Hristo Shipkov

Cultured allogenic keratinocytes for extensive burns: A retrospective study over 15 years §

UNLABELLED The aim was to review the use and indications of cultured allogenic keratinocytes (CAlloK) in extensive burns and their efficiency. MATERIALS AND METHODS This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA all patients who received CAlloK. EXCLUSION CRITERIA patients who died before complete healing. Evaluation criteria were clinical. Time and success of wound healing after CAlloK use were evaluated. RESULTS The CAlloK were used for 2 indications - STSG donor sites and deep 2nd degree burns in extensively burned patients. A total of 70 patients were included with severity Baux score of 99.2 (from 51 to 144) and mean percentage of TBSA of 63.49% (from 21 to 96%). Fifty nine patients received CAlloK for STSG donor sites with a mean number of applications of 4 and mean surface of 3800 cm(2) per patient. Treated donor sites were re-harvested 2.5 times. The mean time of complete epithelialization was 7 days. In 11 patients, CAlloK were used for deep 2nd degree burns. The mean percentage of burned surface was 73.7%. The mean surface of CAlloK per patient was 2545 cm(2). Complete healing was achieved in 6.4 days. CONCLUSION The CAlloK allow rapid healing of STSG donor-sites and deep 2nd second degree burns in extensively burned patients.

Cultured autologous keratinocytes in the treatment of large and deep burns: a retrospective study over 15 years.

AIM The aim was to review the use and indications of cultured autologous epidermis (CAE) in extensive burns and to evaluate the efficiency of our strategy of burn treatment. MATERIALS AND METHODS This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA all patients who received CAE. EXCLUSION CRITERIA patients who died before complete healing and patients who received exclusively cultured allogeneic keratinocytes. Evaluation criteria were clinical. Time and success of wound healing after CAE graft were evaluated. RESULTS A total of 63 patients were included with severity Baux score of 107 (from 70 to 140) and mean percentage of TBSA of 71% (from 40% to 97%). The CAE were used as Cuono method, in STSG donor sites and deep 2nd degree burns and in combination with large-meshed STSG (1:6-1:12) in extensively burned patients. Cuono method was used in 6 patients. The final take was 16% (0-30) because of the great fragility of the obtained epidermis. Nine patients with deep 2nd degree burns (mean TBSA 81%, from 60 to 97%) were successfully treated with only CAE without skin grafting. Combined technique (STSG meshed at 1:6-1:12 covered with CAE) was used in 27 patients (mean TBSA 69%, from 49% to 96%) with 85% success rate. Finally, donor sites treated with CAE in 49 patients could be harvested several times thanks to rapid epithelialization (time of wound healing was 7 days (from 5 to 10 days)). CONCLUSION The CAE allow rapid healing of STSG donor sites and deep 2nd second degree burns in extensively burned patients.

Superficial femoral artery perforator flap: anatomical study of a new flap and clinical cases.

Background: The medial thigh has been infrequently studied as a donor site for pedicled or free flaps. In their previous studies, the authors observed a direct cutaneous branch from the superficial femoral artery. This study aimed to investigate the anatomy and potential possibility for flap elevation (the midmedial thigh flap) on this direct branch of the superficial femoral vessels. Methods: Circumferential adipocutaneous thigh flaps were harvested from 14 fresh adult cadaver legs. The direct cutaneous branch from the superficial femoral vessels was located between the sartorius and gracilis muscles. Pedicle location, diameter, and length and position of the great saphenous vein and saphenous nerve were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area of cutaneous territory supplied by the studied perforator. Results: The pedicle was located at an average distance of 22.79 ± 1.55 cm below the pubic tubercle on the medial axis of the thigh, and it was found in 100 percent of dissections. It was always located between the sartorius and gracilis muscles, with a mean diameter of 2.82 ± 0.69 mm and mean length of 4.79 ± 0.52 cm. The average area of skin perfused was 182.24 cm2, located preferentially distal and posterior to the perforator pedicle. Two clinical cases illustrate the feasibility of the midmedial thigh perforator flap. Conclusions: The superficial femoral artery perforator flap appears to be reliable and has a constant vascular anatomy. Donor-site morbidity is low, resulting in only a vertical scar on the medial thigh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Acute paediatric bite injuries treated on inpatient basis: A 10-year retrospective study and criteria for hospital admission

