 8.0. The gain score on DSE was statistically significant, and the effect size was bigger than 3. The patients with junior or senior high degrees had the highest gain score on DSE, and the ones with college or above degrees had the lowest. The patients with college or above degrees had the highest PrepDM score, and the ones with elementary school or below had the lowest. Age and sex were not significant correlates of PrepDM. The patients with college or above degrees had the highest preparedness, but the lowest gain on DSE. CONCLUSION: Education levels are associated with the usefulness of cPDA, both for the preparedness and decision efficacy of patients. The results provide insight into the feasibility of cPDA for the decision-making of pre-operative intraocular lens selection.

Potential predictors of quality of life in patients with venous leg ulcers: A cross-sectional study in Taiwan.

Internationally, the impact of venous leg ulcers (VLUs) on the quality of life is well recognised; however, in Taiwan, the focus is only on chronic wound management. This cross-sectional correlational study conducted at the cardiovascular and plastic surgery clinics of a regional teaching hospital between August 2019 and June 2020 investigates venous clinical severity, pain, fatigue, depression, sleep quality, quality of life, and related factors among 167 patients with VLUs. The potential predictors of the quality of life in terms of activities were venous clinical severity (P < 0.001), pain (P = 0.004), and fatigue (P < 0.001) after adjusting for covariates. The potential predictors of the quality of life in terms of the psychological domain were marital status (single/divorced) (P = 0.016), marital status (widowed) (P = 0.027), venous clinical severity (P < 0.001), pain (P = 0.001), and fatigue (P = 0.002). The potential predictors of the quality of life with regard to symptoms were venous clinical severity (P < 0.001), pain (P < 0.001), fatigue (P = 0.001), and depression (P = 0.038). These potential predictors can serve as the basis of interventions for patients with VLUs, such as those related to nutrition or training in wound dressing.

Abducens nerve palsy treated by tethering the globe to the lateral orbital rim with a bone screw.

We report the case of a 38-year-old man with abducens palsy following a traumatic skull injury who failed multiple strabismus surgeries. A suture-armed 5 mm micro bone screw was placed on the anterior face of the lateral orbital rim and used to tether and abduct the globe. The patient remained orthotropic in primary position 12 months postoperatively.

Factors Affecting the Efficacy of Suction Curettage Using an Arthroscopic Shaver for Bromhidrosis.

BACKGROUND: Suction-curettage using an arthroscopic shaver is the most effective surgical treatment for bromhidrosis; however, information regarding the procedure is limited. This study investigated the factors that affect the efficacy of suction-curettage. PATIENTS AND METHODS: We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage using an arthroscopic shaver between 2011 and 2019. RESULTS: Excellent or good efficacy with improved malodor was achieved in 418 axillae (97.21%). Secondary suction-curettage was performed for 11 (2.56%), with excellent results. Efficacy and need for secondary suction-curettage were not associated with age, sex, shaving time, and tumescent infiltration use. Complications were observed in 52 (12.09%) axillae, including hematoma or seroma, epidermis decortication, skin necrosis, and infections; 10 (2.33%) required local debridement for wounds. Complications showed a significant difference with respect to age (p < .001). Pain scores on postoperative Day 2 were significantly lower for patients treated using tumescent infiltration than those for the others (1.65 ± 0.84 vs 4.57 ± 1.16; p < .001). CONCLUSION: The results suggest that 7 to 15 minutes of suction curettage using an arthroscopic shaver is sufficient to achieve good efficacy for bromhidrosis with few complications. Older age was a risk factor for complications, and tumescent infiltration use achieved good postoperative pain control. LEVELS OF EVIDENCE: II.

Poria cocos (Fuling) targets TGFß/Smad7 associated collagen accumulation and enhances Nrf2-antioxidant mechanism to exert anti-skin aging effects in human dermal fibroblasts.

Oxidative stress is a major cause of aging related skin injuries. Hydrogen peroxide related ROS accumulation triggers increase in matrix metalloproteinases and elevated collagen degradation, which is a characteristic of skin aging. In this study, we investigated the protective effect of Poria cocos, used widely in the treatment of inflammatory diseases, against H2 O2 induced oxidative stress. The aqueous extract of dried P. cocos was obtained by heating 10 g in 500 ml of distilled water. The mixture was evaporated up to 400 ml and the remaining 100 ml was filtered through muslin cloth repeatedly to obtain a clear aqueous extract of the P. cocos. Hs68 human dermal fibroblast cells were challenged with 100 µM of H2 O2 for 24 h. Following H2 O2 challenge, the cells were treated with increasing concentration of P. cocos extract (100-400 µg/ml) for 24 h. P. cocos extract hindered the H2 O2 induced cell death significantly that was correlated with reduction in ROS accumulation. Western blot analysis show that P. cocos extract suppressed the expression of metallomatrix proteinases, inflammatory markers and skin aging markers, but increased TGF-ß1 levels and antioxidant related proteins. These data suggest that P. cocos is effective in attenuating oxidative stress associated skin aging effects and may be a potential agent in cosmetics products.

