Tumescent technique for split-thickness skin graft donor sites: A systematic review of randomized controlled trials.

BACKGROUND: Split-thickness skin grafting (STSG) is widely used for reconstructive wound management. This review aimed to use level I evidence to determine if tumescent techniques were safe and effective compared to other interventions for STSG donor sites. It was hypothesized that tumescent techniques were safe and effective for STSG donor sites. METHODS: Five databases (MEDLINE via PubMed, Embase, Cochrane Library, Web of Science, and Scopus) were searched to identify studies concerning the use of tumescent solutions for STSG. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Cochrane's guidelines were strictly followed. RESULTS: Nine randomized controlled trials met the criteria. Included studies were published from 2001 to 2021, with results from 40 of 121 possible queried outcomes and complications. Outcomes included patient demographics, formulations of tumescent solutions, tumescent technique, hemodynamics, pain, perfusion, graft take, healing time, and postoperative complications. The tumescent technique reduced estimated blood loss (standard mean differences [SMD]: -2.68, 95%CI: -3.41 to -1.94; participants = 72; studies = 2; I2 = 96%; p < 0.001), and postoperative analgesic use within 24 hours (SMD: -1.75, 95%CI: -2.09 to -1.41; participants = 202; studies = 2; I2 = 96%; p < 0.001), without increasing graft loss/take (SMD: 0.29, 95%CI: -0.02 to 0.61; participants = 158; studies = 3; I2 = 41%; p = 0.07) and infection (risk ratios [RR]: 0.52, 95%CI: 0.08 to 3.54; participants = 87; studies = 3; I2 = 0%; p = 0.58) complications compared to other interventions. CONCLUSIONS: Level I evidence demonstrated tumescent techniques were safe and effective for STSG donor sites. Tumescent techniques reduced blood loss and postoperative analgesic use within 24 hours without increasing graft loss/take and infection complications compared to other interventions. Inconsistencies between studies limit conclusions and emphasize the need for standardized protocols regarding tumescent solution formulations, techniques, and reported outcomes.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis.

BACKGROUND: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed. RESULTS: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63. CONCLUSIONS: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.

Platelet-rich plasma vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis: a cost-effectiveness Markov decision analysis.

BACKGROUND: Both platelet-rich plasma (PRP) and corticosteroid injections may be used to treat lateral epicondylitis. We evaluated the cost-effectiveness of PRP injections vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with recalcitrant lateral epicondylitis, unresponsive to conservative measures, treated with a single injection of PRP or triamcinolone 40 mg/mL. Transition probabilities were derived from randomized controlled trials, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry reported using Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and costs from institution financial records. Analyses were performed from health care and societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICERs), reported as US dollars / quality-adjusted life-year (USDs/QALY) and net monetary benefit (NMB) to represent the values of an intervention in monetary terms. Willingness-to-pay thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed over 10,000 iterations. RESULTS: Both PRP and triamcinolone 40-mg/mL injections were considered cost-effective interventions from a health care and societal perspective below the WTP threshold of $50,000. From a health care perspective, PRP injections were dominant compared with triamcinolone 40-mg/mL injections, with an ICER of -$5846.97/QALY. PRP injections provided an NMB of $217,863.98, whereas triamcinolone 40 mg/mL provided an NMB of $197,534.18. From a societal perspective, PRP injections were dominant compared to triamcinolone 40-mg/mL injections, with an ICER of -$9392.33/QALY. PRP injections provided an NMB of $214,820.16, whereas triamcinolone 40 mg/mL provided an NMB of $193,199.75. CONCLUSIONS: Both PRP and triamcinolone 40-mg/mL injections provided cost-effective treatments from health care and societal perspectives. Overall, PRP injections were the dominant treatment, with the greatest NMB for recalcitrant lateral epicondylitis over the time horizon of 5 years.

Preoperative Considerations for the Prevention of Surgical Site Infection in Superficial Cutaneous Surgeries: A Systematic Review.

