Reconstruction of Defects Involving the Nasal Ala and the Nasolabial Fold: The Role of the Microvascular Prehelical Rim Graft.

PURPOSE: To demonstrate a surgical technique for reconstructing defects involving the triangle of the nasal ala, nasolabial fold and upper lip. PROCEDURE: Retrospective survey with follow-up including 4 consecutive patients with extensive skin and soft tissue defects. RESULTS: Successful reconstruction with good nasal function and acceptable cosmetic result was achieved in all patients. CONCLUSION: The microvascular helical rim graft offers a unique option to reconstruct defects in this specific triangular area of the face when standard techniques have failed.

The reoperation cascade after breast augmentation with implants: what the patient needs to know.

Breast augmentation with implants is the most commonly performed aesthetic surgical procedure. However, the risk of complications requiring revision surgery with unsatisfactory final results is often underestimated. In a 10-year retrospective study, patients receiving implant exchange or implant removal after breast augmentation were reviewed with regards to surgical technique, implant type and position, complications and follow-up interventions. As many as 230 patients were included with a mean age of 40.23 years. A total of 192 (83.5%) had primary augmentation for aesthetic reasons, 24 (10.4%) patients were transsexuals and 14 (6.1%) were treated for malformations. The median primary implant size was 260, 224 and 327 g for aesthetic, malformation and transsexual patients, respectively. Capsular contracture was the leading cause for revision in aesthetic patients whereas size and shape were the main reasons for reoperation in transsexual and malformation patients, respectively. As many as 25% of patients required more than one revision procedure. The time between operations in aesthetic augmentation patients was significantly shorter for the second revision procedure (106.2 months vs. 11.4 months, p<0.0001). The cumulative risk for needing a second revision procedure in aesthetic patients at 12 months was 24.5%. There was no correlation between implant site, size, position or type of complication and the number of revision procedures. Our data highlight the high complication rate of revision surgery involving implant removal or replacement. We conclude that patients must be routinely informed of the high risk and arduous consequences of revision surgery, which should be stated as such in the written consent for the procedure.

Attempted suicide by self-immolation is a powerful predictive variable for survival of burn injuries.

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4-3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4-4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient's mortality after burn injuries such as the widely used ABSI.

30 years later--does the ABSI need revision?

In light of changes in patient demographics together with constant developments in burn care, the predictive accuracy of the Abbreviated Burns Severity Index (ABSI) - first described in 1982 - for estimating the mortality of present day burns patients, may be questionable. We reviewed the records of 2813 burns patients treated between January 1968 and December 2008 in the intensive care unit at our institution, aiming to identify emerging discrepancies between the estimated and calculated outcome, based on each of the ABSI variables and the total burn score. The predictive value of each of the defined ABSI variables was confirmed to be highly significant. Univariable and multivariable analysis revealed an exponential increase in odds ratio (OR) for mortality for patients older than 60 years and more than 30% TBSA burned and showed OR values over 10 times higher than other significant variables like inhalation injury. Nevertheless, the ABSI for the estimation of mortality in our entire patient collective was highly accurate and could not be optimised by adapting the point distribution to the increase in OR. Our data indicates that despite significant changes in patient demographics and medical advances over the past 30 years, the ABSI scoring system is still an accurate and valuable tool in the prediction of burn patient mortality.

A prevascularized tissue engineering chamber supports growth and function of islets and progenitor cells in diabetic mice.

Recent studies have shown that type 1 diabetes can be reversed in a murine model by islet transplantation to a vascularized tissue engineering chamber. In preliminary experiments using a prevascularized chamber we observed that islet grafts not functioning initially can show a delayed onset of function several weeks after implantation. We sought to characterize this phenomenon. Islets were transplanted into prevascularized tissue engineering chambers based on the epigastric vessels in streptozotocin induced diabetic C57BL/6J mice. Animals were transplanted with 500 islets and observed at 1, 4, 8 and 16 weeks post transplantation. Weekly blood glucose (BG) measurements revealed an average onset of maintained graft function 6.8 weeks post transplantation. Graft function was proven by a return to a diabetic state following chamber removal. Mature grafts showed islet tissue clustered together within the tissue construct. The quantity of endocrine tissue staining positive for insulin correlated with graft function at 8 and 16 weeks. However, at 1 and 4 weeks, islet tissue was not evidently visible as observed by endocrine staining. All islet tissue showed dense vascularization and sporadic sympathetic innervation, irrespective of the graft's function. Immunopositive cells for Cytokeratin-7 and -19 were observed in the grafts at early time points and hormone producing cells appear to have been differentiated from these progenitors. Our data demonstrates that pancreatic duct-derived progenitors remain viable in vivo and eventually differentiate and mature to functional islets following transplantation. Our prevascularized tissue-engineering chamber in the groin supports maturation and function of the grafted tissue by two months after implantation.