Evaluation of the role of povidone‑iodine in the prevention of surgical site infections

Background

The occurrence of surgical site infections (SSIs) is associated with increased risk of mortality, development of other infections, and the need for reintervention, posing a significant health burden. The aim of this review was to examine the current data and guidelines around the use of antiseptic povidone‑iodine (PVP-I) for the prevention of SSIs at each stage of surgical intervention.

Methods

A literature search for selected key words was performed using PubMed. Additional papers were identified based on author expertise.

Results

Scientific evidence demonstrates that PVP-I can be used at every stage of surgical intervention: preoperative, intraoperative, and postoperative. PVP-I is one of the most widely used antiseptics on healthy skin and mucous membranes for preoperative surgical site preparation and is associated with a low SSI rate. For intraoperative irrigation, aqueous PVP-I is the recommended agent and has been demonstrated to decrease SSIs in a range of surgical settings, and for postoperative wound healing, there is a growing body of evidence to support the use of PVP-I.

Conclusions

There is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation. The use of a single agent (PVP-I) at each stage of surgical intervention could potentially provide advantages, including economic benefits, over agents that can only be used at discrete stages of the surgical procedure.

Key message

Evidence supports the use of PVP-I at all stages of surgical intervention, from preoperative measures (including skin preparation, preoperative washing, and nasal decolonization) to intraoperative irrigation, through to postoperative wound management. However, there is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

An overview of surgical techniques and non-surgical treatments in lifting the eyebrow including current treatments available

The eyebrow is a complex structure of the human face, which has both functional (communication) and aesthetic aspects and contributes to a persons’ individual appearance. Ptosis of the eyebrow is a common condition, especially among the elderly and smokers. Facial appearance is disrupted by eyebrow ptosis, and in many cases, correction and treatment are needed. No specific type of browlift has been shown to be superior to another, and since there is a wide variation in treatment preference between patients, it requires an individual approach to each specific patient. This review provides an overview of the history of the browlift, non-surgical treatment and current surgical techniques available.

Level of evidence: Not ratable.

Evaluation of the antiseptic activity of 5% alcoholic povidone-iodine solution using four different modes of application: a randomized open-label study

BACKGROUND

Before some invasive procedures, such as injections, surgical incision or intravascular catheter insertions, alcoholic antiseptics (e.g., alcoholic povidone-iodine [PVP-I]) are widely used to prevent infection.

AIM

This randomized, open-label study investigated the impact of mode of application (which includes both application technique and volume) on the antiseptic activity of 5% alcoholic PVP-I solution.

METHODS

Alcoholic PVP-I was administered on the backs of healthy adults using four modes of application: A, concentric circle method, 3mL; B, concentric circle method, 10 mL; C, back-and-forth friction method, 3 mL; D, back-and-forth friction method, 10 mL.

PRIMARY ENDPOINT

antiseptic activity of alcoholic PVP-I, assessed via change from baseline in log₁₀/cm² colony-forming units (CFU) count for total aerobic and facultative anaerobic bacteria. Safety was monitored.

FINDINGS

113 healthy participants were screened; 32 were randomized. Alcoholic PVP-I showed significant antiseptic activity with all modes of application (p<0.001 for each), providing an overall mean decrease from baseline in CFU count of >3 log₁₀/cm² (p<0.001). Significantly greater efficacy was seen with back-and-forth friction (modes C and D) versus concentric circles (modes A and B): covariate adjusted change in log₁₀/cm² CFU count 0.22; 90% confidence intervals: 0.07, 0.37 (p=0.017). No safety issues were observed.

CONCLUSION

Alcoholic PVP-I demonstrated high antiseptic activity for all modes of application. Greater efficacy was achieved with back-and-forth friction versus concentric circles, showing that application technique may influence antiseptic activity; these findings suggest that when comparing the efficacy of antiseptic substances (e.g., alcoholic PVP-I and alcoholic chlorhexidine [CHX]), comparable application techniques should be used.

