Hani Sinno

Complements and the Wound Healing Cascade: An Updated Review

Wound healing is a complex pathway of regulated reactions and cellular infiltrates. The mechanisms at play have been thoroughly studied but there is much still to learn. The health care system in the USA alone spends on average 9 billion dollars annually on treating of wounds. To help reduce patient morbidity and mortality related to abnormal or prolonged skin healing, an updated review and understanding of wound healing is essential. Recent works have helped shape the multistep process in wound healing and introduced various growth factors that can augment this process. The complement cascade has been shown to have a role in inflammation and has only recently been shown to augment wound healing. In this review, we have outlined the biology of wound healing and discussed the use of growth factors and the role of complements in this intricate pathway.

Level of evidence in plastic surgery research.

Background: There has been a recent shift toward evidence-based medicine in the medical and surgical literature. The objective of this study was to determine the level of evidence of published plastic surgery articles. Methods: A review of the following four major plastic surgery journal publications was performed to determine the level of evidence utilized in the published studies: Plastic and Reconstructive Surgery (PRS), Annals of Plastic Surgery (Annals), Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS), and American Journal of Aesthetic Surgery (Aesthetic) from January 1 to December 31, 2007. Results: Of the 1759 articles reviewed, 726 (41 percent) were included (animal studies, cadaver studies, basic science studies, review articles, instructional course lectures, and correspondence were excluded). The articles were ranked according to their level [level I (highest evidence, e.g., randomized-controlled trials) to level IV (lowest evidence, e.g., case reports)]. The average level of evidence in each journal was as follows: PRS, 3.05; Aesthetic, 3.11; JPRAS, 3.35; and Annals, 3.31. The evidence differed significantly between journals (p < 0.05), except when JPRAS was compared with the Aesthetic journal. Only 2.2 percent of articles were level I evidence. Conclusions: The average level of evidence in four major plastic surgery journals was 3.2 (level III). In order for the plastic surgery profession to become a participant in higher-level evidence-based medicine, greater emphasis must be placed on prospective randomized blinded trials.

Utility outcome scores for unilateral facial paralysis.

BackgroundFacial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. MethodsUtility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. ResultsA total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56 ± 0.18, 0.78 ± 0.21, and 0.79 ± 0.21 respectively] were significantly different (P < 0.0001) from the corresponding outcome scores for monocular blindness [0.61 ± 0.21, 0.83 ± 0.21, and 0.85 ± 0.18, respectively] and binocular blindness [0.33 ± 0.18, 0.65 ± 0.28, and 0.65 ± 0.29, respectively]. Linear regression analysis using age, race, income, and education as predictors of each of the utility scores for facial paralysis showed no statistical significance. ConclusionsIn samples of the general population and medical students, all utility score outcome measures for facial paralysis were lower than those for monocular blindness. Our sample population, if faced with unilateral facial paralysis, would theoretically undergo facial reanimation procedures with a willingness to sacrifice 8 years of life and be willing to undergo a procedure with a 21% chance of mortality to attain perfect health, respectively.

Acellular dermal matrix in cleft palate repair: an evidence-based review.

Background: The repair of wide cleft palates and secondary palatal fistulas remains a challenge for pediatric plastic surgeons. To reduce the incidence of fistulization, use of acellular dermal matrix to facilitate closure has been reported in the literature. A review of the literature was performed to assess whether sufficient evidence exists to recommend the routine use of acellular dermal matrix for either primary palatoplasty or secondary palatal fistula repair. Methods: A literature search for the period between 1970 and 2011 was performed. All articles with clinical application of acellular dermal matrix in primary palatoplasty or palatal fistula repair were included. Data were analyzed using weighted averages to compare fistula rates between repairs performed with and without acellular dermal matrix (historical controls) for each repair type (primary versus secondary fistula repairs). Results: Four studies examined the use of acellular dermal matrix in primary palatoplasty (n = 92) with a mean cleft width of 14.2 mm. The overall fistula rate was 5.4 percent compared with 10.6 percent in the non–acellular dermal matrix historical control group. Five studies used acellular dermal matrix in palatal fistula repair (n = 74). The overall recurrent fistula rate was 8.1 percent compared with 12.9 percent in the historical control group. Conclusions: Based on the available data, the results imply that acellular dermal matrix may have a potential benefit in reducing fistula formation/persistence in palate surgery. However, the authors did not find sufficient prospective randomized (level II or better) evidence to recommend the routine use of acellular dermal matrix for cleft palate repair.

