Overcoming functional challenges in autologous and engineered fat grafting trends.

Autologous fat grafting offers significant promise for the repair of soft tissue deformities; however, high resorption rates indicate that engineered solutions are required to improve adipose tissue (AT) survival. Advances in material development and biofabrication have laid the foundation for the generation of functional AT constructs; however, a balance needs to be struck between clinically feasible delivery and improved structural integrity of the grafts. A new approach combining the objectives from both the clinical and research communities will assist in developing morphologically and genetically mature AT constructs, with controlled spatial arrangement and increased potential for neovascularization. In a rapidly progressing field, this review addresses research in both the preclinical and bioengineering domains and assesses their ability to resolve functional challenges.

Who operated on me? What patients understand about surgical trainees.

AIMS: To evaluate whether information delivered to patients about the level of training of the person operating on them is understandable and meaningful. To establish whether post-operative patients can identify when a doctor, undergoing training in surgery, has performed their surgery. To identify terms that are clear to patients, which can be used to improve understanding. METHOD: A 15-question survey was developed to evaluate the expectations, understanding and knowledge post-operative patients had about their recent surgery. Patients were questioned about the level of training of their surgeon, the current designations used and their knowledge about surgical training. RESULTS: Over a one-month period, 161 patients were requested to fill in surveys. Sixty-one percent of patients agreed that it is very important to know the level of training of their surgeon, but only 39% of patients could correctly identify this. Of the 62 patients who thought that a consultant had performed their procedure, 40% were correct. The terms we use to denote level of training are confusing to the majority of patients. CONCLUSION: The majority of patients are unable to recognise the level of training of the person who operated on them. There is a common public misconception that the consultant surgeon will be the operator in the majority procedures, however in teaching hospitals, a significant number of procedures are performed by doctors working under the supervision of the consultant surgeon. Many patients are not being adequately educated prior to surgery about the level of training of the person doing their procedure.

A Comparative Outcome Study of Hamstring Versus Tibialis Anterior and Synthetic Grafts for Deltoid to Triceps Transfers.

PURPOSE: To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts. METHODS: A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014. RESULTS: Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms. CONCLUSIONS: Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Tendon Transfer Surgery for People With Tetraplegia: An Overview.

After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.

A regional programme to improve skin cancer management.

BACKGROUND AND CONTEXT: In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives. ASSESSMENT OF PROBLEM: There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care. RESULTS: The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians. STRATEGIES FOR IMPROVEMENT: The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors. LESSONS: Skin cancer management can be improved by a coordinated approach between primary and secondary care.

Skin closure after laparotomy with staples or sutures: a study of the mature scar.

BACKGROUND: Surgeons are divided in their method of choice for skin closure following laparotomy. We suggest that the most important determinant should be the resulting scar. This study aims to compare both patients' and independent observers' assessment of mature laparotomy scars that had been closed with either subcuticular sutures or external staples. METHODS: Consecutive patients were enrolled at least 1 year following colorectal surgery. Scars were assessed with the validated Patient and Observer Scar Assessment Scoring (POSAS) tool. Photographs were assessed by a blinded independent panel. RESULTS: Overall, 232 patients were enrolled (90 suture, 143 staples). The two groups were well matched by factors affecting wound healing. Patients' overall opinion of their scar was significantly better for the Suture group than the Staples group (P = 0.028) despite there being no difference in their self-assessment of the components of their scar score (pain, itch, colour, stiffness, thickness, irregularity). The panel recorded similar overall scores for the Suture and Staples groups (P = 0.059). There was a significant lower (better) score recorded for the scar area component for the Suture group than the Staples group (P = 0.008) but no differences for the other components (vascularity, pigmentation or thickness). DISCUSSION: This study has shown that independent of skin closure method, patients who have undergone major abdominal surgery have a positive opinion of their mature scars. The patients' overall impression of the wound favours a sutured closure due to a smaller scar area (no staple marks). In all other respects, skin closure with staples would appear acceptable.

A randomized steady-state bioavailability study of synthetic versus natural (kiwifruit-derived) vitamin C.

