Minimally Invasive Facial Cosmetic Procedures

Minimally invasive procedures including neurotoxins, dermal fillers, deoxycholic acid, lasers, peels, and microneedling offer powerful, less permanent adjuncts to surgery that are highly effective in select patients. Injectables and skin resurfacing techniques target facial irregularities including wrinkles and fine lines, decrease in volume and contour, and unwanted fat. Determining the best approach for a given patient involves careful consideration of the patient's health conditions, unique anatomic characteristics, tissue quality, and desired results. A detailed understanding of facial anatomy, aesthetics, and techniques is necessary to master these approaches. This article addresses the spectrum of nonsurgical cosmetic procedures to rejuvenate and optimize the face.

A novel technique of preserving internal mammary artery perforators in nipple sparing breast reconstruction

SUMMARY

As nipple-sparing mastectomy with implant-based reconstruction has increased, attention must be paid to the viability of the nipple-areolar complex. This article describes the use of preoperative Doppler ultrasound to identify the internal mammary artery perforators. Preserving the internal mammary artery improves vascular supply to the nipple-areolar complex.

Frailty as a predictor of surgical outcomes in older patients

BACKGROUND

Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure. Frailty is thought to estimate physiologic reserves, although its use has not been evaluated in surgical patients. We designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models.

STUDY DESIGN

We prospectively measured frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective surgery between July 2005 and July 2006. Frailty was classified using a validated scale (0 to 5) that included weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. Patients scoring 4 to 5 were classified as frail, 2 to 3 were intermediately frail, and 0 to 1 were nonfrail. Main outcomes measures were 30-day surgical complications, length of stay, and discharge disposition. Multiple logistic regression (complications and discharge) and negative binomial regression (length of stay) were done to analyze frailty and postoperative outcomes associations.

RESULTS

Preoperative frailty was associated with an increased risk for postoperative complications (intermediately frail: odds ratio [OR] 2.06; 95% CI 1.18-3.60; frail: OR 2.54; 95% CI 1.12-5.77), length of stay (intermediately frail: incidence rate ratio 1.49; 95% CI 1.24-1.80; frail: incidence rate ratio 1.69; 95% CI 1.28-2.23), and discharge to a skilled or assisted-living facility after previously living at home (intermediately frail: OR 3.16; 95% CI 1.0-9.99; frail: OR 20.48; 95% CI 5.54-75.68). Frailty improved predictive power (p < 0.01) of each risk index (ie, American Society of Anesthesiologists, Lee, and Eagle scores).

CONCLUSIONS

Frailty independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models. Assessing frailty using a standardized definition can help patients and physicians make more informed decisions.

How to measure the quality of surgery-related web sites

Appropriateness and adequacy of health information on the Internet varies. Given there is no validated instrument for web site evaluation focusing on elective general surgical procedures, our goal was to create a composite score as a web site quality rating system. The components of a composite score were developed through a literature review and included Agency for Healthcare Research and Quality guidelines of "Having Surgery? What You Need to Know" and previously published health-related web site scales. All criteria are given equal weight (0/1 scale). The composite score is reported as a percentage of a total possible 16 points. To pilot the rating scale, a web search for roux-en-y gastric bypass (RYGB) was used. Validation compared the composite score with an evaluation by surgeons. Mean composite score for 18 RYGB web sites was 48 per cent (range, 19% to 75%). Composite score validation used a cutoff value of 50 per cent. There was 100 per cent agreement (kappa = 1.0) between composite and surgeon scores. This is the first validated comprehensive composite score to evaluate the web site quality for patients undergoing elective surgery. This score shows promise in increasing efficiency of surgical practices by providing a way in which we can evaluate web sites and encourage our patients to become well informed by reading only high-quality web sites.

What is the quality of surgery-related information on the internet? Lessons learned from a standardized evaluation of 10 common operations

BACKGROUND

Although there is high-quality information on the Internet, it is difficult for patients to identify high-quality Web sites from those with inaccurate or misleading information. Our goal was to determine specific characteristics of Web search results that yield high-quality information and can be discerned easily by patients.

STUDY DESIGN

A validated rating system was used to evaluate surgical Web sites for appropriateness and adequacy. Web sites were identified using three search term types (technical, descriptive, and layperson) for 10 common surgical procedures. The top three sponsored (paid) and unsponsored (unpaid) Web site matches were identified. The search and analysis were repeated 1 month later.

