Treatment of keloid scars with intralesional triamcinolone and 5-fluorouracil injections - a randomized controlled trial.

Keloids have high recurrence rates. Current first-line therapy is triamcinolone (TAC) injection, but it has been suggested that approximately 50% of keloids are steroid resistant. We compared the efficacy of intralesional 5-fluorouracil (5-FU) and triamcinalone injections in a double-blind randomized controlled trial. Forty-three patients with 50 keloid scars were treated with either intralesional TAC or 5-FU-injections over 6 months. There was no statistically significant difference in the remission rate at 6 months between the 5-FU and TAC groups (46% vs 60%, respectively). Local adverse effects were higher in the TAC group compared to the 5-FU group. Occurrence of skin atrophy in TAC group was 44% and in the 5-FU group 8% (p < 0.05). Also the occurrence of telangiectasia in the TAC group was 50% and in the 5-FU 21% (p < 0.05). Vascularity of the keloids, assessed by spectral imaging and immunohistochemical staining for blood vessels, after treatment decreased in the TAC group, but not in the 5-FU group (p < 0.05). Fibroblast proliferation evaluated by Ki-67 staining significantly decreased in the TAC group (p < 0.05) but increased in the 5-FU group (p < 0.05). TAC and 5-FU injections did not differ in their clinical effectivity in this randomized study, but 5-FU injections lead to increased proliferation rate and did not affect vascular density in histological assessment. Due to the greater number of adverse effects observed after TAC treatment, 5-FU injections may be preferable for cosmetically sensitive skin areas.

Greater Success of Primary Fascial Closure of the Open Abdomen: A Retrospective Study Analyzing Applied Surgical Techniques, Success of Fascial Closure, and Variables Affecting the Results.

BACKGROUND AND AIMS: The open abdomen technique is a standard procedure in the treatment of intra-abdominal catastrophe. Achieving primary abdominal closure within the initial hospitalization is a main objective. This study aimed to analyze the success of closure rate and the effect of negative pressure wound therapy, mesh-mediated medial traction, and component separation on the results. We present the treatment algorithm used in our institution in open abdomen situations based on these findings. MATERIAL AND METHODS: Open abdomen patients (n = 61) treated in Tampere University Hospital from May 2005 until October 2013 were included in the study. Patient characteristics, treatment prior to closure, closure technique, and results were retrospectively collected and analyzed. The first group included patients in whom direct or bridged fascial closure was achieved, and the second group included those in whom only the skin was closed or a free skin graft was used. Background variables and variables related to surgery were compared between groups. RESULTS AND CONCLUSION: Most of the open abdomen patients (72.1%) underwent fascial defect repair during the primary hospitalization, and 70.5% of them underwent direct fascial closure. Negative pressure wound therapy was used as a temporary closure method for 86.9% of the patients. Negative pressure wound therapy combined with mesh-mediated medial traction resulted in the shortest open abdomen time (p = 0.039) and the highest fascial repair rate (p = 0.000) compared to negative pressure wound therapy only or no negative pressure wound therapy. The component separation technique was used for 11 patients; direct fascial closure was achieved in 5 and fascial repair by bridging the defect with mesh was achieved in 6. A total of 8 of 37 (21.6%) patients with mesh repair had a mesh infection. The negative pressure wound therapy combined with mesh-mediated medial traction promotes definitive fascial closure with a high closure rate and a shortened open abdomen time. The component separation technique can be used to facilitate fascial repair but it does not guarantee direct fascial closure in open abdomen patients.

Chitosan membranes in a rat model of full-thickness cutaneous wounds: healing and IL-4 levels.

OBJECTIVE: The aim of this study was to examine the effect of chitosan membrane on wound healing. METHOD: The effect of chitosan membranes was evaluated in an experimental rat model. On day 0, circular full-thickness skin sections were excised from the scalps of rats. The wounds were then measured and the surrounding area tattooed. Rats were sacrificed either immediately after excision, or randomised into control and chitosan groups and followed up on day 3, 7, 14 or 21. Control group wounds were covered with Aquacel (wound dressing). Chitosan group wounds were covered with chitosan membranes and the wound dressing. Wounds and the distances between the tattooed marks were measured on follow-up, the wound sites were harvested and histologically examined, and serum interleukin (IL-4) levels were analysed. RESULTS: A total of 54 rats were examined and all time points included 6 control and 6 chitosan treated animals, except for day 0 which consisted of control animals only. On day 3, wounds in the chitosan group were significantly (p<0.05) smaller (60±6% versus 78±19% of the original wound area) than in the control group. Chitosan membranes were found to degrade at the wound sites between days 7 and 14. Leukocyte counts were lower in the chitosan group than in the control group on day seven (p<0.05). IL-4 levels were significantly higher on day 7 (p<0.001) and 14 (p<0.001) in the chitosan group. CONCLUSION: According to our results chitosan membrane may promote early wound healing, reduce inflammation and affect the IL-4 pathway, however, the membrane degrades at the wound site after day 7.