Psychological counselling in patients with a peripheral facial palsy: initial experience from an expert centre

BACKGROUND

The aims of this pilot study were to evaluate the psychologist's role on the multidisciplinary team during peripheral facial palsy (PFP) patient care and to identify the potential predictors of anxiety and depressive symptoms/disorders in PFP patients.

METHODS

Using the prospective non-controlled study design, PFP patients aged 18-75 years who presented to the Radboud Facial Palsy Expert Centre, the Netherlands, were enrolled during a 1-year interval. The main outcome variables were 1) anxiety and depression in relation to PFP using the Hospital Anxiety and Depression Scale (HADS) and 2) the outcome of psychological counselling in patients with a HADS score ≥ 8.

RESULTS

A sample comprised 25 patients (68% females, 56% right-side PFP, 16% House-Brackmann scale I-II) with a mean age of 50 ± 14 years were referred to a psychologist. The proportion of patients with a HADS score ≥8, were 16 (64%) and 13 (52%), respectively. Especially, coping (in general or coping with the disease, 48%) and/or help with the choice of possible surgery (8.0%) were important reasons for counselling. In one case, a patient had chronic fatigue syndrome and was therefore referred to a psychological specialist centre. One patient was treated with acceptance and commitment therapy (ACT) with good results.

CONCLUSIONS

Despite a small sample size and limited statistical analyses, the results of this study suggest that one-eighth of the PFP patients require psychological evaluation and treatments. This pilot study emphasises the important role of psychological screening and counselling in PFP patient care.

Update on the role of antiseptics in the management of chronic wounds with critical colonisation and/or biofilm

Biofilms play a major role in delaying chronic wounds from healing. A wound infiltrated with biofilm, or "critically colonised" wound, may become clinically infected if the number of microbes exceeds a critical level. Chronic wound biofilms represent a significant treatment challenge by demonstrating recalcitrance towards antimicrobial agents. However, a "window of opportunity" may exist after wound debridement when biofilms are more susceptible to topical antiseptics. Here, we discuss the role of antiseptics in the management of chronic wounds and biofilm, focusing on povidone-iodine (PVP-I) in comparison with two commonly used antiseptics: polyhexanide (PHMB) and silver. This article is based on the literature reviewed during a focus group meeting on antiseptics in wound care and biofilm management, and on a PubMed search conducted in March 2020. Compared with PHMB and silver, PVP-I has a broader spectrum of antimicrobial activity, potent antibiofilm efficacy, no acquired bacterial resistance or cross-resistance, low cytotoxicity, good tolerability, and an ability to promote wound healing. PVP-I represents a viable therapeutic option in wound care and biofilm management, with the potential to treat biofilm-infiltrated, critically colonised wounds. We propose a practical algorithm to guide the management of chronic, non-healing wounds due to critical colonisation or biofilm, using PVP-I.

Cosmetic appreciation and emotional processing in patients with a peripheral facial palsy: A systematic review

Background; The goal of this review is 1) to summarize the studies assessing PFP by casual observers, patients themselves and the cosmetic appreciation of the PFP and 2) to summarize the studies assessing whether there is a difference in emotional recognition/processing of facial emotions and/or cognitive tasks in patients with a PFP. Materials and Methods; A multi-database systematic literature search was performed using the following databases: Pubmed, Embase, Medline, and The Cochrane Library from the earliest date of each database up to December 2019. Population of interest consisted of patients with a PFP and studies that investigated cosmetic appreciation and/or emotional recognition and/or emotional processing in these patients. Two authors rated the methodological quality of the included studies independently using the 'Newcastle - Ottawa Quality Assessment Scale' for nonrandomised studies' (NOS). Two authors extracted the outcome data regarding cosmetic appreciation and/or emotional recognition/processing from the included studies. Results; Twelve hundred and thirty-two studies were found of which eleven studies met the inclusion criteria. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author RL and SP) was 0.68. Two studies investigated emotional processing and/or emotional recognition. Nine studies investigated cosmetic appreciation in both patients and casual observers. Important findings of this systematic review are that there is a correlation between the perceived severity of the PFP of the patients and the ratings by casual observers. Secondly there seems to be a laterality difference in cosmetic appreciation and thirdly there might to be a decreased emotional recognition and processing in patients with a PFP. Conclusion; Emotional recognition and cosmetic appreciation in patients with a PFP is an under investigated area, in which further studies are needed to substantiate the findings in current literature.

