Expansion of Renuvion Application to Areas Beyond the Submental Region: Review and Experience.

Background: Minimally invasive and consistent skin redraping following liposuction remains an elusive goal. With the application of Renuvion (Apyx Medical, Clearwater, FL), helium induced cold atmospheric plasma provides coagulation, collagen contraction, and subsequent skin tightening, making this elusive goal attainable. Objectives: The objective of this study is to evaluate energy settings, and the safety profile of Renuvion in an effort to achieve optimal cosmesis through the improvement of skin laxity. Methods: A retrospective review at a single site evaluated cases of Renuvion between March 2020 and May 2022. Energy settings, use of concomitant VASER (Solta Medical, Bothwell, WA) liposuction frequency, and adverse events were analyzed. Results: In total, 180 patients were evaluated, of whom 135 (75%) underwent concomitant VASER liposuction. Renuvion was used on the abdomen (47.8%), thighs (45.6%), arms (27.2%), submental region (25%), hip rolls (21.2%), and back (19.4%). Among the entire cohort, there were a total of 24 (13.3%) complications. The complications consisted of 3 (12.5%) hematomas, 1 (4.2%) burn, 6 (25%) persistent skin laxity with 2 returned operating room (OR) treatments, 4 (16.7%) seromas, 9 (37.5%) postoperative lymphedema that self-resolved, and 1 (4.2%) self-limited neuralgia. There were no complications that required an immediate return to the OR. Conclusions: Renuvion utilization with or without VASER has a relatively high complication rate-with minor complications as the most common-relatively safe barring proper patient selection, which can be mitigated with proper patient selection.

Practical Review on the Contemporary Diagnosis and Management of Compartment Syndrome.

Acute compartment syndrome (ACS) is a limb-threatening pathology that necessitates early detection and management. The diagnosis of ACS is often made by physical examination alone; however, supplemental methods such as compartment pressure measurement, infrared spectroscopy, and ultrasound can provide additional information that support decision-making. This practical review aims to incorporate and summarize recent studies to provide evidence-based approaches to compartment syndrome for both resource-rich and -poor settings among several patient populations.

Fibular Allograft Osteoplasty and Silicone Arthroplasty following Gunshot Injury of the Metacarpal.

The complexity of a gunshot wound to the hand with segmental bone loss and adjacent joint disruption presents a unique challenge for the reconstructive surgeon. There are several options for posttraumatic reconstruction of hand joint defects, ranging from arthrodesis, implants, and autologous arthroplasty. Despite the abundance of literature regarding guidelines for isolated osteoplasty and arthroplasty, there are only case reports describing management of bone and joint defects, all within the setting of cancer resection. This case report presents a 24-year-old, right-hand dominant man with a gunshot wound to his left hand involving the fifth metacarpal and metacarpal phalangeal joint. The metacarpal was reconstructed with a fibular bone allograft with simultaneous placement of a silicone arthroplasty implant, allowing preservation of motion at the metacarpal phalangeal joint with satisfactory functional outcomes. This illustrates the feasibility of successfully reconstructing segmental bone loss and adjacent joint defects simultaneously in the traumatic setting of firearm injuries.

Influence of Closed-incision Negative Pressure Wound Therapy on Abdominal Site Complications in Autologous Breast Reconstruction.

Background: Closed-incision negative pressure wound therapy (ciNPWT) has shown promise in reducing surgical wound complications. Among its numerous benefits, it allows for exudate management and tension offloading from wound edges. The purpose of this systematic review and meta-analysis was to assess the efficacy of prophylactic ciNPWT versus conventional dressings on abdominal donor site complications in microsurgical breast reconstruction (MR). Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in January 2023. PubMed and Embase were searched to identify all relevant studies. Data collected included rates of total wound complications, wound dehiscence, infection, seroma, and length of hospital stay. Results: A total of 202 articles were screened, and eight studies (1009 patients) met the inclusion criteria. Use of ciNPWT was associated with a significantly lower rate of wound dehiscence (OR, 0.53; 95% confidence interval, 0.33-0.85; P = 0.0085, I2 = 0%). There was no significant difference in the rate of total wound complications [odds ratio (OR), 0.63; 95% CI, 0.35-1.14; P = 0.12, I2 = 69%], donor site infection (OR, 0.91; 95% CI, 0.42-1.50; P = 0.47, I2 = 13%), seroma (OR, 0.74; 95% CI, 0.22-2.49; P = 0.63, I2 = 57%), or length of hospital stay (SMD, 0.089; 95% CI, -0.13-0.35; P = 0.37, I2 = 29%). Conclusions: Although exudate management by ciNPWT fails to reduce surgical site infection, seroma formation, and overall length of stay, ciNPWT tension offloading properties seem to be associated with lower rates of wound dehiscence when compared with conventional dressings in abdominal-based autologous breast reconstruction.

The Impact of Postoperative Antibiotic and Duration After Implant-Based Breast Reconstruction on Resistance Among Cultured Species.