Background: Surgical site infections (SSIs) pose challenges to the outcome of superficial cutaneous procedures. Objective: The objective of this study was to summarize published data regarding appropriate perioperative considerations to decrease SSI, including antiseptic use, topical decolonization, antibiotic prophylaxis, and clean versus sterile technique in superficial cutaneous procedures. A literature search was performed via PubMed and Cochrane Library by using relevant keywords. A total of 37 articles met the inclusion criteria. Strength of data was assessed according to the Oxford Centre criteria and a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: Chlorhexidine is the antiseptic of choice in clean or outpatient superficial cutaneous procedures. Decolonization of carriers of Staphylococcus aureus with mupirocin is warranted for all superficial cutaneous procedures. Minor procedure rooms may be considered for superficial cutaneous procedures that possess an inherently low risk of SSI. Surgeons may consider nonsterile gloves instead of sterile gloves for clean or outpatient superficial cutaneous procedures. Postoperative use of topical antibiotics may be discontinued, as there are risks of adverse effects and increasing bacterial resistance without a significant reduction in SSI. Conclusion and Relevance: This systematic review provides new and updated evidence for the prevention of SSI in superficial cutaneous procedures through antiseptic use, antibiotic use, topical agents, and the surgical environment. The overall quality of evidence is good, with most articles being original research or systematic reviews. However, there is a need for dermatologic- and plastic surgery-specific studies regarding the prevention of SSI.

The Subtleties of Success in Simultaneous Augmentation-Mastopexy.

BACKGROUND: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy. METHODS: A retrospective analysis of one surgeon's consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups. RESULTS: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28). CONCLUSIONS: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon's practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Deep ulnar intraneural ganglia in the palm.

BACKGROUND: While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood. MATERIALS: We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation. RESULTS: A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts. CONCLUSION: Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.

Toward engineering functional organ modules by additive manufacturing.

Tissue engineering is emerging as a possible alternative to methods aimed at alleviating the growing demand for replacement tissues and organs. A major pillar of most tissue engineering approaches is the scaffold, a biocompatible network of synthetic or natural polymers, which serves as an extracellular matrix mimic for cells. When the scaffold is seeded with cells it is supposed to provide the appropriate biomechanical and biochemical conditions for cell proliferation and eventual tissue formation. Numerous approaches have been used to fabricate scaffolds with ever-growing complexity. Recently, novel approaches have been pursued that do not rely on artificial scaffolds. The most promising ones utilize matrices of decellularized organs or methods based on multicellular self-assembly, such as sheet-based and bioprinting-based technologies. We briefly overview some of the scaffold-free approaches and detail one that employs biological self-assembly and bioprinting. We describe the technology and its specific applications to engineer vascular and nerve grafts.

Case report: intraneural ganglion cyst of the ulnar nerve at the wrist.

We report a case of a 69-year-old male who presented with pain, weakness, and clumsiness of his right hand. Initial evaluation suggested possible neoplastic process affecting his cervical spine, which was fortunately ruled out by bone biopsy. Subsequent electrodiagnostic studies and magnetic resonance imaging confirmed a lesion of the deep ulnar motor branch. Exploration of Guyon's canal was performed, and an intraneural ganglion involving the deep motor branch of the ulnar nerve was found and excised. Despite more than 14 months of symptomatic duration, the patient made a near-complete recovery with virtually no functional limitations. This provides supporting evidence for a functional benefit of intraneural ganglion excision and nerve decompression even in cases of chronic muscle atrophy.

Fine tuning lipoaspirate viability for fat grafting.

BACKGROUND: The efficient harvest of abundant viable adipocytes for grafting is of considerable interest. Hand aspiration, low-g-force, short-duration centrifugation, and harvest of the lower sublayer of fat centrifugate maximize viable adiopocytes, but this process is cumbersome with conventional equipment. The Lipose Corporation (Greenwich, Conn.) has produced special syringes, filters, and a low-g-force centrifuge (Viafill system) to facilitate this process. The adipocyte viability using this system is presented. METHODS: Six women underwent fat graft harvest using the Viafill system from the lower hips (n = 6) and/or upper hips (n = 3). After centrifugation for 2 minutes at 50 g, the lower, middle, and top sublayers of the adipose layer were analyzed for viable adipocyte counts using trypan blue vital staining. Additional samples from standard power-assisted liposuction were obtained and analyzed similarly. RESULTS: The mean difference in square-root transformation of cell counts between the bottom sublayer of centrifuged fat and the middle sublayer was 0.95 (95 percent CI, 0.61 to 1.3), and the difference between the middle and top sublayers was 0.67 (CI, 0.50 to 0.84). Thus, the bottom sublayer had approximately 2.5 to 3 times more cells than the top sublayer. The difference between the hand aspirate samples and the power-assisted liposuction samples was significant (1.62; CI, 1.35 to 1.90). CONCLUSIONS: This study reconfirms the authors' early findings that atraumatic harvest of lipoaspirate yields high cell counts and that adipocyte density is greatest at the lowest sublayer of centrifuged fat. The Viafill system provides a more efficient and user-friendly system for fat grafting while maintaining cell counts similar to the authors' technique using conventional equipment.