Association between duration of peripheral facial palsy, severity, and age of the patient, and psychological distress

BACKGROUND

Peripheral facial palsy (PFP) (paralysis) can be a devastating condition that has been shown to have associations with increased depression and worse quality of life. The aim of the present study is to better understand the complex association of psychological distress with the duration, severity, and age of patients with PFP. We hypothesize that a shorter duration of PFP is associated with higher levels of psychological distress.

METHODS

Fifty-nine patients with PFP that existed longer than 3 months were included in this study. The Hospital Anxiety and Depression Scale (HADS) was used to assess the presence and severity of anxiety and depressions. Spearman's correlation analysis was used to determine correlation between psychological distress, duration, severity of the PFP, and age.

RESULTS

Fifty-nine patients were included in this study, of whom 22 were male and 37 were female. The mean age was 55.6 ± 14.6 years and mean duration of PFP from onset ranged from 3 months to 35 years (with a mean duration of 5.39 ± 6.06 years). Twenty-eight patients had left-sided PFP, 30 patients had right-sided PFP, and one patient had bilateral PFP. The majority were caused by Bell's palsy (50.8%). In the group with a duration less than 5 years, there were five (12.8%) patients having a score between 11 and 15 (on HADS) compared to two (10%) patients in the group with a duration of 5 years or more(p = 0.04).

CONCLUSION

There seems to be an association between moderate depression and duration of the PFP. Further studies need to substantiate our findings.

Routine histopathological examination after female-to-male gender-confirming mastectomy

Background

The number of transmen seeking gender-confirming surgery has risen steadily throughout the last decade. Pathologists are increasingly confronted with transmale mastectomy specimens. It is not clear whether routine histopathological examination is useful. This study explored the possible benefit of routine investigation through detailed description of lesions encountered in mastectomy specimens after female-to-male gender-confirming surgery.

Methods

Breast tissue from a cohort of transmen was reviewed. The presence of benign and malignant breast lesions was recorded. The number of terminal duct–lobule units (TDLUs) per ten low-power fields (LPFs) was quantified. Information on hormone therapy and morphometry was retrieved for selected patients.

Results

The cohort included 344 subjects with a mean age of 25·8 (range 16–61) years at the time of surgery; the age at surgery decreased significantly over time. Older individuals presented with a significantly higher number of breast lesions. The number of TDLUs per LPF was lower in heavier breasts, but did not correlate with age. Breast lesions, either benign or malignant, were present in 166 individuals (48·3 per cent). Invasive breast cancer was found in two (0·6 per cent); one tumour was an unexpected finding. The number of breast lesions encountered on histopathological examination increased significantly when more tissue blocks were taken.

Conclusion

The discovery of an unexpected breast cancer in a 31-year-old transman emphasizes the importance of thorough routine histopathological examination of mastectomy specimens. The number of tissue blocks taken should be based on age and breast weight.

Sex Reassignment Surgery in the Female-to-Male Transsexual

In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy (endoscopically assisted). The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap (or an alternative). After about one year, penile (erection) prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reassignment surgery procedures that can be performed in a female-to-male transsexual.

Aesthetic surgery of the female genitalia

Aesthetic genital surgery seems to have become a fashionable issue nowadays. Many procedures and techniques have been described these last years, but very few long-term results or follow up studies are available. The novelty of this aspect of plastic surgery and the lack of evidence-based interventions, have led to a comparison with female genital mutilation. In this article, the authors provide an overview of the possible surgical procedures as well as the general principles of aesthetic surgery of the female genitalia.

