Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair.

BACKGROUND: Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty. OBJECTIVES: To present an effective and safe technique that can address large umbilical herniae during abdominoplasty. METHODS: A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee. RESULTS: At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes). CONCLUSIONS: We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment.

Phenotypic and functional consequences of different isolation protocols on skin mononuclear phagocytes.

Mononuclear phagocytes are present in skin and mucosa and represent one of the first lines of defense against invading pathogens, which they detect via an array of pathogen-binding receptors expressed on their surface. However, their extraction from tissue is difficult, and the isolation technique used has functional consequences on the cells obtained. Here, we compare mononuclear phagocytes isolated from human skin using either enzymatic digestion or spontaneous migration. Cells isolated via enzymatic digestion are in an immature state, and all subsets are easily defined. However, cells isolated by spontaneous migration are in a mature state, and CD141 cross-presenting DCs (cDC1) are more difficult to define. Different pathogen-binding receptors are susceptible to cleavage by blends of collagenase, demonstrating that great care must be taken in choosing the correct enzyme blend to digest tissue if carrying out pathogen-interaction assays. Finally, we have optimized mononuclear phagocyte culture conditions to enhance their survival after liberation from the tissue.

Discriminative Thresholds in Facial Asymmetry: A Review of the Literature.

Background: Facial symmetry is intimately correlated with attractiveness. Perfect facial symmetry is disconcerting and a degree of facial asymmetry is considered normal. There is a lack of data on the limits of normality across facial subunits. Objectives: This systematic review aims to establish categories of facial asymmetry perception for facial aesthetic units by establishing a discriminative threshold of "deformity perception" across facial subunits and a threshold for intervention (unacceptable asymmetry). Methods: A review of the literature was performed across Medline and Embase databases using OvidSP. All prospective studies evaluating the perception of progressive facial asymmetry in laymen or clinicians using a two- or three-dimensional model were included. Studies that did not evaluate rates of perception at varying degrees of asymmetry were excluded as these did not allow for the identification of a perceptive threshold. Results: Each facial feature possesses a unique threshold of perception defined by an abrupt, statistically significant increase in detection. Asymmetry of the eyelid position at rest is the most sensitive facial feature (perceptive threshold, 2 mm) (P < 0.02). This is followed by deviations of the oral commissure (3 mm) (P < 0.001), brow position (3.5 mm) (P < 0.001), nasal tip deviation (4 mm) (P < 0.001), and chin deviation (6 mm) (P < 0.001). Desire for surgery for worsening deformities beyond the intervention threshold is characterized by an exponential, rather than linear, correlation. Conclusions: Categories of facial asymmetry perception establish a framework to counsel patients with facial asymmetries, and are a valuable adjunct to clinical judgment in the management of static and dynamic facial deformities.

Oztag: high risk for hand injuries?

BACKGROUND: Oztag is an Australian tag rugby code in which opponents are 'tackled' by removing Velcro tabs from their shorts. It is assumed to be safer than other higher-contact rugby codes. METHODS: Oztag-related hand injuries were identified by a word search of the electronic emergency department records of Concord Repatriation General Hospital from January 2011 to October 2013. Clinical records were retrospectively reviewed. RESULTS: Twenty-eight presentations were identified. Mean age of patients was 24 years (range 13-38). Injuries included fractures, dislocations and ligamentous injuries, in isolation or combination. The most common injuries were middle phalangeal fractures (six), all of which required operative fixation. No tendon avulsions were identified. The most common mechanism of injury was attempted tackle, which was much more likely to require operative management than any other mechanism (70% versus 14%, P = 0.010). CONCLUSIONS: While the prevalence of Oztag-related hand injuries may be low, the occurrence of potentially debilitating injuries in a young, working population raises concern. The 'tag' tackle, which involves players running at speed with outstretched fingers, is particularly high risk. Prospective audit of injuries is required and players and organizers should be made aware of the dangers of this 'low-contact' sport.

In vivo analysis of dermal and systemic absorption of silver nanoparticles through healthy human skin.

BACKGROUND: Research into nanoparticles has increased markedly during the last decade, especially in light of their potential diagnostic and therapeutic use. While silver has been used since ancient times, a detailed understanding of the kinetics of its dermal absorption requires further study. Thus far, only in vitro and animal models have been used to analyse the absorption characteristics of nanocrystalline silver particles and no in vivo study using intact human skin has demonstrated silver absorption. METHOD: A nanocrystalline silver dressing was applied to a sample of 16 healthy patients with normal intact skin approximately 5 days prior to surgery. The treated skin samples, removed as surgical waste, were then analysed with a tissue mass spectrometry, light microscopy, scanning electron microscopy (SEM) and an X-ray diffusion spectrography (XRD). Silver serum levels were also analysed before and after application of the dressing. RESULTS: A limited amount of silver penetration could be noted even with light microscopy. However, definitive analysis required SEM and XRD confirmation. With SEM, metallic particles could be seen within the dermis. XRD confirmed that these were silver species, possible in oxide form. Furthermore, silver clusters as large as 750 nm could be discerned. In addition, there was no demonstrable rise in serum silver levels post-treatment with the silver dressing. CONCLUSION: Our results suggest that silver nanoparticles are able to penetrate intact human skin in vivo beyond the stratum corneum and can be found as deep as the reticular dermis. The absorbed silver might be in silver oxide form and the silver species appear to form sizeable clusters once absorbed across the epidermis. However, despite silver deposition into the dermis, the silver nanoparticles did not reach systemic circulation and should thus have no end organ consequences.