Background
Reconstruction of total or near‐total nasal defects is challenging and requires the re‐creation of three nasal layers. Fasciocutaneous free flaps have been used effectively for restoring ...the vascularized nasal lining and staged forehead flap for nasal skin replacement, which is a long process. The aim of this study is to share our experience of combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction.
Methods
From December 2015 to July 2021, 10 patients underwent nasal reconstruction with free flaps including 4 medial sural artery perforator (MSAP) flaps, 5 anterolateral thigh (ALT) flaps and 1 radial forearm flap for lining and forehead flaps for skin coverage simultaneously for total or subtotal nasal defects. Nasal obstruction symptoms evaluation (NOSE) score was utilized to evaluate the functional outcome and the aesthetic results were evaluated with the last follow‐up photos with score 1–5 by 5 plastic surgeon and 5 laypersons.
Results
The size of the free flaps ranged from 3 cm x 6 cm to 6 cm x 13 cm. After excluding one patient who expired before forehead flap division due to comorbidities, the average duration between combination surgery and the division of the forehead flap pedicle of the remaining patients was 5.7 months (range, 2–12). For patients without any postoperative events, the duration was 2.2 months (range, 2–3). One free flap had partial necrosis due to infection. The average follow‐up duration was 29.6 months (range, 12–64). The NOSE score was 5.9 (range, 0–10) and the aesthetic score is 4.1 (range, 3–5) in average.
Conclusions
The combination of preliminary free tissue transfer for nasal lining restoration with a paramedian forehead flap for nasal skin replacement in the same stage may shorten the long process and achieve satisfactory reconstruction in complex nasal reconstruction.
The antiepileptic drug phenytoin can cause cutaneous adverse reactions, ranging from maculopapular exanthema to severe cutaneous adverse reactions, which include drug reactions with eosinophilia and ...systemic symptoms, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The pharmacogenomic basis of phenytoin-related severe cutaneous adverse reactions remains unknown.
To investigate the genetic factors associated with phenytoin-related severe cutaneous adverse reactions.
Case-control study conducted in 2002-2014 among 105 cases with phenytoin-related severe cutaneous adverse reactions (n=61 Stevens-Johnson syndrome/toxic epidermal necrolysis and n=44 drug reactions with eosinophilia and systemic symptoms), 78 cases with maculopapular exanthema, 130 phenytoin-tolerant control participants, and 3655 population controls from Taiwan, Japan, and Malaysia. A genome-wide association study (GWAS), direct sequencing of the associated loci, and replication analysis were conducted using the samples from Taiwan. The initial GWAS included samples of 60 cases with phenytoin-related severe cutaneous adverse reactions and 412 population controls from Taiwan. The results were validated in (1) 30 cases with severe cutaneous adverse reactions and 130 phenytoin-tolerant controls from Taiwan, (2) 9 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis and 2869 population controls from Japan, and (3) 6 cases and 374 population controls from Malaysia.
Specific genetic factors associated with phenytoin-related severe cutaneous adverse reactions.
The GWAS discovered a cluster of 16 single-nucleotide polymorphisms in CYP2C genes at 10q23.33 that reached genome-wide significance. Direct sequencing of CYP2C identified missense variant rs1057910 (CYP2C9*3) that showed significant association with phenytoin-related severe cutaneous adverse reactions (odds ratio, 12; 95% CI, 6.6-20; P=1.1 × 10(-17)). The statistically significant association between CYP2C9*3 and phenytoin-related severe cutaneous adverse reactions was observed in additional samples from Taiwan, Japan, and Malaysia. A meta-analysis using the data from the 3 populations showed an overall odds ratio of 11 (95% CI, 6.2-18; z=8.58; P < .00001) for CYP2C9*3 association with phenytoin-related severe cutaneous adverse reactions. Delayed clearance of plasma phenytoin was detected in patients with severe cutaneous adverse reactions, especially CYP2C9*3 carriers, providing a functional link of the associated variants to the disease.
This study identified CYP2C variants, including CYP2C9*3, known to reduce drug clearance, as important genetic factors associated with phenytoin-related severe cutaneous adverse reactions.
Phosphate level is often deranged during acute illness, regardless of the presence of kidney injury or not. A few studies described that hypophosphatemia may associated with outcome in patients ...admitted to the burn unit, but the literatures for hyperphosphatemia is limited. Our study aims to evaluate if hyperphosphatemia, one of the sign of severe tissue damage or kidney injury, will associate with mortality of patients with severe burns.