Penile reconstruction

A variety of surgical options exists for penile reconstruction. The key to success of therapy is holistic management of the patient, with attention to the psychological aspects of treatment. In this article, we review reconstructive modalities for various types of penile defects inclusive of partial and total defects as well as the buried penis, and also describe recent basic science advances, which may promise new options for penile reconstruction.

The modified Fitzpatrick Wrinkle Scale: a clinical validated measurement tool for nasolabial wrinkle severity assessment

BACKGROUND

The number of existing wrinkle assessment scales makes it difficult to compare the efficacy of cosmetic techniques in rejuvenating photoaged skin. A single and simple assessment scale that reliably quantifies wrinkle depth is needed.

OBJECTIVE

The objective was to validate the Modified Fitzpatrick Wrinkle Scale (MFWS) as a nasolabial wrinkle severity assessment tool.

METHODS AND MATERIALS

The MFWS comprises three main classes, in which definitions are based on a set of reference photographs and descriptions, and three interclasses, in which definitions are based only on descriptions. Assessors were trained to apply this scale to volunteers and study patients by using photographs of nasolabial wrinkles either alone or with descriptions. Inter- and intraassessment reliability coefficients were calculated using weighted kappa statistics.

RESULTS

In patients, the combined intraassessor reliability from both sides of the face was 0.71 (95% confidence interval [CI], 0.68-0.74) when only photographs were used and 0.79 (95% CI, 0.76-0.82) when descriptions were added. Interassessor reliability for the photographs alone was 0.65 (95% CI, 0.62-0.68) and 0.74 (95% CI, 0.69-0.79) for photographs plus descriptions.

CONCLUSIONS

The MFWS is a reliable method for quantitative assessment of nasolabial skin folds, with good inter- and intraassessor reliability. Including descriptions with the photographs increased reliability.

A Two-Stage Phase I Trial of Evolence30 Collagen for Soft-Tissue Contour Correction

BACKGROUND

The ideal dermal filler should be nonpermanent but with a durable effect lasting between 1 and 2 years, which is not the case with the resorbable fillers that are currently available. Evolence30 is a new, porcine-derived collagen gel based on the Glymatrix cross-linking technology, which results in a more natural and longer-lasting collagen product.

METHODS

In this first clinical trial of Evolence30 (30 mg/ml), the safety and efficacy of this new filler were tested and compared with those of Zyplast (bovine cross-linked) collagen, after treatment of nasolabial folds in 12 volunteers. Safety assessments included two hypersensitivity tests, physical examination of injections sites, punch biopsies for histopathology, adverse events, and blood sample analysis. The seven-grade, validated Modified Fitzpatrick Wrinkle Scale was used by three independent blinded assessors to evaluate efficacy.

RESULTS

No treatment-related adverse events were reported. Only transient erythema was observed in both treated sides, and there were no abnormal laboratory findings. None of the sera contained immunoglobulin (Ig) M, IgA, or IgE antibodies against porcine collagen at any time during the study. Initially, Evolence30 and Zyplast improved wrinkle severity to a similar extent. However, in an average follow-up of 18 months, assessment by the blinded assessors showed that the treatment effect on the Evolence30-treated side was superior in 9 of the 11 participants who were treated (p = 0.022).

CONCLUSIONS

Evolence30 is a new, porcine-derived collagen product based on the Glymatrix cross-linking technology that enables a safe and effective correction of the nasolabial folds. This correction lasts significantly longer than that with Zyplast.