Successful foot salvage with microvascular flaps in diabetic patients.

BACKGROUND AND AIMS: Complex nontraumatic foot lesions often lead to major lower-limb amputation in diabetic patients. We aimed to evaluate outcome of free flap transfer in such cases. MATERIALS AND METHODS: A total of 11 consecutive diabetic patients, hospitalized between 2007 and 2012 at a university central hospital for a free flap transfer, were followed until September 2013. Amputation-free survival, patient survival, and complete wound healing were defined as primary endpoints. Healing time of tissue lesions was analyzed. All pre- and postoperative data were retrospectively collected from hospital charts. RESULTS: Complete tissue healing at 6 and 12 months after free flap transfer were 55% (6/11) and 82% (9/11), respectively. The median time to complete tissue healing was 123 days (range, 45-207 days). Overall limb salvage, survival, and amputation-free survival rates at 12 months were 90%, 91%, and 82%, respectively. The clinically important endpoint, namely, amputation-free survival with completely healed wounds, was attained in 9 of 11 patients at 1 year. CONCLUSION: Free tissue transfer enables successful wound healing and limb salvage rather than amputation in selected diabetic patients with difficult-to-heal wounds. Complete healing of tissue lesions is slow even after successful surgery. Preoperative assessment of the condition of patients is the key to success.

Primary closure of the abdominal wall after "open abdomen" situation.

"Open abdomen" is a strategy used to avoid or treat abdominal compartment syndrome. It has reduced mortality both in trauma and non-trauma abdominal catastrophes but also has created a challenging clinical problem. Traditionally, open abdomen is closed in two phases; primarily with a free skin graft and later with a flap reconstruction. A modern trend is to close the abdomen within the initial hospitalization. This requires multi-professional co-operation. Temporary abdominal closure methods, e.g. negative pressure wound therapy alone or combined with mesh-mediated traction, have been developed to facilitate direct fascial closure. Components separation technique, mesh reinforcement or bridging of the fascial defect with mesh and perforator saving skin undermining can be utilized in the final closure if needed. These techniques can be combined. Choice of the treatment depends on the condition of the patient and size of the fascia and skin defect, and the state of the abdominal contents. In this paper we review the literature on the closure of an open abdomen and present the policy used in our institution in the open abdomen situations.

Reconstruction of the vulva with sensate gluteal fold flaps.

BACKGROUND AND AIMS: Soft-tissue reconstruction of the vulva following resection of malignancies is challenging. The function of perineal organs should be preserved and the reconstructed area should maintain an acceptable cosmetic appearance. Reconstruction with local flaps is usually sufficient in the primary phase after a radical vulvectomy. Numerous flaps have been designed for vulvar reconstruction usually based on circulation from the internal pudendal artery branches. In this paper we introduce our modification of the gluteal fold V-Y advancement flap as a primary reconstruction after a radical vulvectomy. PATIENTS AND METHODS: Twenty-two patients were operated with a radical vulvectomy because of vulvar malignancies. The operation was primary in eight and secondary in 14 patients. The reconstruction of the vulva was performed in the same operation for each patient. RESULTS: All flaps survived completely. Wound complications were registered in three patients. Late problems with urinary stream were corrected in two patients. A local recurrence of the malignancy was observed in six patients during the follow-up period. CONCLUSIONS: Gluteal fold flap is easy to perform, has a low rate of complications and gives good functional results. Even a large defect can be reconstructed reliably with this method. A gluteal fold V-Y advancement flap is sensate and our modification allows the flap to be transposed with lesser dissection as presented before.

Tension suture technique combined with lidocain-adrenalin-saline-infiltration decreases complications in abdominoplasty.