Abstract The aim of this study was to evaluate the acute bite wounds in children treated on an inpatient basis over a 10-year period and the criteria for inpatient treatment. This study comprised all acute mammalian bite injuries in relation to all paediatric bite injuries seen at the Emergency Surgical Department (ESD). Inclusion criteria were: aged between 0–18 years; acute human or animal bite injuries (presenting for the first time); and inpatient treatment. Exclusion criteria were: bite wounds treated elsewhere and referred for complications; bites treated on an outpatient basis referred for complications; and all insect bites. Over 10 years, 12,948 children were seen at the ESD. There were 167 children (0.77%) with mammalian bite wounds. Twelve of them responded to the inclusion criteria. They presented 7.18% of all mammalian bite injuries and 0.09% of all paediatric emergency visits at the ESD. The average age was 3.82 ± 1.63 years (from 1.3–7 years). The time elapsed between the accident to the wound debridement was 118.64 ± 101.39 minutes. There were 10 dogs, one horse, and one rabbit bite. Surgical treatment comprised debridement, saline irrigation, and primary closure or reconstruction. All patients received antibiotics in the postoperative period. The average hospital stay was 5.92 ± 2.39 days. In one case a partial distal flap necrosis occurred. Animal bite injuries treated on an inpatient basis are predominantly dog bites in young children under 10 years of age, with deep, extended, and commonly multiple injuries. Only 7% of paediatric bite injuries require inpatient treatment.

Simultaneous Abdominoplasty and Umbilical Hernia Repair via Laparoscopy: a Preliminary Report

Abstract Background: Umbilical hernias (UH) are common in postpartum patients seeking abdominal contouring surgery and the question of simultaneous abdominoplasty and UH repair is raised. This presents, however, a risk to the umbilicus vascularisation with possible umbilical necrosis. To minimize this risk we associated abdominoplasty with laparoscopic UH repair. The aim of this study was to present the technique of simultaneous abdominoplasty and UH repair and the first results. Materials and methods: Simultaneous abdominoplasty and laparoscopic mesh UH repair was analysed in the first 10 cases. The intervention was performed by a plastic surgeon and a general surgeon. It begins as a standard abdominoplasty with flap elevation, umbilicus detachment and diastasis repair, if indicated. The second stage is the UH repair via laparoscopy using an intraperitoneal mesh. The third stage consists of umbilical transposition and closure of the abdominoplasty incision. Results: We had no complications at the umbilicus or the hernia mesh. In all cases, umbilical vascularisation was preserved and no hernia recurrence was noted. Conclusions: Our first results suggest that the simultaneous UH repair with abdominoplasty is safe, minimizing the risk to the umbilicus blood supply. These first results encourage us to recommend this approach and perform a more detailed analysis of the whole series since our first case.

Evaluation of the risk of post-operative bleeding complications in skin cancer surgery without interruption of anticoagulant/antithrombotic medication: A prospective cohort study