Validity of a Structured Method of Selecting Abstracts for a Plastic Surgical Scientific Meeting

In 1999, the European Association of Plastic Surgeons accepted a structured method to assess and select the abstracts that are submitted for its yearly scientific meeting. The two criteria used to evaluate whether such a selection method is accurate were reliability and validity. The authors previously established this method to be reliable on the basis of a prospective evaluation of the selection process used for the 2000 meeting of the European Association of Plastic Surgeons. It is more difficult to assess the validity of this method because there is no objective standard of quality of a scientific abstract against which the accuracy of selection can be assessed. This study statistically evaluated the accuracy of the meeting participants' assessment of presentations made during the meeting as the criterion standard for abstract selection on the basis of data obtained from the 2002 selection process. The authors evaluated the interobserver repeatability among five meeting participants of selecting the best presentations, the validity of the method of abstract selection after this criterion standard had been established, and the validity of reviewers' rating of abstracts as indicators of the scientific value of the actual presentations. The authors conclude that the assessment of platform presentations at a plastic surgical meeting is reliable. Accepting this assessment as the criterion standard, however, they could not prove the validity of their selection method or the validity of the reviewers' rating of abstracts as an indicator of the scientific value of the actual presentations.

Perforator flap terminology: update 2002

The first terminology consensus on perforator flaps, reached in 2001, was reviewed and further simplified following the Sixth International Course on Perforator Flaps.

Soft tissue reconstruction with the superior gluteal artery perforator flap

The development of the perforator flap technique revolutionized the practice of soft tissue transfer. The main goal of this technique is muscle sparing at the donor site for function and strength. Meanwhile, this concept is being widely applied for reconstruction of tissues throughout the entire body. Perforator flaps are the ultimate upgrade of the well-known myocutaneous flaps. Theoretically, any myocutaneous flap can be harvested as a perforator flap if skin resurfacing is needed. Although the DIEP flap, the anterolateral thigh flap, and the TAP flap are probably more frequently used for breast, trunk, and upper and lower limb reconstruction, as well as head and neck reconstruction, the SGAP flap takes its own position in the large group of perforator flaps and has its own specific indications.

The effect of ultrasound-assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall

Scientific reports of clinical in vivo research into the effects and side-effects of ultrasonic-assisted liposuction (UAL) are scarce. Advocates of UAL claim that the damage to vascular and nervous structures is limited and even less than with conventional and/or tumescent liposuction (CL). The effect of tumescent infiltration alone and combined with either CL or UAL was assessed by performing injection studies of the panniculus adiposus of the lower abdominal wall of 20 fresh cadavers and five abdominoplasty specimens. Besides the control and infiltration groups (n=5 in each), there was an additional group of ten cadaver flaps and five abdominoplasty flaps that underwent infiltration followed by UAL in the right half of the flap and infiltration followed by CL in the left half of the flap. Radiographs of these flaps were shown to a blinded panel of ten plastic surgeons, who were asked to evaluate and compare the damage on the basis of the number and magnitude of contrast-medium extravasations in the flap. Vascular damage to the perforating vessels was seen even after infiltration alone, although it was very limited. A variable amount of damage (ranging from little to extensive) was observed in the CL and UAL groups. Statistical analysis of the judgments of the observers could not show that either technique was less damaging than the other. UAL is, therefore, probably more beneficial to the surgeon than to the patient. The financial investment in the device is justified for surgeons with large liposuction practices, mainly, and probably solely, because of the reduced physical strain for the surgeon.

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.

The use of pedicled perforator flaps for reconstruction of lumbosacral defects

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.

The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores

We describe the use of a large skin-subcutaneous tissue flap based on one perforator of the superior gluteal artery (SGA) to reconstruct large midline posterior defects in one stage. The integrity of the gluteus muscles is preserved and we feel this is particularly important in non-paralysed patients. Donor sites were always closed primarily. Use of the superior gluteal artery perforator (SGAP) flap preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We recommend this flap in an area where reconstructive possibilities are limited, as it preserves other reconstructive flap options, both on the ipsilateral and contralateral sides.

Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless?