Nerve compressions in the upper extremity.

Nerve compressions in the extremities are very common. This article will present relevant pathophysiology of peripheral nerve compression, discuss appropriate patient evaluation techniques, and present current standard methods of treatment for the more common nerve compressions of the upper extremity.

Nerve transfers for brachial plexus reconstruction.

Brachial plexus injuries result in devastating loss of function for patients and present incredible challenges for peripheral nerve surgeons. Recently, nerve transfers have produced superior results compared with traditional interposition nerve grafts for brachial plexus reconstruction. The authors present a review of current surgical options for treatment of partial and complete adult brachial plexus injuries using nerve transfers.

Nerve transfers in the hand and upper extremity surgery.

Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery. Lessons of tendon transfers have taught that nerves to specific musculotendinous units are expendable, and greater understanding of peripheral nerve topography has revealed redundant fascicles in peripheral nerves. Transfer of these redundant or expendable nerves to recipient nerves close to the end organ allows for earlier reinnervation and preservation of those musculotendinous units. Such nerve transfers provide significantly better treatment options in many cases of nerve injury where previous outcomes were expected to be poor, such as with proximal injuries, long nerve gaps, or unavailability of the proximal injured segment. This article will review current nerve transfers in the hand and upper extremity.

Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy.

Restoration of shoulder function is one of the most critical goals of treatment of brachial plexus injuries. Primary repair or nerve grafting of avulsion injuries of the upper brachial plexus in adults often leads to poor recovery. Nerve transfers have provided an alternative treatment with great potential for improved return of function. Many different nerves have been utilized as donor nerves for transfer to the suprascapular nerve and axillary nerve for return of shoulder function with variable results. As our knowledge of shoulder neuromuscular anatomy and physiology improves and our experience with nerve transfers increases, so evolve the specific transfer procedures. This article presents a technique and rationale for reconstructing shoulder function by transferring the distal spinal accessory nerve to the suprascapular nerve and the nerve branch to the medial head of the triceps to the axillary nerve, both through a posterior approach.

IGF-1 produced by cone photoreceptors regulates rod progenitor proliferation in the teleost retina.

Teleost eyes grow throughout life by adding neurons and stretching extant tissue. New retinal neurons of all types are added at the ciliary margin and new rod photoreceptors are inserted throughout retina in the outer nuclear layer (ONL). New rod photoreceptors result from the division of progenitor cells located in the ONL amidst functioning rod photoreceptor cell nuclei, but it is not known how new rod addition is regulated. Previous experiments using an organotypic retinal slice preparation revealed that insulin-like growth factor 1 (IGF-1) up-regulates the division of the rod progenitor cells [Dev. Brain Res. 76 (1993) 183], but the site of IGF-1 action was unknown. Here, we show where in the retina IGF-1 is made, where IGF receptors are located, and we identify the role of IGF-1 in adult retinal rod neurogenesis with both gain-and loss-of-function experiments. We found that IGF-1 is expressed by cone photoreceptor cells and its abundance varies with a daily rhythm, being significantly higher at night. In vivo application of exogenous IGF-1 increases rod progenitor cell division, an effect that is greater at night than during the day. We also show that inhibiting the function of IGF receptors decreases proliferation of rod progenitor cells. Finally, we show that IGF receptors are located on rod progenitor cells as well as on cone and rod photoreceptors. Taken together, these data suggest that the rhythmic production and release of IGF-1 plays a role in regulating the insertion of new rod photoreceptors into the retina. The diurnal change in IGF-1 abundance and effects of exogenous IGF-1 are consistent with the previous demonstration that rod progenitor cell division is threefold greater at night than in the day [Brain Res. 673 (1995) 119; Brain Res. 712 (1996) 40]. We also show that the insertion of new rod photoreceptors at the central edge of the ciliary neurogenic zone very likely also depends on IGF-1 production by cone photoreceptors. We propose that addition of new rod photoreceptors into the functioning retina is regulated through a feedback mechanism mediated at least in part via the IGF-1 produced in the cone photoreceptors.