Abstract Background. Previous reports showed lack of consensus concerning interruption of anticoagulant/antithrombotic (AC/AT) treatment before skin cancer surgery. Aim. The aim of this study was to evaluate the risk of postoperative bleeding in patients on AC/AT treatment undergoing skin cancer surgery without interruption of this treatment. Method: This prospective cohort study included 271 consecutive patients divided into two groups – patients without and patients with AC/AT therapy. Inclusion criteria were skin cancer (basal-cell carcinoma, squamous-cell carcinoma, or malignant melanoma). Exclusion criteria were patients undergoing regional lymph node dissection or sentinel lymph node biopsy. Postoperative bleeding complications taken into consideration were those evaluated as moderate or severe and requiring some form of surgical or non-surgical hemostasis on an outpatient or inpatient basis. Results. There were 47 patients in the AC/AT group and 224 in the control group (mean age = 76.6 and 68 years, respectively), with almost equal distribution of tumours in both groups. There were 34.1% of patients on AT, 55% on AC treatment, and 10.6% on mixed treatment (AC+AT or AT+AT). Postoperative bleeding complications did not show a statistically significant difference between the two groups (p = 0.063). Conclusion. Skin cancer surgery can be safely performed without discontinuation of AC/AT treatment, since the risk of postoperative bleeding is statistically insignificant.

The forehead flap for immediate reconstruction of the nose after bite injuries: indications, advantages, and disadvantages.

To the Editor: We read with great interest the article of Huang and Wong, the ‘‘Nasal Reconstruction With Forehead Flap After Dog Bite.’’ Their report illustrates the feasibility of immediate nose reconstruction with the forehead f lap after bite injuries. We have had similar experience reported in the past and would like to share some more ideas about these challenging cases. Bite injuries to the face often affect the nose and can cause severe damages with huge functional and aesthetic impact on the affected zone. These wounds can be repaired primarily if treated shortly after injury. The forehead f lap remains a basic tool for the reconstruction of the nose and can be used at the time of primary wound repair without increased risk of infection. We feel there are 2 basic questions that the physician should be able to answer in similar cases: Should we use a f lap? and In what case should we use the forehead f lap? The classic notion in bite injuries is that intricate f laps and Z-plasties are rarely, if ever, indicated acutely. These techniques are contraindicated in an emergency because they might cause additional tissue necrosis and undesirable final result. More often than not, careful wound management preserves seemingly marginal tissue and the use of f laps leads to unnecessary harvest of normal tissue. However, 2 options exist in front of a large nasal bite defect that cannot be closed in another way but with a f lapVeither healing by secondary intention and secondary reconstruction or by f lap closure. In secondary intention, healing heavy fibroses installs with resulting deformation of the preserved nasal structures, rendering consecutive attempts for reconstruction difficult. Furthermore, the psychological impact from the existing unsightly wound can be devastating. Closing the wound with a f lap will decrease fibroses formation and diminish the psychological impact on the patient, providing primary closure and partial restoration of anatomy. The disadvantage is that lining and skeleton reconstruction are not recommended in this acute setting. In these cases, the restoration of cartilage and bone skeleton is mandatory to obtain good aesthetic and functional results. However, the immediate implantation of cartilage or bone grafts remains uncertain and dangerous. If the defect is closed by a f lap, this can be started within a couple of weeks, once the wound and the f lap have healed without complications. Thus, the f lap can potentially accelerate the timing of bone and/or cartilage reconstruction. A basic concern, as mentioned by Huang and Wong, is the fact that bite wounds are heavily contaminated. Thus, the use of flaps and skin grafts remains controversial. However, axial pattern flaps have robust vascularization and can successfully resist to bacterial contamination. This is supported by Kountakis et al who declare that wounds resulting from animal bites to the head and neck can be repaired primarily, especially when treated shortly after injury. Regarding the functional and aesthetic importance of the organs in the head and neck area, plastic and reconstructive techniques including various local or regional flaps should be used at the time of primary wound repair. In a recent study, we have reported on pediatric bite injuries treated on inpatient basis. We feel that if a bite wound is treated early enough with adequate irrigation, primary closure is feasible with a low complication rates even if f laps are used. Thus, this principle can be applied for bite injuries in other locations as thorax and hand. The second question is ‘‘In what case should the forehead f lap be used?’’ Undoubtedly, it is indicated in large transfixiant defects. Rohrich and Watumull stated that transfixiant defects of 2 to 3 cm should be considered for forehead f lap reconstruction. We feel that all-total or near-total nasal avulsion injuries and large transfixiant defects not amenable to closure by other methods should be considered for forehead f lap reconstruction. Forehead f lap seems to be indicated as well in large nontransfixiant defects that cannot be skin grafted (eg, exposed cartilage without perichondrium and bone without periosteum) and where no other f lap is applicable. For example, the nasolabial f lap was indicated for up to 2 cm lateral and alar defects. In larger defects, the forehead f lap should be considered. In summary, f lap reconstruction after bite injuries is feasible in the acute setting. It seems to offer several advantages such as primary healing with decreased fibroses (contrary to healing by secondary intention), decreased delays for bone and cartilage reconstruction, and decreased psychological impact of the injury. The good blood supply of the region and flap and the functional and aesthetic importance are conditions that imply and allow this primary reconstruction. Cartilage and bone grafts are not recommended in the acute setting. The forehead f lap can be considered in the following cases: total or near-total nasal avulsion injuries, large transfixiant defects not amenable to closure by other methods as well as in large nontransfixiant defects that cannot be skin grafted and where no other f lap is applicable.