The spontaneous return of sensation in autologously reconstructed breasts, especially in the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, generated the belief that sensory reinnervation by nerve repair of the flap would be superfluous. This study compares the sensation of the following non-reconstructed and reconstructed breasts: (1) non-operated breasts; (2) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap with sensory nerve repair; (3) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap without nerve repair; and (4) flaps of patients reconstructed with the free TRAM flap without nerve repair. Statistically significant lower pressure thresholds were found for DIEP flaps with nerve repair through Semmes-Weinstein testing. More segments of the DIEP flaps with nerve repair reacted to cold, warm and vibratory stimuli compared to flaps without nerve repair. Delayed but satisfactory sensory evoked potential responses were obtained for all reconstructed breasts, but in 46% of TRAM flaps no response could be registered compared with 23% and 0% for DIEP flaps without and with nerve repair, respectively. Questionnaires confirmed the objective data and showed return of erogenous sensation in 30% of the patients with DIEP flaps with nerve repair. Our data reconfirm the possibility of spontaneous return of sensation in pedicled and/or free lower abdominal flaps without nerve repair. Nerve repair in free DIEP flaps nevertheless does restore sensation earlier postoperatively, increases the quality and quantity of sensation in the flap and has a higher chance of providing erogenous sensation. The benefits obtained outweigh the disadvantages of the increased operating time.

The antecubital fasciocutaneous island flap for elbow coverage

Soft-tissue defects in the area of the periolecranon may be a source of concern to the reconstructive surgeon who aims for durable protection with a minimum of drawbacks. Lamberty and Cormack described the antecubital fasciocutaneous flap both as a local transposition and as a free flap. The island version of this flap enables a single-stage transfer of thin, pliable, sensitive skin into the region of the periolecranon without further scarring around the defect. In general, most of the donor site can be closed primarily together with a small, full-sheet, split-thickness skin graft on the remaining skin defect on the volar surface of the distal forearm. An additional advantage of this flap is the rather straightforward dissection with minimal repercussion on the forearm contour. An anatomic overview as well as 4 patients are described to illustrate the appealing features of this fasciocutaneous flap.

A simple mathematical formula for custom-made croissant tissue expanders

The popularity of croissant-type tissue expanders has increased steadily during the past 5 years. Croissant-shaped expansion offers the advantage of creating a tailored skin flap that is advanced easily into an elliptical skin defect without the formation of dog-ears or without the need for backcuts in the expanded flap. Because the majority of lesions can be considered elliptical in shape, surgical removal is performed easily with an adapted croissant expander. We present a simple mathematical formula for calculating the exact dimensions of the required croissant expander. A good clinical result was obtained using this formula to design large custom-made croissant tissue expanders in a patient with a giant nevus.

Doppler flowmetry in the planning of perforator flaps

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

The fate of the oblique abdominal muscles after free TRAM flap surgery

During recent years, clinical research on the donor site morbidity after free or pedicled transverse rectus abdominis myocutaneous (TRAM) flap surgery has been focusing on the reduced flexion capacity of the abdominal wall. However, the rectus abdominis muscles have close interactions with their synergists and antagonists and collaborate with their neighbouring muscles. The purpose of this study was to examine the consequences of partially resecting the rectus abdominis muscle on the different muscle groups of the abdominal wall. Twenty free TRAM flap patients, 12-61 months (mean 32.1 months) after surgery, were clinically examined, evaluated for curl-up performance and underwent isokinetic dynamometry for flexion, extension and rotation. The patients were compared with 20 non-operated controls. Nineteen patients answered a questionnaire. Abdominal wall abnormalities occurred in 10 patients: umbilical asymmetry (n = 3), abdominal wall asymmetry (n = 4), lower abdominal bulging (n = 2) and hernia (n = 1). Curl-up performance was less in the TRAM flap patients (P = 0.001, Mann-Whitney). Isokinetic flexion, extension and rotation were also less in the TRAM flap patients (Fisher's exact test). This study indicates that what has been believed to be 'limited' surgical damage to the abdominal wall leads to an important reduction in flexion strength but to an even more important reduction of rotation strength due to bilateral displacement and damage of the insertion of the oblique muscles. Partial compensation by synergists is variable and unpredictable on an individual basis. These functional disorders can potentially lead to important changes in activities of daily life.