The study was a post hoc analysis of prospectively collected data from patients admitted to the burn unit between September 2006 and December 2011. Patients were stratified into normophosphatemic or hyperphosphatemic group by baseline plasma phosphate level. The primary endpoint is 90-day mortality.
Total 301 patients were included (hyperphosphatemia: n = 52; normophosphatemia: n = 249). The hyperphosphatemic group had lower Glasgow Coma Scale, mean arterial blood pressure, hemoglobin level, albumin, and higher TBSA of burns, APACHE II score, ABSI score, Acute kidney injury (AKI), and creatinine. The 90-day mortality was higher in the hyperphosphatemic group than in the normal group (53.8% vs 18.1%, P < .001) and this difference was still significant when adjusting for several confounding factors (hazard ratio, 2.05; 95% CI, 1.17-3.59). Multivariable Cox analysis showed risk factors of mortality included TBSA of burns, hyperphosphatemia, reduced urine output, and APACHE II score.
Our study found in addition to TBSA of burns and inhalation injury, baseline hyperphosphatemia in patients with severe burns is also associated with higher mortality.
The crescentic alar groove serves as a topographic landmark that frames the ala and separates this convex structure from the surrounding cosmetic subunits. This aesthetic landmark can be attenuated ...or even obliterated during wound repair in this area. Flaps spanning the alar crease are often noticeably bulky with a pin-cushioned appearance in nasal reconstruction, and it is challenging to reproduce a natural-appearing alar groove. The authors proposed a novel technique with a modified, interrupted inverted horizontal mattress suture to create an alar groove. From March of 2016 to May of 2021, 22 consecutive patients with alar defects who underwent nasal reconstruction with the paramedian forehead flap were identified. All patients underwent the authors' novel technique for the creation of the alar groove. The mean follow-up time was 3 years 7 months (range, 14 months to 5 years). A total of 32 alar crease creation suture operations were performed. All uneven wounds healed uneventfully within 2 weeks. Two cases of postoperative fading alar grooves required alar crease creation sutures to be redone. The authors' novel alar crease creation suture is a safe, straightforward, and reliable technique to create an aesthetic alar groove in forehead flap nasal reconstruction. It can create a medially shallow and laterally deep alar crease without apparent complications.
Therapeutic, IV.
Hypertrophic scars (HSs) are formed via an aberrant response to the wound healing process. HSs can be cosmetic or can result in functional problems. Prolonged proliferation and remodeling phases ...disrupt wound healing, leading to excessive collagen production and HS formation. However, there are currently no satisfactory drugs to prevent HS formation. Mesenchymal stem cell (MSC) conditioned medium (CM) has therapeutic effects on wound healing and preventing HS formation. Bone marrow concentrate (BMC) contains various growth factors and cytokines that are crucial for regeneration and has been applied in the clinical setting. In this study, we evaluated the effects of BMC-induced MSC CM on HS formation in a rabbit ear model.
We established a rabbit ear wound model by generating full-thickness wounds in the ears of rabbits (n = 12) and treated wounds with MSC CM, BMC CM, or BMC-induced MSC CM. Dermal fibroblasts from human hypertrophic scar were stimulated with transforming growth factor beta 1 (TGF-β1) for 24 h and cultured in each culture medium for 72 h. We measured the hypertrophic scar (HS) formation during the skin regeneration by measuring the expression of several remodeling molecules and the effect of these conditioned media on active human HS fibroblasts.
Our results showed that BMC-induced MSC CM had greater antifibrotic effects than MSC CM and BMC CM significantly attenuated HS formation in rabbits. BMC-induced MSC CM accelerated wound re-epithelization by increasing cell proliferation. Additionally, BMC-induced MSC CM also inhibited fibrosis by decreasing profibrotic gene and protein expression, promoting extracellular matrix turnover, inhibiting fibroblast contraction, and reversing myofibroblast activation.
BMC-induced MSC CM modulated the proliferation and remodeling phases of wound healing, representing a potential wound healing agent and approach for preventing HS formation.