BACKGROUNDS AND AIMS: Due to growing interest into body contouring has abdominoplasty become one of the most common aesthetic operations. New techniques have appeared to reduce the relatively high incidence of complications in abdominplasty. One technique is the tension suture technique, which can be combined with lidocain-adrenalin-saline-infiltration. Our aim was to analyse the results of this combined technique. MATERIAL AND METHODS: This retrospective study consisted of 95 women operated on in a private hospital by one senior plastic surgeon between years 2004 and 2009. Sixty patients had other operations in addition to abdominoplasty: 49 liposuctions, six breast reductions or mastopexies, three umbilical hernioplasties, one brachioplasty, one partial excision of labias, and one blepharoplasty. RESULTS AND CONCLUSIONS: The operative time was 82 minutes ranging from 45 to 173 minutes. Peroperative bleeding was a mean of 196 ml in abdominoplasty only and 254 ml when combined with additional operation. Patients did not have any major complications and the total incidence of minor--not clinically significant--complications was 12.6%. Obesity, smoking, comorbidities, previous operations on belly area or additional operations did not affect the complication rates. Our study supports the view that the tension suture technique combined with lidocain-adrenalin-saline-infiltration decrease the formation of seroma and wound complications in abdominoplasty. Lidocain-adrenalin-saline-infiltration also fastens and eases the operation without increasing the risk of bleeding in experienced hands.

Wound healing after open appendectomies in adult patients: a prospective, randomised trial comparing two methods of wound closure.

BACKGROUND: The skin is closed in open appendectomy traditionally with few interrupted nonabsorbable sutures. The use of this old method is based on a suggestion that this technique decreases wound infections. In pediatric surgery, skin closure with running intradermal absorbable sutures has been found to be as safe as nonabsorbable sutures, even in complicated cases. Our purpose was to compare the safety of classic interrupted nonabsorbable skin closure to continuous intradermal absorbable sutures in appendectomy wounds in adult patients. METHODS: A total of 206 adult patients with clinically suspected appendicitis were allocated to the study and prospectively randomized into two groups of wound closure: the interrupted nonabsorbable (NA) suture and the intradermal continuous absorbable (A) suture group. Primary wound healing was controlled on the first postoperative day, at 1 week clinically and after 2 weeks by means of a telephone interview. Follow-up data were obtained from 185 patients (90 in group NA and 95 in group A). RESULTS: Continuous absorbable intradermal suturing was as safe as nonabsorbable sutures in regard to wound infections. CONCLUSION: Continuous, absorbable sutures can be used safely even in complicated appendicectomies without increasing the risk of wound infection. Considering the benefits of absorbable suturing, we recommend this method in all open appendectomies.

Amniotic membrane reduces wound size in early stages of the healing process.

OBJECTIVE: To investigate the effects of dispase de-epithelialised, glycerol cryopreserved amniotic membrane (AM) on full-thickness skin defects, using a rat model. METHOD: Skin defects of 15 mm diameter were surgically created and measured on the scalps of 53 male rats. Animals were divided into two groups and followed for 0, 3, 7, 14 or 21 days. AM group wounds were covered with de-epithelialised AM and sodium chloride-moistened Aquacel (ConvaTec Inc.); control group wounds were covered with sodium chloride-moistened Aquacel alone. After the follow-up, wounds were measured again, serum samples were taken and wound sites were harvested for histological analysis. Systemic interleukin-4 (IL-4) levels were analysed from serum. RESULTS: On day 3, a statistically significant difference (p < 0.01) was observed in mean wound size, with wound size in the AM group smaller than in the control group (60 ± 12% vs 81 ± 13% of the original size); other time points showed no significance difference in wound size between the two groups. We could not detect differences between the groups in histological parameters or serum IL -4 levels. CONCLUSION: According to this study, AM enhances early stage wound healing in terms of wound size but its effect decreases in later phases. The IL-4 results provide no clear evidence that IL-4 contributes to the effect of AM on wound healing. DECLARATION OF INTEREST: This study was financially supported by the Competitive Research Funding of the Tampere University Hospital (Grant 9H041, 9J047). The authors have no additional conflicts of interest to declare.

Latissimus dorsi free flap harvesting may affect the shoulder joint in long run.