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Hyperbaric oxygen therapy and free radical production: an experimental study in doxorubicin (Adriamycin) extravasation injuries

The role of hyperbaric oxygen (HBO) therapy in free radical-mediated tissue injury is not clear. HBO has been shown to enhance the antioxidative defense mechanisms in some animal studies, but HBO has also been reported to increase the production of oxygen free radicals. To investigate this controversy, we studied the effect of HBO in a doxorubicin (Adriamycin) extravasation model, because the cytotoxic activity of doxorubicin is partly related to its quinone structure, which leads to the formation of cytotoxic oxygen intermediates. Fifty-four Sprague-Dawley rats underwent injection of 0.3 ml doxorubicin solution (2 mg per milliliter) intradermally on both flanks as described by Rudolph and colleagues. Group I (N = 28) received HBO treatment (2 hours at 2 ATA) for 3 days prior to injection and 7 days postinjection. Group II (N = 26) received no HBO treatment. At 2, 3, and 5 weeks, the size of the ulcers and the surrounding area of alopecia in group I (+HBO) were significantly larger than in group II (-HBO): 112.2 mm2 vs. 42.8 mm2 (p < 0.01) and 1,132.2 mm2 vs. 364.8 mm2 (p < 0.005). Biochemical analysis of the biopsied skin ulcers, to measure the parameters of oxygen free radical production, indicated (similar) low levels of xanthine oxidase for both groups. However, significantly elevated levels of malonyldialdehyde (MDA), indirect evidence of free radical production, was observed in group I (+HBO) in comparison with group II (-HBO): 36.58 vs. 5.84 ng per minute per milligram protein (p < 0.001), which might indicate free radical-induced cellular injury. It is concluded that in this animal study the cytotoxicity of doxorubicin is potentiated by HBO therapy. The elevated levels of MDA suggest a direct additive cytotoxic effect by increased membrane lipid peroxidation. HBO therapy, therefore, might be deleterious in the early (preulcer) stage of doxorubicin extravasation.

A universal incision for tissue expander insertion

A new type of V- or W-shaped intralesional incision for tissue expander insertion is presented. The experience with 50 of these incisions in 36 consecutive patients in the period 1990-93 without any complication has proved the safety of this approach and the advantages of V- or W-shaped incisions over tangential or radial incisions.

Scar-length reduction by ring-shaped expansion

Conventional tissue expansion with rectangular or round expanders often results in considerable dog-ear formation and, after resection, in lengthening of the final scar. The resulting scar is, always much longer than the maximal diameter of the skin lesion. These disadvantages are partially avoided by the use of croissant-shaped expanders. Taking the idea of the croissant-shaped expander and thinking further in terms of differential expansion, a new expander has been designed. It consists of a ring-shaped expander that is placed under the normal skin around the lesion. When the appropriate expansion is reached, the skin lesion is excised and the defect is closed with a running subcuticular suture, pulling as much skin as possible centripetally. The resulting scar is shorter than the maximal diameter of the skin lesion. The new expander has been tested in two patients in regions that are reputed for poor scar quality (the back and the upper arm). The results are encouraging.

Intermittent occlusion of the ulnar artery

Intermittent occlusion of the ulnar artery developed in a patient causing cramp in her right hand. Both flexion and extension of the wrist completely obstructed bloodflow in the ulnar artery, at a level just proximal to the wrist. At operation, a tight band of antebrachial fascia was found to be the cause of this intermittent arterial occlusion. Surgical release of this fascial band produced complete relief of her symptoms.

Renal trauma and hypertension

A retrospective study (1972-1983) was made of 622 consecutive patients who suffered renal trauma, in order to assess the incidence and prevalence of post-traumatic renal hypertension. In 435 (76%) of the 569 survivors long-term followup data and blood pressure recordings were obtained, 13 months to 12 years after trauma (mean, 5.6 years). Renal trauma could not be linked to an increased incidence of hypertension: on first control, only 94 patients (21%) demonstrated a casual elevated blood pressure (greater than 140/90 mm Hg). The presence of a fixed hypertension was validated in only 14 patients. Twelve of them were extensively screened in the Department of Internal Medicine. In none of these patients could a definite relationship between hypertension and renal trauma be documented. Furthermore, an extensive review was done of 223 cases of post-traumatic renal hypertension reported in the literature from 1951 until 1984. Careful analysis of these previously described cases (71 publications) leads us to criticize the widespread accepted cause-effect condition with regard to post-traumatic renal hypertension. It is concluded that adequate management of renal injuries with early diagnosis and individualised surgical treatment can prevent this extremely rare complication.