Although studies on skin microbiome of acute and chronic wounds abound, evidence on newly built microbial communities of subacute wounds remains scant. To characterize the skin microbiome of recently ...healed (scarred) burn wounds in relation to unaffected skin surfaces, we collected weekly swabs from patients with moderate to severe burns in the 3rd postburn month for 4 weeks in 2015. We performed skin type (moist, dry, and oily)‐matched comparisons within six burn patients (43 pairs of swabs) and with 13 skin‐healthy, control patients (22 pairs of samples) using 16S ribosomal RNA gene sequencing results. Results of comparative microbiome analysis showed that, there were no substantial variations in the microbial abundance (all p > 0.05) or composition (all p > 0.01, adjusted for multiple comparisons) between samples obtained from wound scars and those from unaffected surfaces of burn patients. Nor did we find significant temporal dynamics in microbial richness or diversity in burn samples (all p ≥ 0.05). However, samples from burn patients harbored more Firmicutes (median: 25.6%, interquartile range IQR: 14.3%–52.8%) than those of control patients (14.9%, IQR: 6.7%–27.0%; p: 0.016), even after adjusting for host age, sex, and skin type‐matching (p: 0.026). The number of observed bacterial operational taxonomic units at the genus level was reduced in burn patients (median: 62, IRQ: 32–85) as compared to control patients (median: 128, IQR: 112–136; age‐, skin type‐adjusted p < 0.01). Meanwhile, estimates of community diversity and evenness for surveyed body sites of burn patients were higher than those of control patients (all adjusted p ≤ 0.05). With a much‐reduced bacterial burden and a relative overgrowth of Staphylococcus spp., the skin microbiota of burn patients remained dysbiotic in the subacute phase as compared to that of skin‐normal patients.
Postburn Contractures of the Hand Fufa, Duretti T., MD; Chuang, Shiow-Shuh, MD; Yang, Jui-Yung, MD
The Journal of hand surgery (American ed.),
09/2014, Letnik:
39, Številka:
9
Journal Article
Recenzirano
Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by ...multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.
Objective: Posttraumatic growth (PTG) is commonly observed in trauma survivors. Information on PTG and its predictors among burn survivors is relatively limited. The present study sought to ...investigate the prevalence and predictors of PTG in burn survivors. The predictors of interest included the variables from Tedeschi and Calhoun's model of PTG (core belief challenge, deliberate rumination, trauma disclosure, and perceived social support) and positive personality attributes (resilience, grateful disposition, and dispositional forgiveness). Method: Participants were 116 burn survivors of the 2015 Formosa Fun Coast Water Park explosion in Taiwan. The mean age at the event was 22.3 years (SD = 4.2), with the average total body surface area (TBSA) burned of 49.5% (SD = 19.6). Results: Two years after the explosion, 51.7% of the burn survivors experienced "significant" PTG (i.e., at least moderate growth). This proportion rose to 80.2% and 88.8% when assessing PTG at the domain and item levels, respectively. The variables from Tedeschi and Calhoun's model and positive personality attributes both significantly and substantially predicted PTG postburn, after adjusting for demographic and burn characteristics. Moderation analyses revealed that the effect of deliberate rumination on PTG postburn was stronger among those with low and moderate levels of resilience. The effect of trauma disclosure on PTG postburn was stronger among those with low and moderate dispositional forgiveness. Conclusion: These findings highlight the applicability of psychological theories of PTG to trauma-related growth of burn survivors.
Clinical Impact Statement
The main findings of this study were threefold. First, posttraumatic growth (PTG) is highly prevalent in burn survivors. Second, variables derived from Tedeschi and Calhoun's model of PTG strongly predicted PTG postburn. Third, positive personality attributes (i.e., resilience, grateful disposition, and dispositional forgiveness) strongly predicted PTG postburn and moderated the effects of theoretically derived variables on PTG postburn. These findings highlight the applicability of psychological theories of PTG to trauma-related growth of burn survivors. Several of the predictors examined could be considered targets for postburn psychological intervention (e.g., gratitude and forgiveness), which may facilitate PTG.
The coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors ...for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation.
A retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury.
The area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury.
We developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.
•This study is the first machine learning approach for differentiating between mild and severe inhalation injury (INH).•It can also distinguish between INH and no INH.•The dichotomous classification predicted by two models is associated with subsequent clinical outcomes.
Background
To introduce an innovative refinement, the “double V cutting folded derotation graft” (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong ...holding force and efficient cartilage use.
Methods
A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (
n
= 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (
n
= 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-
t
and independent-
t
tests.
Results
The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The
P
values of the independent-
t
tests were 0.991, 0.564 and 0.439, respectively.
Conclusions
Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening.
Level of evidence III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors
www.springer.com/00266
.
PDF