On the Contraindications for the Use of the Temporalis Muscle Flap in Head and Neck Reconstruction

To the Editor:—We read with great interest the article of Naaj et al, which nicely presents their results of reconstrucions after ablative surgery for various oral cancers with the emporalis muscle flap (TMF). The TMF has withstood the test of time. In the modern ra of microvascular oral reconstruction, the TMF reains a valuable and reliable tool in skull base surgery nd orbital, intraoral, and extraoral reconstruction. This s particularly true in older patients, with 1 or several omorbidities which preclude the use of the longer free ap reconstruction. We have successfully used the TMF for the past 15 ears in cases of oral and extraoral reconstruction. However, we would like to make several notes concerning the contraindications for the use of the TMF discussed by Naaj et al. The authors declare that “tumor resections where the internal maxillary artery is divided” comprise a contraindication for the use of this flap. In our experience the ectioning of the internal maxillary artery itself is not a ontraindication to the use of the TMF. Both deep temporal rteries that provide its blood supply are situated very close o the medial side of the coronoid process. In this way, they are protected, and even if the internal maxillary artery is injured or sectioned, this usually happens distal to these vessels. We have performed marginal mandibular resections with coronoidectomy in oral cancers with successful preservation of the deep temporal vessels and after TMF reconstruction. We have also performed total maxillectomies with sacrifice of the internal maxillary artery with successful TMF reconstruction. In this sense, saying that the division of the maxillary artery is a contraindication to the use of TMF, Naaj et al cite the article of Rapidis and Day. In their article Rapidis and Day presented 21 patients with TMF reconstructions, 18 of whom had maxillary resections. Furthermore, in 1 of their patients, reconstruction of the infratemporal fossa was performed. In this series there were no cases of total flap necrosis, which supports the feasibility of the operation even in this area. The second point is the reliability of TMF after radiation therapy. Naaj et al state that this is a relative contraindication. It is well accepted that radiation therapy has deleterious effects on the vascularization of the irradiated regions. When the temporalis muscle comes into the field of previous radiation, one may suppose that its viability is diminished. However, we have successfully used the TMF for reconstruction after radiation in several cases, and we have not encountered any problems with TMF viability in any of them. We have used the flap in

Innovations for the treatment of a complex bone and joint infection due to XDR Pseudomonas aeruginosa including local application of a selected cocktail of bacteriophages

found a high prevalence of ESBL producers, but no CPE. In conclusion, we report two temporally and geographically linked patients with community-onset urinary tract infection caused by the same OXA-48-producing E. coli clone. The association between OXA-48 and Cambodia in NZ suggests the Cambodian patient may have acquired the organism during recent travel and indirectly transmitted to the second patient via unknown community transmission pathways. It is possible that OXA-48-positive CPE are under-recognized in NZ due to the challenges of laboratory detection. Screening with adequate selective media for CPE is highly recommended. The forthcoming national response plan to CPE in NZ has potential to help address some of these issues.