Whether vitamin C from wholefoods has equivalent bioavailability to a purified supplement remains unclear. We have previously showed that kiwifruit provided significantly higher serum and tissue ascorbate levels than synthetic vitamin C in a genetically vitamin C-deficient mouse model, suggesting a synergistic activity of the whole fruit. To determine if these results are translatable to humans, we carried out a randomized human study comparing the bioavailability of vitamin C from kiwifruit with that of a vitamin C tablet of equivalent dosage. Thirty-six young non-smoking adult males were randomized to receive either half a gold kiwifruit (Actinidia Chinensis var. Hort 16A) per day or a comparable vitamin C dose (50 mg) in a chewable tablet for six weeks. Ascorbate was monitored weekly in fasting venous blood and in urine, semen, leukocytes, and skeletal muscle (vastus lateralis) pre- and post-intervention. Dietary intake of vitamin C was monitored using seven day food and beverage records. Participant ascorbate levels increased in plasma (P < 0.001), urine (P < 0.05), mononuclear cells (P < 0.01), neutrophils (P < 0.01) and muscle tissue (P < 0.001) post intervention. There were no significant differences in vitamin C bioavailability between the two intervention groups in any of the fluid, cell or tissue samples tested. Overall, our study showed comparable bioavailability of synthetic and kiwifruit-derived vitamin C.

Do functional keratin dressings accelerate epithelialization in human partial thickness wounds? A randomized controlled trial on skin graft donor sites.

OBJECTIVE: To determine if the experimental (keratin-based) dressing accelerates epithelialization rates during healing of partial-thickness wounds, relative to a Standard Care dressing. METHOD: A randomized control trial was conducted using a Standard Care dressing side by side with the experimental dressing on a sample (n=26) of partial-thickness donor site wounds. The proximal/distal placement of the control and treatment was randomized. Percentage epithelialization after approximately 7 days was estimated from which time to fully epithelialize can be inferred. Patients were grouped into "young" (≤50 y/o) and "old" (>50 y/o). RESULTS: For the "old" patients (n=15), the median epithelialization percentage at 7 days is 5% and was significantly (P=.023) greater for the experimental dressing. For the "young" patients (n=11), the median epithelialization percentage at 7 days was 80% and there is no significant difference between the experimental and Standard Care control dressings. CONCLUSIONS: The experimental dressing significantly increases the rate of epithelialization of acute, traumatic partial-thickness wounds in older patients. We suggest that the dressing may be clinically useful in similar situations where epithelialization may be delayed because of patient or wound characteristics.

Reduction mammaplasty and resource allocation--are patients being treated fairly? An examination of the current New Zealand situation, and looking towards the future.

AIM: To review the access to publically-funded reduction mammaplasty for New Zealand (NZ) women. Additionally, to evaluate quality of life gains from reduction mammaplasty and other surgical treatments of chronic conditions. Ultimately to determine whether access to surgical treatment for this condition is equitable. METHOD: Four tertiary referral centres for Plastic Surgery in NZ completed a survey to characterise patient access. A literature search was done to investigate the global situation and obtain quality of life information following breast reduction and other operations for chronic conditions. RESULTS: The survey showed there was significant inequity in allocation and access to breast reduction surgery in NZ over time and geographical location. There were hopes that the Ministry of Health Prioritisation Tool would ensure more equitable access to plastic surgical procedures nationally in the future. A similar situation exists in Europe in regards to allocation, and insurance companies dictate access in the US. There was overwhelming evidence to support quality of life gains with reduction mammaplasty, which are equal to if not greater than more accessible operations. CONCLUSION: In NZ there is inequitable access to surgery for patients who would be treated by breast reduction surgery, with substantial variation across geography and time. A new Prioritisation Tool may address this discrepancy. Much evidence exists that quality of life gains for reduction mammaplasty are equivalent to other surgical procedures, which are more readily available. The challenge is to improve equity of access across all surgical conditions.

Human skeletal muscle ascorbate is highly responsive to changes in vitamin C intake and plasma concentrations.