RESULTS

One hundred forty-five Web sites were retrieved: 90 unsponsored and 55 sponsored. Unsponsored sites had higher mean composite scores than sponsored Web sites (50.6% versus 25%, p < 0.0001). Searches using layperson terms had lower mean composite scores compared with those using technical terms (36.9% versus 47.5%, p < 0.02). Professional Web sites had the highest mean composite scores (66.3%); legal Web sites had the lowest (6.3%). On regression analysis, unsponsored Web sites were associated with higher composite scores (p < 0.0001); number 1 match results (p < 0.02) and using layperson search terms (p < 0.052) were associated with lower mean composite scores. Repeat search results demonstrated no significant differences, except number 3 match results were no longer significant.

CONCLUSIONS

To optimize patients' Web searches, surgeons should recommend unsponsored sites; suggest professional society sites, if available; and provide technical search terms. But information on some topics, such as risks of not undergoing surgery, remains poor and requires discussion between the surgeon and patient.

The Pathogenesis of Burn Wound Conversion

OBJECTIVE

Burn wound progression is a poorly understood process by which certain superficial partial-thickness burns spontaneously advance into deep partial-thickness or full-thickness wounds. Progression of an injury into deeper tissue is an important phenomenon in the treatment of thermal injury due to the fact that burn wound depth may be a significant determinant of morbidity and treatment. This article reviews current knowledge of the pathogenesis, molecular and cellular mechanisms, local and systemic factors, and treatment modalities related to wound conversion.

DATA SOURCES AND STUDY SELECTION

All peer-reviewed, original, and review articles published in English-language literature relevant to the topic of burn wound conversion on animals and human subjects were selected for this review.

DATA EXTRACTION AND SYNTHESIS

After assessing data relevance, independent extraction by a sole reviewer was performed. Data were tabulated according to the following categories: pathogenesis, mechanisms, local and systemic factors, and treatment.

CONCLUSIONS

Burn wound progression is complex and caused by additive effects of inadequate tissue perfusion, free radical damage, and systemic alterations in the cytokine milieu of burn patients, leading to protein denaturation and necrosis. Even though insufficient evidence exists for causal inferences, infection, tissue desiccation, edema, circumferential eschar, impaired wound perfusion, metabolic derangements, advanced age, and poor general health play important roles. Although consensus-building research is ongoing, current mainstays of treatment include adequate fluid resuscitation, nutritional support, and local wound care, with an emphasis on topical antimicrobial agents and biosynthetic dressings. Identifying early indicators by elucidating possible interacting or synergistic mechanisms and by developing preventative strategies will enhance prevention and treatment.

Microwave ablation in a hepatic porcine model: correlation of CT and histopathologic findings

BACKGROUND

Thermal ablative techniques have gained increasing popularity in recent years as safe and effective options for patients with unresectable solid malignancies. Microwave ablation has emerged as a relatively new technique with the promise of larger and faster burns without some of the limitations of radiofrequency ablation (RFA). Here we study a new microwave ablation device in a living porcine model using gross, histologic, and radiographic analysis.

MATERIALS AND METHODS

The size and shape of ablated lesions were assessed using six pigs in a non-survival study. Liver tissue was ablated using 2, 4, and 8 min burns, in both peripheral and central locations, with and without vascular inflow occlusion. To characterize the post-ablation appearance, three additional pigs underwent several 4 min ablations each followed by serial computed tomography (CT) imaging at 7, 14, and 28 days postoperatively.

RESULTS

The 2 and 4 min ablations resulted in lesions that were similar in size, 33.5 cm(3) and 37.5 cm(3), respectively. Ablations lasting 8 min produced lesions that were significantly larger, 92.0 cm(3) on average. Proximity to hepatic vasculature and inflow occlusion did not significantly change lesion size or shape. In follow-up studies, CT imaging showed a gradual reduction in lesion volume over 28 days to 25-50% of the original volume.

DISCUSSION

Microwave ablation with a novel device results in consistently sized and shaped lesions. Importantly, we did not observe any significant heat-sink effect using this device, a major difference from RFA techniques. This system offers a viable alternative for creating fast, large ablation volumes for treatment in liver cancer.

Modalities for the assessment of burn wound depth

OBJECTIVE

Burn wound depth is a significant determinant of patient treatment and morbidity. While superficial partial-thickness burns generally heal by re-epithelialization with minimal scarring, deeper wounds can form hypertrophic or contracted scars, often requiring surgical excision and grafting to prevent a suboptimal result. In addition, without timely intervention, more superficial burn wounds can convert to deeper wounds. As such, the rapid and accurate assessment of burn wound depth is a priority in treating burn-injured patients. The object of this article is to review current research on modalities useful in the assessment of burn wound depth with emphasis on the relative costs and benefits of each technique.