High Incidence of Axillary Web Syndrome among Breast Cancer Survivors after Breast Reconstruction.

OBJECTIVE: The aim of this study was to identify if breast reconstruction is a surgical risk factor for axillary web syndrome (AWS) in breast cancer (BC) patients. METHODS: The data of 207 patients who have been diagnosed with unilateral BC and who had mastectomy and lymph node dissection were retrospectively reviewed. Information of their clinical and pathological data, whether they had immediate -reconstruction and intraoperative radiotherapy, surgical methods, and postoperative complications during the 3 months after their surgery (AWS, lymphedema, seroma, and myofascial adhesion) were collected, and the incidence of AWS was compared between different surgical methods. RESULTS: The overall incidence of AWS was 48.8% in 207 patients. Of the 22 patients who received reconstruction, 19 developed AWS, yielding an incidence of 86%. Multivariate logistic regression modeling showed that patients who underwent reconstruction had a significantly higher incidence of AWS (odds ratio, 4.74), as did patients with postoperative complication of myofascial adhesion (odds ratio, 7.07). CONCLUSIONS: BC survivors after breast reconstruction are susceptible to AWS, and there is a significant association between myofascial adhesion and AWS. Our results can stimulate further investigation and provide an evidence base for the development of educational guidance for patients who plan to undergo breast reconstruction.

Fascia lata augmented nasal transposition of split lateral rectus in complete oculomotor nerve palsy with a previous failed surgery.

PURPOSE: To report our experience in the management of a complete oculomotor nerve palsy with a previous failed surgery. METHODS: We used a fascia lata augmented nasal transposition of the split lateral rectus in a patient who had complete oculomotor nerve palsy with recurrent exotropia after previous recession-resection surgery. The lateral rectus muscle was split in half, and then joined end-to-end with fascia strips with a 5-0 polyester nonabsorbable suture. The superior and inferior fascia strips were transposed to the adjacent of the superior and inferior corners of the insertion of medial rectus. With the globe being adducted about 10 degrees, the strips were sutured on the globe using fixed 5-0 polyester sutures. RESULTS: The patient showed orthotropic alignment at the primary position at the 5-month post-operation follow-up. CONCLUSION: With adequate preoperative imaging-aided evaluation and meticulous intraoperative exploration, fascia lata augmented nasal transposition of split lateral rectus could be an option of treatment for complete oculomotor nerve palsy after a previous failed surgery.

Temporal transposition of the split medial rectus muscle when the medial rectus is the sole functioning rectus muscle.

Multiple cranial nerve palsies often lead to complex clinical presentations. We report 2 cases in which a combination of multiple palsies resulted in paralytic esotropia with the medial rectus being the sole functioning rectus muscle. Both cases were treated with temporal transposition of split medial rectus.

Closed incision negative pressure therapy following abdominoplasty after breast reconstruction with deep inferior epigastric perforator flaps.

Autologous breast reconstructions using deep inferior epigastric perforator (DIEP) flaps create a large incision, presenting an opportunity for surgical site complications. In this pilot study, we aimed to examine outcomes in DIEP donor site incisions managed with standard dressings (control; n = 5) or closed incision negative pressure therapy (ciNPT; n = 5). We observed no significant differences between group age, body mass index, and past medical history. Both treatment groups had a similar duration of hospital stay, the number of blood transfusions, and pain scores on postoperative day 2 (P > .05). There was a trend of higher drainage (P = .251) and shorter time to incision healing (P = .067) in the ciNPT group than the control though the difference was not statistically significant. We did observe a significant improvement in scar pigmentation, vascularity, and pliability at 3, 6, and 12 months post-surgery in the ciNPT group compared with control (P < .05). No surgical site complications were reported in the ciNPT group within the follow-up period. In the control group, one patient developed wound edge fat necrosis requiring reoperation. In conclusion, we report that ciNPT is a useful incision management system for DIEP flap donor site incisions and it facilitated improved scar quality over standard dressings in this small pilot study. Further clinical studies are required to assess the full advantages provided by ciNPT.