BACKGROUND: There is a growing presence of literature within plastic surgery that establishes best practice for postoperative antibiotics after implant-based breast reconstruction (IBBR), although it has not been widely adopted or translated into clinical practice. This study aims to determine how antibiotic and duration affects patient outcomes. We hypothesize that IBBR patients who receive a longer duration of postoperative antibiotics will demonstrate higher rates of antibiotic resistance as compared with the institutional antibiogram. METHODS: A retrospective chart review included patients who underwent IBBR between 2015 and 2020 at a single institution. Variables of interest included patient demographics, comorbidities, surgical techniques, infectious complications, and antibiograms. Groups were classified by antibiotic (cephalexin, clindamycin, or trimethoprim/sulfamethoxazole) and duration (≤7 days, 8-14 days, and >14 days). RESULTS: There were a total of 70 patients who experienced infections included in this study. Onset of infection did not differ based on antibiotic during either device implantation (postexpander P = 0.391; postimplant P = 0.234). Antibiotic and duration did not have an established relationship with explantation rate either (P = 0.154). In patients who had Staphylococcus aureus isolated, there was significantly increased resistance to clindamycin when compared with the institutional antibiogram (sensitivities of 43% and 68%, respectively). CONCLUSIONS: Neither antibiotic nor duration displayed a difference in overall patient outcomes, including explantation rates. In this cohort, S. aureus strains isolated in association with IBBR infections demonstrated a higher level of resistance to clindamycin compared with strains isolated and tested within the broader institution.

The effects of prolonged intraoperative hypothermia on patient outcomes in immediate implant-based breast reconstruction.

BACKGROUND: The importance of thermoregulation in surgical procedures has become a recent focus for anesthesiologists and surgeons to improve patient outcomes. In breast surgery, maintenance of normothermia has been shown to reduce surgical-site infections. However, there is a paucity of information evaluating the relationship between intraoperative core body temperatures and reconstructive surgical outcomes. METHODS: A retrospective review of patients who underwent immediate breast reconstruction following mastectomy from 2015 to 2020 was performed. Patients were classified into a majority normothermic (NT) group if patients spent greater than half of the operative time ≥36 °C or a majority hypothermic (HT) group if patients spent greater than or equal to half of the operative time <36 °C. Patient demographics, comorbidities, surgical techniques, and postoperative complications were recorded. Complications were classified according to the Clavien-Dindo Classification. Univariate and multivariate statistics were used to assess significant relationships. RESULTS: A total of 329 patients met inclusion criteria, of which 174 were in the NT group and 155 were in the HT group, yielding 302 and 264 total breasts, respectively. There was no significant difference in rates of infection (p = 1.0), seroma (p = 0.27), hematoma (p = 0.61), or wound dehiscence (p = 1.0). However, patients in the HT group had significantly more overall ischemic complications (p = 0.009) and, specifically, grade IIIb ischemic complications (p = 0.04). After controlling for tobacco use, body mass index, mastectomy pattern, radiation, operating surgeon, and mastectomy weight, multivariate analysis showed increased ischemic complications in the HT group (p = 0.04). CONCLUSION: Prolonged intraoperative hypothermia can increase the risk for the development of ischemic wounds such as tissue necrosis or eschar formation that require operative intervention. This presents reconstructive complications that increase both patient and health system burdens that could be addressed through the maintenance of normothermia. Further studies using real-time flap temperature would provide more accurate insight into the relationship between temperature and implant-based breast reconstruction.

Quantity of Acellular Dermal Matrix in Immediate Breast Reconstruction and Outcomes.

PURPOSE: This study aimed to determine the impact of the quantity of acellular dermal matrix (ADM), "ADM burden," used in implant-based breast reconstruction on infection, drain duration, and seroma formation. METHODS: A single-institution, retrospective review from 2015 to 2020 was conducted for patients who underwent immediate, implant-based breast reconstruction after mastectomy. Three cohorts were generated based on the amount of ADM used: (1) total ADM, (2) sling ADM, and (3) no ADM. RESULTS: In total, there were 374 patients who satisfied the inclusion criteria yielding 641 breasts with 143, 432, and 66 breasts in the total ADM, sling ADM, and no-ADM groups, respectively. The no-ADM group had higher mastectomy weights (788.4 g) than the sling (654.2 g) and total ADM (503.4 g) groups (F = 10.8, P < 0.001). Total ADM had higher rates of explantation secondary to infection compared with no ADM (P < 0.001). Linear regression analysis for drain duration was significant for body mass index (P < 0.0001) but not for ADM quantity (P = 0.52). Logistic regression analysis demonstrated a higher risk of infection in the total ADM group (odds ratio [OR], 5.4; P < 0.0001). Diabetes mellitus was a risk factor for both infection (OR, 3.6; P = 0.05) and seroma formation (OR, 0.04; P = 0.04). CONCLUSIONS: Higher ADM burden is associated with an increased risk of infections and device explantation secondary to those infections. Although ADM has created new avenues in breast reconstruction, these findings indicate a need to evolve the technique to minimize the ADM burden. By doing so, patients can minimize their risk of postoperative complications while reducing the financial impact on institutions.