Patient selection optimization following combined abdominal procedures: analysis of 4925 patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair.

Background: Massive weight loss following bariatric surgery causes unwanted excess skin and subcutaneous tissue. Intraoperative abdominal wall exposure during abdominal contouring surgery provides the possibility for concurrent ventral, umbilical, or inguinal hernia repair. The authors evaluated the incidence of postoperative complications following abdominal contouring surgery with or without concurrent hernia repair and the impact of surgical specialty. Methods: Analysis of patients undergoing abdominal contouring surgery with or without concurrent hernia repair was performed using the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. The incidence of postoperative complications was determined. Logistic regression assessed influence of demographics and comorbidities on postoperative outcomes. Control group (body mass index > 27.5) and high-risk group (body mass index > 40) undergoing a hernia repair were also included for comparison. Results: Among 4925 patients, 63.7 percent underwent abdominoplasty and/or panniculectomy only; 36.3 percent underwent a simultaneous hernia repair. The abdominal contouring surgery with simultaneous hernia repair group had a higher complication rate than the abdominal contouring surgery group (18.3 percent versus 9.8 percent, p < 0.001). Body mass index was associated with increased wound complications and major complications in both groups. Diabetes, smoking, chronic steroid use, and hypertension increased wound complications in the abdominal contouring surgery/hernia repair group. Conclusions: Patients undergoing hernia repair with abdominal contouring surgery may have higher postoperative complication rates than after abdominal contouring surgery alone. Hypertension, smoking, and chronic steroid use were predictors for negative outcomes. Furthermore, surgical specialty is associated with significantly different complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Utility scores for facial disfigurement requiring facial transplantation [outcomes article].

Background: Controversy exists as to whether the benefits of facial transplantation outweigh the risk of continuous immunosuppression. Utility scores [range, 0 (death) to 1 (perfect health)] are a standardized tool with which to objectify health states or diseases and can help answer such controversy. Methods: An Internet-based utility assessment study using visual analogue scale, time trade-off, and standard gamble was used to obtain utilities for facial disfigurement requiring facial transplantation from a sample of the general population and medical students at McGill University. Average utility scores were compared using t test, and linear regression was performed using age, race, and education as independent predictors of each of the utility scores. Results: A total of 307 people participated in the study. All measures (visual analogue scale, time trade off, and standard gamble) for facial disfigurement (0.46 ± 0.02, 0.68 ± 0.03, and 0.66 ± 0.03, respectively) were significantly different (p < 0.001) from the corresponding ones for monocular blindness (0.62 ± 0.02, 0.83 ± 0.02, and 0.82 ± 0.02, respectively) and binocular blindness (0.33 ± 0.02, 0.62 ± 0.03, and 0.61 ± 0.03, respectively). Age was inversely proportional to the utility scores in all groups (p < 0.01), decreasing a utility score of 0.006 for every increase in year of age. Conclusion: A sample of the general population and medical students, if faced with facial disfigurement, would undergo a face transplant procedure with a 34 percent chance of death and be willing to trade 12 years of their life to attain perfect health.

The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: a utility outcomes score assessment.

BackgroundRevision rhinoplasty for functional deformities can be both an aesthetic and reconstructive surgical challenge. We set out to quantify the health state utility assessment of living with the physical appearance of nasal asymmetry along with having nasal obstruction. The use of utility scores has helped to establish the health burden of living with various medical conditions. We sought to quantify living with a health state of nasal asymmetry with nasal obstruction after primary rhinoplasty using utility outcome scores. MethodsWe used previously validated utility outcome measures to quantify the health burden of this clinical scenario in 128 prospective subjects. These subjects were from a sample of the population and medical students recruited to complete a survey to determine the utility outcome score of revision rhinoplasty using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) tests to obtain utility scores for revision rhinoplasty. Linear regression and Student t test were used for statistical analysis. ResultsAll measures (VAS, TTO, and SG) for functional nasal deformity (0.80 ± 0.13, 0.90 ± 0.12, and 0.91 ± 0.13, respectively) of the 128 prospective subjects participating in this online study were significantly different (P < 0.005) from the corresponding scores for monocular blindness (0.63 ± 0.15, 0.85 ± 0.16, and 0.85 ± 0.19, respectively) and binocular blindness (0.38 ± 0.18, 0.66 ± 0.25, and 0.69 ± 0.24, respectively). Being white was inversely related to the VAS utility scores for rhinoplasty (P < 0.05). Additionally, female sex was positively correlated to the TTO score. Age, income, and education were not predictors of utility scores. ConclusionsIn a sample of the population and medical students, VAS, TTO, and SG utility scores for revision rhinoplasty were determined and can be compared objectively with other health states and diseases with known utility scores. In a preoperative setting, women were objectively willing to potentially “trade” more years of life to treat a functional nasal deformity. If faced with a deformed nose after primary rhinoplasty, our sample population would consent to undergo a revision rhinoplasty procedure with a theoretical 9% chance of mortality and were willing to trade 3.6 years of their remaining life.