The Effects of Combining Progressive Tension Sutures, Closed Drain, and Fibrin Sealant in Abdominoplasty Wound After Deep Inferior Epigastric Perforator Flap Harvesting.

BACKGROUND: This study is a retrospective review to compare combining progressive tension sutures, closed drain, and fibrin sealant effects on seroma formation, postoperative drainage volume, and hospital stay for abdominoplasty after deep inferior epigastric artery perforator (DIEP) flap. We ever published a 0% seroma rate in abdominoplasty after DIEP flap using progressive tension sutures and closed drain. Massive abdominal wound drainage caused delayed drain removal and increased hospital stay and medical costs. METHODS: We retrospectively evaluated 54 abdominoplasty patients between December 2013 and September 2017; 43 patients used fibrin glue and 11 used progressive tension sutures and closed drain. RESULTS: Abdominal drainage for the first 3 postoperative days was 84.65 ± 52.95 mL in the fibrin group, with total drainage of 127.70 ± 125.50 mL and 214.45 ± 104.35 mL in the no fibrin group, with total drainage of 350.45 ± 213.58 mL. Drains were removed on postoperative day 6.21 ± 1.44 in the fibrin group and day 9.64 ± 1.96 in the no fibrin group. The association of the first 3 days and total drainage volumes with the drain removal day significantly differed in the fibrin and no fibrin groups. Hospital stay was 9.88 ± 3.55 and 12.45 ± 5.22 days in the fibrin and no fibrin group, respectively, with borderline significant differences. CONCLUSIONS: Donor site abdominoplasty after DIEP flap combining progressive tension sutures, closed drainage, and fibrin glue can prevent seroma occurrence, reduce postoperative abdominal drainage and need for blood transfusion, and achieve early removal of the abdominal drain, shorter hospital stay, and lower medical cost.

Vagal baro- and chemoreceptors in middle internal carotid artery and carotid body in rat.

The glossopharyngeal nerve, via the carotid sinus nerve (CSN), presents baroreceptors from the internal carotid artery (ICA) and chemoreceptors from the carotid body. Although neurons in the nodose ganglion were labelled after injecting tracer into the carotid body, the vagal pathway to these baro- and chemoreceptors has not been identified. Neither has the glossopharyngeal intracranial afferent/sensory pathway that connects to the brainstem been defined. We investigated both of these issues in male Sprague-Dawley rats (n = 40) by injecting neural tracer wheat germ agglutinin-horseradish peroxidase into: (i) the peripheral glossopharyngeal or vagal nerve trunk with or without the intracranial glossopharyngeal rootlet being rhizotomized; or (ii) the nucleus of the solitary tract right after dorsal and ventral intracranial glossopharyngeal rootlets were dissected. By examining whole-mount tissues and brainstem sections, we verified that only the most rostral rootlet connects to the glossopharyngeal nerve and usually four caudal rootlets connect to the vagus nerve. Furthermore, vagal branches may: (i) join the CSN originating from the pharyngeal nerve base, caudal nodose ganglion, and rostral or caudal superior laryngeal nerve; or (ii) connect directly to nerve endings in the middle segment of the ICA or to chemoreceptors in the carotid body. The aortic depressor nerve always presents and bifurcates from either the rostral or the caudal part of the superior laryngeal nerve. The vagus nerve seemingly provides redundant carotid baro- and chemoreceptors to work with the glossopharyngeal nerve. These innervations confer more extensive roles on the vagus nerve in regulating body energy that is supplied by the cardiovascular, pulmonary and digestive systems.

Malignant Phyllodes Tumor Recurrence in the Pleural Cavity via the Deep Inferior Epigastric Perforator Flap and Internal Mammary Vessel Bundle: A Case Report.

We report a rare case that after rapid recurrence there was pathological transition from a fibroadenoma and benign phyllodes tumor to borderline and malignant phyllodes tumor. Another rare finding included tumor dissemination in the pleural cavity via reconstructed deep inferior epigastric perforator flap edge and internal mammary vessel bundle. Hence, we eliminated the use of internal mammary vessel bundle as the recipient vessel for free-flap reconstruction to avoid recurrence in the pleural cavity. Remarkably, we achieved successful reconstruction of 2 huge defects (reconstruction of breast following mastectomy and that of chest wall following en bloc excision of recurrence) using 2 different free flaps.