Rational guidelines in renal trauma assessment

Optimal management in renal trauma necessitates an adequate delineation of location and extent of the renal injury. However, as a result of the rapid rise in the costs of medical care, a complete and elaborate radiographic evaluation of all patients with suspected renal injury no longer seems justified. We reviewed our experience with 622 consecutive cases of renal injury to find the most economical diagnostic sequence with the clearest findings. An intravenous pyelography (IVP) still is the first and mostly the sole examination to do in patients with clinical or laboratory evidence of renal trauma. Microscopic hematuria alone is no longer an indication to perform urography. If indicated, an IVP should be performed as an emergency procedure in all cases and especially in the patient with multiple trauma. Children are more susceptible to renal trauma and require a higher index of suspicion. In the few patients with indeterminate findings on urography, renal angiography must be considered (especially when renal pedicle injury is suspected) or a computerized tomography (CT) scan (especially in the patient with multiple trauma). Ultrasound and CT examinations are not to be done on a routine basis in the initial assessment or the follow-up of renal trauma.

Renal injury management: no longer controversial

Optimal management of renal injuries used to be a subject of controversy between the advocates of 'early intervention' and 'expectant' approach. Nowadays, most opinions have blended into a consensus for all but a small number and type of renal injuries. The purpose of this study was to investigate if the therapeutic approach in renal injuries is no longer controversial. We report the long-term results in 622 consecutive patients with renal injury, admitted to the University Hospital St Radboud in Nijmegen, The Netherlands, between 1972 and 1983. During this 11-year period a middle-course management was followed relative to indication and timing of operative intervention. This type of approach proved quite successful not only in reducing the nephrectomy rate but at the same time in lowering the incidence of early and late complications. It is concluded that choice and timing of therapy in renal injuries should depend on: 1. Accurate diagnosis of the extent of the renal injury, 2. Associated major injuries and 3. Clinical condition of the patient. Such an individualized approach most benefits the patient.

Urinary tract injuries in children: are they different from adults?

A retrospective study was carried out of 103 consecutive cases of urologic trauma in childhood. All data were compared with those of a study in 550 adult urological trauma patients to identify problems specific to the paediatric age group. Differences in anatomy and physiology make children more likely to sustain urological injury than adults, in cases of direct as well as indirect trauma. In childhood there is a significant higher incidence of preexisting renal disease. Assessment of urinary tract injuries in paediatric patients requires a higher index of suspicion and a broader indication for immediate radiographic evaluation. The therapeutic approach of urinary tract injuries in children should be identical to that in adults. The controversial renal lacerations can be managed medically (shallow renal lacerations) as well as surgically (major bleeding or extravasation, transsection of the kidney). Whenever possible, operation should be performed as an elective delayed procedure 2 to 6 days after injury. With this approach maximal renal salvation can be achieved without raising overall mortality and morbidity rates.

Emergency management of lower urinary tract injuries

Trauma to the bladder and (or) urethra mostly occurs in multiple trauma patients and their emergency management often poses problems to both the general surgeon and the urologist. Fourteen cases of bladder rupture and 16 cases of urethral laceration were retrospectively studied, with regard to etiology, trauma mechanism, diagnosis and therapeutic possibilities. Immediate diagnosis and surgical repair are important to reduce mortality and morbidity in cases of bladder rupture. The emergency treatment of urethral injuries is more controversial. The different factors influencing the therapeutic approach are discussed and rational guidelines are suggested to decrease the high complication rate of these injuries.