Recurrent Skin and Soft Tissue Infection following Breast Reduction Surgery Caused by Gordonia bronchialis: A Case Report.

The expanding knowledge of the breast microbiome and its constituents necessitates understanding of how it plays into human disease. Consideration of how to identify novel organisms in breast tissue is a topic of hot debate. We report a case of a 26-year-old woman with repeat incisional break-down and sanguinopurulent drainage who required repeat incision and drainage procedures after bilateral breast reduction. Cultures revealed no growth until 4 months postoperation when matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) revealed Gordonia bronchialis, a fastidious, slow-growing organism. To date, there are fewer than 30 reported cases of G. bronchialis infections and only one with breast involvement. Our patient required 6 weeks of amoxicillin-clavulanate therapy and frequent follow-up for symptom resolution. This case demonstrates the need for additional microbiologic data in patients with delayed, persistent infections after breast surgery.

A1 Pulley Tenderness as a Modification to Tenderness along the Flexor Sheath in Diagnosing Pyogenic Flexor Tenosynovitis.

Background: Pyogenic flexor tenosynovitis (PFT) is frequently diagnosed by physical examination according to the Kanavel signs. This study proposes a modification of the Kanavel sign "tenderness over the course of the flexor sheath" by including palpation of the A1 pulley to increase specificity for diagnosis. Methods: A retrospective review was performed over 8 months for patients in the emergency department who received a consult to hand surgery to rule out PFT. Two cohorts, nonPFT infections and PFT infections, were studied for the presence or absence of the four Kanavel signs, as well as tenderness specifically over the A1 pulley on the affected digit(s) or T1 pulley of the thumb. Results: There were a total of 33 patients in the two cohorts (21 nonPFT, 12 PFT) with statistically significant differences with regard to the presence of all the Kanavel signs. A1 pulley tenderness had the greatest odds ratio, positive predictive value, specificity, and accuracy when compared with all Kanavel signs. When used in conjunction with each Kanavel sign, there was an increase in specificity in all four signs. Receiver operating characteristic analysis revealed increased area under the curve with A1 pulley tenderness added, indicating improved ability to classify hand infections as PFT versus nonPFT. Conclusion: Although the classic Kanavel signs have shown reliable clinical utility, this study finds that tenderness at the A1 pulley can be a useful specification of "tenderness over the course of the flexor sheath" to help with the diagnosis of PFT.

Trampoline Park Injuries and Their Burden on Local Orthopaedic and Emergency Services.

OBJECTIVE: To investigate the incidence of trampoline park injuries (TPIs) at a local recreational facility and to quantify the burden on emergency and orthopaedic services at our institute. METHODS: All patients that presented to the Emergency Department (ED) from the trampoline park via ambulance from July 2014 to November 2015 were included in the study. Patients' medical records were reviewed for clinical details including date, location and type of injury, treatment received, length of stay and outpatient follow-up. A cost analysis was performed to estimate the financial impact of each injury. RESULTS: A total of 71 patients were included in the study, with a mean age of 20 (7-48). Soft tissue sprains (n=29, 41%) and fractures (n=25, 35%) were the most common injuries, with the majority occurring in the lower limb. Two patients sustained open tibial fractures necessitating transfer to level 1 trauma centres. Fourteen patients (20%) underwent surgery, predominantly requiring open reduction and internal fixation. Overall, 18 patients (25%) required admission to hospital with mean length of stay of 2 days. The cost for pre-hospital, emergency and in-patient care amounted to over £80,000. CONCLUSION: TPIs pose a significant financial cost for local orthopaedic and emergency services. Contrary to studies evaluating home trampoline injuries, the majority of fractures at trampoline parks occurred in the lower limbs. Improved injury prevention strategies are required to help reduce morbidity and lower the financial implications for local NHS trusts.

The acute transcriptome response of the midbrain/diencephalon to injury in the adult mummichog (Fundulus heteroclitus).

Adult fish produce new cells throughout their central nervous system during the course of their lives and maintain a tremendous capacity to repair damaged neural tissue. Much of the focus on understanding brain repair and regeneration in adult fish has been directed at regions of the brainstem and forebrain; however, the mesencephalon (midbrain) and diencephalon have received little attention. We sought to examine differential gene expression in the midbrain/diencephalon in response to injury in the adult fish using RNA-seq. Using the mummichog (Fundulus heteroclitus), we administered a mechanical lesion to the midbrain/diencephalon and examined differentially expressed genes (DEGs) at an acute recovery time of 1 h post-injury. Comparisons of whole transcriptomes derived from isolated RNA of intact and injured midbrain/diencephalic tissue identified 404 DEGs with the vast majority being upregulated. Using qPCR, we validated the upregulation of DEGs pim-2-like, syndecan-4-like, and cd83. Based on genes both familiar and novel regarding the adult brain response to injury, these data provide an extensive molecular profile giving insight into a range of cellular processes involved in the injury response of a brain regenerative-capable vertebrate.