METHODS

PubMed and Cochrane computerized databases were used for data retrieval, using the search terms "burns," "burn wounds," "burn depth," "burn depth measurement," and "burn depth progression." In addition, bibliographic references from prior reviews of burn depth were reviewed. All peer-reviewed, English-language articles relevant to the topic of burn depth measurement were reviewed, including those focusing on animal and human populations. Where appropriate, conclusions drawn from review articles and expert analyses were included.

RESULTS

Although bedside evaluation remains the most common modality of diagnosing the depth of burn wounds, recent technological advances have broadened the scope of depth assessment modalities available to clinicians. Other depth assessment techniques include biopsy and histology, and perfusion measurements techniques such as thermography, vital dyes, indocyanine green video angiography, and laser Doppler techniques.

CONCLUSION

Of the depth assessment modalities currently used in clinical practice, LDI and ICG video angiography offer the best data-supported estimates of accuracy. Until the future of new modalities unfolds, a combination of clinical evaluation and another modality--thermography, biopsy, or, ideally, ICG video angiography or LDI--is advised to best assess the depth of acute burn wounds.

Antisense TGF-beta2 immunotherapy for hepatocellular carcinoma: treatment in a rat tumor model

BACKGROUND

The overexpression of transforming growth factor-beta (TGF-beta) in hepatocellular carcinoma (HCC) appears to induce immunosuppression toward the tumor cells.

METHODS

A rat HCC cell line, Morris hepatoma rat cell line (MRH)-7777 (MRH), was transfected with antisense TGF-beta2 in pCEP-4 vector and used as immunotherapy against the development of wild-type tumors. An enzyme-linked immunosorbent assay (ELISA) confirmed that TGF-beta2 production was markedly lower for antisense modified cells as compared to wild-type tumor cells. Tumors were initiated by injecting MRH cells into the flanks of Buffalo rats. This was followed by biweekly vaccinations with irradiated MRH cells (unmodified, pCEP-4 alone, or antisense TGF-beta2 modified).

RESULTS

In the group that received irradiated MRH unmodified cells, 55% of rats died from tumor burden, and 36% developed tumor regression. In the group that received irradiated MRH cells modified with pCEP-4 vector alone, 50% died from tumors and 33% had spontaneous regression. In animals treated with pCEP-4/TGF-beta antisense modified cells, none developed tumors. Cell-mediated cytotoxicity assays demonstrated a twofold increase in lytic activity in the effector cells of the animals treated with antisense modified cells.

CONCLUSIONS

These results demonstrate the successful treatment of HCC tumors in rats by a HCC vaccine genetically altered with antisense TGF-beta2. Decreased production of TGF-beta in HCC vaccine enhances immunogenicity against wild-type HCC tumor cells.

Visually significant cystoid macular edema in pseudophakic and aphakic patients with glaucoma receiving latanoprost

PURPOSE

To investigate the incidence of visually significant cystoid macular edema associated with the use of latanoprost in patients with glaucoma after cataract surgery.

PATIENTS AND METHODS

This is a multicenter, retrospective study of 185 patients, of whom 173 were pseudophakic (212 eyes) and 12 were aphakic (13 eyes), who were treated for glaucoma with latanoprost 0.005%. The posterior lens capsule was intact in 125 eyes, open or absent as a result of surgery in 25 eyes, and status-post-yttrium-aluminum-garnet capsulotomy in 75 eyes. Visual acuity was documented before and after initiating latanoprost therapy, and patients with a reduction of two or more lines on the Snellen chart were examined by fluorescein angiography for cystoid macular edema.

RESULTS

Visual reduction was documented in four (2.16%) patients. Three of the four patients had cystoid macular edema, and the fourth was thought to have lost a central island of vision from glaucoma. The three patients with cystoid macular edema all had ruptured posterior capsules, requiring anterior vitrectomy, and one had a previous episode of cystoid macular edema 3 years before starting latanoprost therapy.

CONCLUSION

These findings suggest that visually significant cystoid macular edema associated with latanoprost therapy in pseudophakic or aphakic patients is uncommon. If there is a cause-and-effect relationship between latanoprost therapy and clinically significant cystoid macular edema, the incidence appears to be low.