Indications for Free-Tissue Transfer in Cleft Palate Reconstruction

To the Editors: We read with great interest the article of Ozkan et al on the reconstruction of palatal defects with the anterolateral thigh (ALT) free flap. Their interesting study has raised several questions that we would like to comment on. Ozkan et al reported on 8 cases of reconstruction of palatal defects of various etiology with the ALT free flap. However, in 5 of these cases, palatal defects were cleft palate-related defects: primary cleft in 1 case, a secondary cleft palate-defect in 1 case, and palatal fistulae in 3 cases. Although free-tissue transfer has been increasingly used for reconstruction of oncologic maxillary and palatal defects, it is rarely used in patients with cleft palate defects. In our experience, we have not encountered a primary cleft palate defect that could not be reconstructed with one of the well-established techniques for palatoplasty. However, Ozkan et al report a case of primary cleft palate that needed free-flap reconstruction. Free-tissue transfer remains a technique that is generally needed in recalcitrant palatal fistulae and oronasal communications. Such secondary cleft palate defects can be a difficult-to-solve problem, especially in multioperated cases (multiple failures of cleft palate and palatal fistulae repairs). Multiple failed attempts of closure lead to scarring and fibrosis of the palatal tissue, which in turn increase the size of the defect due to scar contraction. After several surgical attempts, local tissues may become rigid, poorly vascularized, and unusable. In such cases, well-vascularized pliable tissue can be borrowed from the neighboring tongue, buccal surface, or extraorally. In our practice, we favor the local and/or regional options with special emphasis on the posteriorly based buccinator musculomucosal flap (BMMF). We opt for this flap because it is reliable, well-vascularized, and brings similar tissue to the defect. The procedure is one-staged just as the free-tissue transfer; however, it is simpler, faster, and does not require special equipment and training for microsurgery. The BMMF can reach even the most anterior palatal regions. In cases where this is not possible, the anteriorly based BMMF can be used having in mind that it is a 2-staged procedure and requires interdental space for passage. It is true that a single BMMF may be insufficient to cover large defects. But in these cases, bilateral BMMF either pedicle or as islanded can be used and can cover virtually the entire palate. In this sense, we believe that freetissue transfer should be reserved for the cases where all simpler solutions are exhausted or rendered unusable. We feel that the indication of free-flap reconstruction in primary cleft palate is rather overestimated if ever existent, and it should be reserved for the most recalcitrant cases. Which free flap should be used? Undoubtedly, this should be a thin and pliable flap with long vascular pedicle. In this sense, the ALT flap does not seem to be the most suitable choice. We believe that this flap is quite thick for isolated palatal fistula repair (in any case it is thicker than the radial forearm flap in the same individual and probably even thicker than the first dorsal metatarsal artery flap) and this was also underlined by Ozkan et al. Furthermore, it is quite unsuitable especially in male patients because of the intraoral hair growth. Actually, Ozkac et al were forced to perform a “deepithelialization for hair removal” in one of their patients. In this sense, if ALT flap is still quite suitable in cases of oncologic palatal and/or maxillary reconstruction, we believe that it is less suitable for cleft palate defects reconstruction, which was also underlined by Schwabegger et al. Finally, Ozkan et al have defined the indications for free-tissue transfer as follows: previous failures, heavily scarred and poorly vascularized tissue around the defect, defects unsuitable for local and regional tissues, and use of osseous flap only when the residual cleft requires bone graft. Actually, this was well summarized by Schwabegger et al who stated that the primary indication for freeflap reconstruction in patients with cleft palate defect is the repeated failure of local and regional flaps. In conclusion, we would like to thank Ozkan et al for their interesting series which will bring further clarity to the difficult problem of palate reconstruction, in particular in cleft palate-related secondary reconstruction.