BACKGROUND: Vitamin C (ascorbate) is likely to be essential for skeletal muscle structure and function via its role as an enzyme cofactor for collagen and carnitine biosynthesis. Vitamin C may also protect these metabolically active cells from oxidative stress. OBJECTIVE: We investigated the bioavailability of vitamin C to human skeletal muscle in relation to dietary intake and plasma concentrations and compared this relation with ascorbate uptake by leukocytes. DESIGN: Thirty-six nonsmoking men were randomly assigned to receive 6 wk of 0.5 or 2 kiwifruit/d, an outstanding dietary source of vitamin C. Fasting blood samples were drawn weekly, and 24-h urine and leukocyte samples were collected before intervention, after intervention, and after washout. Needle biopsies of skeletal muscle (vastus lateralis) were carried out before and after intervention. RESULTS: Baseline vastus lateralis ascorbate concentrations were ~16 nmol/g tissue. After intervention with 0.5 or 2 kiwifruit/d, these concentrations increased ~3.5-fold to 53 and 61 nmol/g, respectively. There was no significant difference between the responses of the 2 groups. Mononuclear cell and neutrophil ascorbate concentrations increased only ~1.5- and ~2-fold, respectively. Muscle ascorbate concentrations were highly correlated (P < 0.001) with dietary intake (R = 0.61) and plasma concentrations (R = 0.75) in the range from 5 to 80 µmol/L. CONCLUSIONS: Human skeletal muscle is highly responsive to vitamin C intake and plasma concentrations and exhibits a greater relative uptake of ascorbate than leukocytes. Thus, muscle appears to comprise a relatively labile pool of ascorbate and is likely to be prone to ascorbate depletion with inadequate dietary intake. This trial was registered at the Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) as ACTRN12611000162910.

Renal transplant recipients have elevated frequencies of circulating myeloid-derived suppressor cells.

BACKGROUND: Cancer, particularly cutaneous squamous cell carcinoma (SCC), is a major cause of mortality in renal transplant recipients (RTRs). Myeloid-derived suppressor cells (MDSC) play a central role in suppressing cancer immunosurveillance but their potential mobilisation in RTRs and levels relative to those of other immunoregulatory dendritic cell (DC) populations have not been analysed. METHODS: The circulating frequencies of MDSC and DC were analysed by multicolour flow cytometry in immunocompetent patients without (n = 13) or with (ICI-SCC(Pos), n = 14) current SCC, normal donors (NDs, n = 34), chronic kidney disease patients (CKD patients, n = 22) and RTRs (n = 31). RESULTS: Compared to NDs, RTRs had significantly elevated levels of both CD14(Neg) and CD14(Pos) MDSC subsets (P < 0.001), while CKD patients and ICI-SCC(Pos) had significantly elevated levels of only the CD14(Neg)-MDSC subset. DC frequencies were significantly decreased in RTRs and CKD patients but were at normal levels in ICI-SCC(Pos). The MDSC/DC ratio was significantly elevated (P < 0.05) in RTRs (median = 5.7), CKD patients (median = 3.2) and ICI-SCC(Pos) (median = 3.5) relative to NDs (median = 0.7). The use of immunosuppressive drugs in CKD patients and past/current occurrence of SCC in RTRs was associated with significantly increased CD14(Neg)-MDSC frequencies. MDSC enriched from RTRs, when co-cultured with activated NDs T cells significantly suppressed extracellular IL-10 levels and can, when activated with formyl-methionyl-leucyl-phenylalanine, inhibit T-cell proliferation. CONCLUSIONS: RTRs, CKD patients and ICI-SCC(Pos) have increased MDSC frequencies and MDSC/DC ratios. These changes may impact on cancer immunosurveillance. Therefore, MDSC represent both a potential therapeutic target and prognostic marker in these patients, with respect to the development of SCC and other malignancies.

First and subsequent nonmelanoma skin cancers: incidence and predictors in a population of New Zealand renal transplant recipients.

BACKGROUND: Renal transplant recipients (RTRs) have an increased risk of developing nonmelanoma skin cancers (NMSCs). The aims of this study were to determine the incidence and subsequent history of NMSCs in RTRs, together with risk factors. METHODS: All patients transplanted between July 1972 and March 2007, and followed up at Christchurch Hospital, New Zealand, were studied. Immunosuppression regimens were mostly prednisone, azathioprine, cyclosporine and prednisone, mycophenolate mofetil, cyclosporine since 1998. RESULTS: Of 384 RTRs, 96 developed at least one NMSC. The median time to first NMSC was 18.3 years (95% CI 14.2, 22.9) from transplant, as estimated by survival analysis. Individual predictors of first NMSC in RTRs were older age at first transplant (P < 0.0001), male sex (P = 0.006) and initial immunosuppression regimen (P = 0.001); only age (P < 0.0001) and male gender (P = 0.003) were significant predictors in a joint model. The mean rate of subsequent NMSCs was 1.67 per year (95% CI = 1.32, 2.11). Older age at first renal transplant (P = 0.009) or at discovery of the first NMSC (P = 0.01) was associated with a higher annual rate of new NMSC following the discovery of the first NMSC. The median survival time to a second NMSC was 2.2 years (CI 1.4, 3.0). Fourteen patients died of metastatic squamous cell carcinoma (15% case fatality). CONCLUSIONS: NMSCs are a major health issue for RTRs, especially in older males. Once RTRs have developed their first NMSC, ongoing surveillance and prompt treatment are essential.