BACKGROUND: The latissimus dorsi (LD) muscle or myocutaneous flap is one of the most commonly used flaps and is believed to result in minimal donor-side morbidity. The impact on shoulder function from LD removal is important due to the common nature of this procedure. Previous studies have been performed after relatively short follow-up time and mostly after breast reconstruction. The purpose of this study was to objectively evaluate shoulder function years after latissimus dorsi muscle free flap operation. METHODS: Between 1998 and 2004, eight patients who underwent LD-free flap for lower limb (7) or head and neck (1) soft tissue reconstruction were enrolled in this study. Scar, shoulder pain, function, mobility, stability and strength were evaluated and measured by using the Patient Scar Assessment Questionnaire (PSAQ), the Scar Evaluation Scale (SES) score, the American Shoulder and Elbow Surgeons (ASES) form, goniometer and isokinetic tests. Measurements of the operated sides were compared to the non-operated sides. RESULTS: Mean age was 54 ± 21 years and mean follow-up was 92.5 ±â€†36 months after surgery. Mean PSAQ was 73 (65%), mean SES score was 2 ±â€†1. When comparing the operated sides to the unoperated sides, ASES score was significantly lower in the operated side (76 versus 93, p = 0.008); The range of motion in active and passive endorotation, active extrarotation and active forward elevation were significantly reduced after surgery. Operated side revealed a significant joint instability (3.6 versus 1.2, p = 0.007) using the ASES form. Isokinetic tests revealed that only intra-rotation strength was significantly reduced (35.74 Newton-metre versus 42.7 Newton-metre, p = 0.03) in the operated side. CONCLUSION: LD harvesting can affect the function of the shoulder joint in the long run. Reduced mobility, instability and weakness could be obtained with objective measurements. However, the results should be interpreted with caution because of the small sample size, internal controls and retrospective nature of this study.

The outcome of reduction mammaplasty is affected more by psychosocial factors than by changes in breast dimensions.

BACKGROUND AND AIMS: Several randomised studies have proved the effects of breast reduction surgery. However, search for predictive factors has not been successful. Therefore we decided to analyse breast dimension changes and to see whether these, or patient characteristics or individual psychosocial factors have an effect on the outcome. MATERIAL AND METHODS: Twenty-nine patients were assessed at baseline and at six months follow-up. Outcome measures used were two health-related quality of life questionnaires, a breast-associated symptoms questionnaire, a pain-rating questionnaire, and a mood questionnaire. Detailed breast dimensions were recorded. Forward stepwise linear regression was applied to detect possible associations between outcome measure changes and breast dimensions or patient-related factors. RESULTS: Preoperatively anxious patients had more improvement in the quality of life index scores, but less improvement in the mental health scores when compared to patients not anxious. Patients with physically demanding work had more improvement in the quality of life index scores and a trend to less improvement in the mental health scores when compared to patients with physically less stressful work. Patients with no overweight had a trend to better improvement in self-esteem. CONCLUSIONS: The outcome of reduction mammaplasty is affected more by psychosocial factors than by changes in breast dimensions.

Late results of skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) facilitates optimal immediate breast reconstruction (IBR) by preserving the inframammary fold and most of the breast skin. Concerns persist that SSM might increase the rate of local recurrence as the surgical approach is less extensive. Patients who had SSM and IBR over 10 years at a single institution were reviewed. METHODS: A total of 207 consecutive women who underwent SSM and IBR from 1992 to 2001 were included in the study. The patient records were analysed retrospectively and follow-up data were included. RESULTS: Postoperative complications included native skin flap necrosis (10.1 per cent), haematoma (10.6 per cent), infection (3.4 per cent), anastomotic thrombosis (5.3 per cent) and hernia (2.6 per cent). During a mean follow-up of 70 months, 5.8 per cent of patients with stage 0-2 disease developed a locoregional recurrence, although none of these later had a systemic recurrence. The rate of locoregional recurrence was 31 per cent (five of 16) in women with stage 3 breast cancer. CONCLUSION: SSM followed by IBR was both surgically and oncologically safe, especially for early-stage breast cancer.

Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures.

AIM: The aim of the study was to analyse the number of soft-tissue complications after internal fixation of calcaneal fractures and to evaluate risk factors leading to these complications. MATERIAL: A retrospective analysis of 126 consecutive patients with 148 operatively treated calcaneal fractures was performed. Only primarily closed fractures were included in the study. RESULTS: Wound healing was problematic in 35 cases (24 per cent). The wound was infected in 23 cases (16 per cent) and a wound edge necrosis was observed in 12 cases (8 per cent). The soft tissue complication needed operative treatment in 20 cases (14 per cent). The complications did not lead to amputations in any case. In the end of the follow up all wounds had healed. CONCLUSIONS: The statistical analysis identified a longer delay in surgery and longer operation time to be positive risk factors for wound complications.

Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap.