Preoperative diplopia: the most important prognostic factor for diplopia after surgical repair of pure orbital blowout fracture.

Background: No consensus exists in the literature regarding the risk factors associated with new or residual diplopia after pure orbital blowout fracture (BOF) repair. Objective: To assess and evaluate the risk factors associated with diplopia after surgical repair of pure BOF. Methods: Patients with pure BOF who were managed surgically were identified in an 11-year period at the McGill University Health Center. The association between new or residual diplopia postsurgical repair and various risk factors was assessed using &khgr;2 and Fisher exact tests, and multivariate analysis was conducted using logistic regression. Results: A total of 61 patient charts were reviewed. Results demonstrated the presence of preoperative diplopia and radiologic evidence of extraocular muscle (EOM) swelling to be strongly associated with diplopia at 6 months after repair (P < 0.05). Patients who presented preoperatively with diplopia had a 9.91 times greater probability of developing diplopia postoperatively (P = 0.035; 95% confidence interval, 1.17-83.80). Conclusions: Preoperative diplopia is the best predictor of the presence of postoperative diplopia after BOF repair. Initial injury to the EOM leading to EOM swelling and preoperative diplopia seems to be the origin of diplopia after surgical repair of pure BOF.

Topical application of complement C3 in collagen formulation increases early wound healing.

Abstract Background: The complement system is composed of bactericidal and hemolytic proteins that increase capillary leakage and inflammatory cell migration. The role of complement C3 to augment wound healing has not yet been studied. Methods: We examined the effects of topical complement C3 formulation at two concentrations (10 and 100 nM) on the rat surgical skin incision model. Skin was examined for maximal breaking strength and sectioned for histological examination. Fibronectin and collagen I content were measured using western blot analysis. Results: There was a statistically significant 74% increase in maximum wound strength with the topical application of 100 nM of C3 at day 3 (850 ± 138 g) when compared to the control rats (490 ± 57 g). Histological correlation was seen with an increased inflammatory cell and fibroblast infiltration in treated wounds as compared to control rats as early as 3 days post-wounding. Western blots revealed increased fibronectin and collagen I levels in C3 treated wounds. Conclusions: Topical application of complement C3 in collagen formulation to skin wounds significantly increases wound healing as early as 3 days after wounding. This is correlated with increased inflammatory cell recruitment and the subsequent early fibroblast migration and increased collagen deposition and organization in wounds.

Utility Outcome Assessment of the Aging Neck following Massive Weight Loss

Objective The authors set out to quantify the health state utility assessment of living with the physical appearance of the aging neck following massive weight loss. Described utility scores may help to establish the health burden of the aging neck in the growing bariatric patient population. Study Design Prospective cohort observational study. Setting Tertiary referral medical center. Subjects and Methods Three validated tools were used to determine utility scores for living with an aging neck: visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). A 5-point Likert scale was used to evaluate the subjects’ ease of understanding. A prospective sample of volunteers from the general population and medical students was used for this assessment. Results In total, 118 prospective volunteers were included in the survey. All measures (VAS, TTO, SG); (0.89 ± 0.07, 0.94 ± 0.08, and 0.95 ± 0.10, respectively) varied (P < .0001) from the corresponding ones for monocular blindness (0.62 ± 0.18, 0.87 ± 0.15, and 0.85 ± 0.20, respectively) and binocular blindness (0.32 ± 0.18, 0.66 ± 0.25, and 0.64 ± 0.28, respectively). Conclusion The authors objectified the health state of living with an aging neck in the massive weight loss patient with utility scores (TTO, 0.94) comparable with those living with obstructive sleep apnea. This sample population, if faced with an aging neck following massive weight loss, would undertake a neck rejuvenation procedure with a theoretical 5% chance of mortality and would be willing to trade 2.1 years of remaining life-years to attain this procedure.