Endothelial precursor cells home to a vascularized tissue engineering chamber by application of the angiogenic chemokine CXCL12.

Tissue engineering of vascularized constructs has great utility in reconstructive surgery. While we have been successful in generating vascularized granulation-like tissue and adipose tissue in an in vivo tissue engineering chamber, production of other differentiated tissues in a stable construct remains a challenge. One approach is to utilize potent differentiation factors, which can influence the base tissue. Endothelial precursor cells (EPCs) have the ability to both carry differentiation factors and home to developing vasculature. In this study, proof-of-principle experiments demonstrate that such cells can be recruited from the circulation into an in vivo tissue engineering chamber. CXC chemokine ligand 12 (CXCL12)/stromal cell-derived factor 1 was infused into the chamber through Alzet osmotic pumps and chamber cannulation between days 0 and 7, and facilitated recruitment of systemically inoculated exogenous human EPCs injected on day 6. CXCL12 infusion resulted in an eightfold increase in EPC recruitment, 2 (p = 0.03) and 7 days postinfusion (p = 0.008). Delivery of chemotactic/proliferation and/or differentiation factors and appropriately timed introduction of effective cells may allow us to better exploit the regenerative potential of the established chamber construct.

Necrotising fasciitis and cellulitis after traditional Samoan tattooing: case reports.

Traditional Samoan tattooing, ta tatau, is a vital part of Samoan culture. It is being performed with greater frequency on New Zealand resident Samoans. Unfortunately, ta tatau has recently been the causal factor in two significant infectious cases, in one of which death resulted. The two cases were clinically reviewed. An investigation into the history and practice of ta tatau was made in an attempt to identify causal factors that could be addressed. The two cases had similar causal themes. These included improper sanitary techniques, ta tatau being performed in unlicensed premises by temporary tattooists, patients that were unwilling to access medical services due to the expectations of tradition, lack of follow-up and lack of infection advice by the tattooist. Life threatening infectious complications has not previously been described for traditional Samoan tattooing. Improper sanitary conditions in combination with late presentation to medical services have been suggested as the cause of these cases. The technique, tools, culture and trends are discussed and recommendations are made for reducing infectious complications.

Postdischarge clean wound infections: incidence underestimated and risk factors overemphasized.

BACKGROUND: Wound infections are a leading cause of postoperative morbidity and a cost to both the individual and community. The surgeon now has a reduced appreciation of wound-infection rates because of shorter hospital stays and an increasing reliance on the primary care physicians. The incidence of wound infections which occurred following clean surgical procedures, as well as whether they could have been predicted by the known risk factors, were analysed in the present prospective study. METHODS: A prospective audit of the first 30 postoperative days following clean general surgical wounds was undergone, with inpatient assessment by a research nurse, and subsequent outpatient followup by patient telephone interview. RESULTS: Of 1964 clean wounds over a 30-month period, 98.5% were traced. The overall clean-wound infection rate was 12.6% (inpatient:4.5%; outpatient: 8.1%). Inpatient infection rates(but not postdischarge wound-infection rates) were significantly correlated (P < 0.05)to the American Society of Anesthesiologists' rating, operation duration, preoperative day stay, and age. Infection rates varied with operation type: vascular (18.3%), breast (16.0%),abdominal (10.3%), hernia (8.0%), head and neck (7.1%). CONCLUSIONS: The overall wound-infection rate is higher than previously described with two thirds of infections occurring after discharge. While inpatient wound-infection rates fit known risk factors, postdischarge wound-infection rates do not. Certain clean-wound operations have a higher incidence of infection than others. Consideration needs to be given to the identification of risk factors for postdischarge wound infections,and to further trials of prophylactic antibiotics in clean surgery.