Although the free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap is in routine use for breast reconstruction, little is known of its hemodynamics. The purpose of this study was to determine whether any differences exist when the free TRAM flap is anastomosed to the thoracodorsal or internal mammary vessels. The study comprised 25 patients receiving a free TRAM flap for breast reconstruction. The thoracodorsal vessels were used as recipients in 21 patients and the internal mammary vessels were used in 4 patients. Blood flow rate was measured directly in the donor and recipient arteries, and after anastomosis by a transit-time ultrasonic flowmeter (CardioMed). Two- and 3-mm probes were used. The blood flow rate in the donor artery (deep inferior epigastric) before flap dissection was 11 +/- 6 ml per minute (mean +/- standard deviation). The rate was significantly (p < 0.05) lower (5 +/- 3 ml per minute) in the recipient thoracodorsal artery than in the donor, but after transplantation it increased to 14 +/- 5 ml per minute (p < 0.05), attaining the same value as the donor artery. The blood flow rate in the intact internal mammary artery was significantly higher (25 +/- 10 ml per minute) than in the donor and thoracodorsal arteries, but after anastomosis it dropped to the same value (12 +/- 3 ml per minute; p < 0.05) as the donor artery. The intake of blood in TRAM flaps supplied by the intemal mammary artery seems to be no greater than that in free flaps anastomosed to thoracodorsal vessels, although the flow in the internal mammary artery was much higher. The authors concluded that the blood supply in a free TRAM flap is independent of the flow in the recipient artery and that thoracodorsal vessels, although often in a scarred bed and radiated, are as suitable for anastomosing a free TRAM flap as are internal mammary vessels.

Evaluation of blood flow in free microvascular flaps.

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.

Osteosynthesis and allogeneic bone grafting in complex osteoporotic fractures.

Thirty patients with osteoporotic fractures were treated operatively. An allogeneic bone transplant was used in combination with a conventional osteosynthesis in each patient. The bone graft was pulverized in a bone mill and used as a substitute graft to fill the bone defect, add stability, and enhance bone union. Fractures healed without complications in 20 patients. The osteosynthesis failed in 4 patients. The fracture failed to unite in an additional 3 patients. One deep infection occurred. A biopsy taken from the allogeneic bone at plate removal after fracture union demonstrated mature bone and new bone formation. The use of pulverized allograft bone for large bone defects in patients with osteoporotic fractures yields acceptable results with no adverse effects.

Asymmetry of gait after free flap reconstruction of severe tibial fractures with extensive soft-tissue damage.

Gait patterns of the preferred speed were investigated on 17 patients recovering (9 months-14 years) after reconstruction of severe tibial fractures. A novel data-acquisition system was used to record the plantar pressures as well as electromyographic (EMG) activities during walking. The results indicated incomplete recovery of symmetrical gait patterns. In particular, the duration of the stance phase was shorter on the operated side (mean (SD) 701 (90) ms compared with 765 (128) ms, p < 0.001). The peak pressure points under the foot were different on bilateral comparison, the operated side being regularly higher under the lateral forefoot area. This may imply attempts to reduce the loading of the ankle joint during stance. The pressure distribution models reflected these asymmetrical patterns more specifically than the EMG activities of the lower leg muscles examined.

Drainage is of no use in primary uncomplicated cemented hip and knee arthroplasty for osteoarthritis: a prospective randomized study.

In a prospective, randomized study, 58 patients with primary cemented hip arthroplasty and 39 patients with primary cemented knee arthroplasty were divided into groups with postoperative closed-suction drainage and without drainage. There was no difference in healing of the wounds, postoperative blood transfusions, complications, or range of motion. Although there was more soaked dressing requiring reinforcements in the groups without drainage, as a result of this study, we no longer use drains in uncomplicated cemented primary hip and knee arthroplasties for osteoarthritis.

Free microvascular tram flaps: report of 185 breast reconstructions.

The free TRAM flap is the most elegant technique currently available for breast reconstruction. We describe here the surgical technique, the complications, the possible effects of the prognosis of the breast cancer, and the learning curve of the surgical team. From December 1990 to the end of 1995 we reconstructed 185 breasts (10 bilateral) in 175 patients with free TRAM flaps; 27 were immediate reconstructions. We harvested the flap based on the inferior epigastric pedicle on the opposite side to the affected breast. To dissect the rectus muscle we used a muscle-sparing technique. The flap was designed and de-epithelialised while still on the abdomen, and was anastomosed to the thoracodorsal or circumflex scapular vessels with loupes only. In the immediate reconstructions we removed the breast tissue through a periareolar incision; we dissected the group I axillary lymph nodes and exposed the recipient vessels through a separate incision. The areolar complex was autotransplanted as a free skin graft. Only two flaps were lost. Eight patients were reoperated on for thrombosis of the vessels. The complication rate was nearly 50% among the first 50 patients. However, as surgical experience grew, the figure was reduced, eventually being down to 20%-25%. Of the patients who had delayed reconstructions only two died during the follow-up period of 48 months. One patient had a local recurrence above the TRAM skin. During the last eight years the free TRAM flap has been our main method of breast reconstruction. Free flaps today are reliable and the reconstruction does not seem to worsen the prognosis of breast cancer.