Kevin Adams

Simplified negative pressure wound therapy: clinical evaluation of an ultraportable, no-canister system

The aim of this study was to evaluate a prototype negative pressure wound therapy (NPWT) system that has been developed to simplify NPWT for wounds at the lower end of the acuity scale. The new device has a single preset pressure of −80 mmHg, is single use and operates without an exudate canister. The disposable NPWT system (PICO™) was tested in a prospective, non‐comparative, multicentre clinical trial to assess device functionality and clinical acceptance. Twenty patients were recruited for a maximum treatment period of 14 days. The NPWT devices were fitted with data log chips to enable longitudinal assessment of negative pressure and leak rates during therapy. Sixteen (80%) patients had closed surgical wounds, two (10%) patients had traumatic wounds and two (10%) patients received meshed split thickness skin grafts. The mean study duration was 10·7 days (range: 5–14 days) and the mean dressing wear time per individual patient was 4·6 days (range: 2–11). Fifty‐five percent of wounds had closed by the end of the 14‐day study or earlier, with a further 40% of wounds progressing to closure. Real‐time pressure monitoring showed continuous delivery of NPWT. Three cases are discussed representing different wound locations and different patient factors that can increase the risk of post‐surgical complications. Clinical studies of the disposable NPWT system confirmed the ability of the simplified single‐use device to function consistently over the expected wear time. The anticipated reduced costs, ease of use and increased mobility of patients using this system may enable NPWT benefits to be available to a greater proportion of patients.

Depot- and ethnic-specific differences in the relationship between adipose tissue inflammation and insulin sensitivity

Objective  It is unclear whether there are differences in inflammatory gene expression between abdominal and gluteal subcutaneous adipose tissue (SAT), and between black and white women. We therefore tested the hypotheses that SAT inflammatory gene expression is greater in the abdominal compared to the gluteal depot, and SAT inflammatory gene expression is associated with differential insulin sensitivity (SI) in black and white women.

Full-thickness skin grafts: maximizing graft take using negative pressure dressings to prepare the graft bed.

Background:Full thickness skin grafts (FTSGs) remain a good option for resurfacing defects of the face, neck, and dorsum of the feet. It results in soft, pliable, functional skin with minimal contraction. However, FTSG may result in patchy or irregular “take” resulting in recurrent contractures and pigmentary discrepancies. This study examines the use of a negative pressure dressing (NPD) to increase FTSG take. Methods:Wounds resulting from trauma, postburn contracture release, and an excision of a congenital nevus were included in the study. The wounds were prepared by surgical excision or debridement. A NPD was then applied for a period of 7 days, at which time the wounds were inspected and, if there was sufficient granulation tissue, covered with a FTSG. If the wound had not yet granulated sufficiently another NPD was placed and reassessed in 7 days. The FTSGs were harvested from the groin and abdominal area exactly to the size of the defect. A sponge bolster dressing was then applied. The take of the FTSG was judged using a grid of 1 × 1-cm squares. The wounds were measured and the amount of graft take was calculated as a percentage of the wound size. Complications in both the wound as well as the donor sites were noted. Results:Twenty-four patients were included in the study. The mean age was 6 years (range 1–14 years), including 9 burn contracture excisions, 14 road traffic accident-related injuries, and 1 excision of a congenital nevus. The site involved was the foot (6 patients), ankle (9 patients), axilla (2 patients), forearm (4 patients), face (2 patients), and the neck (1 patient). The average surface area of the defect was 78 cm2 (range 18–264 cm2). Groin skin was harvested in all the cases. The NPD was applied on average for 8 days (range 7–15 days). The mean graft take was 95% (range 70%–100%). Only 1 patient had significant graft loss of 30%. Donor site morbidity was low, attaining primary closure in all but 2. Mean follow-up was 9 months. Conclusion:The results of this study confirm that the use of NPD enhances FTSG take.

Reduced Gluteal Expression of Adipogenic and Lipogenic Genes in Black South African Women Is Associated with Obesity-Related Insulin Resistance

CONTEXT Black South African women are less insulin sensitive than their White counterparts, despite less central and greater peripheral fat deposition. We hypothesized that this paradox may be explained, in part, by differences in the adipogenic capacity of sc adipose tissue (SAT). OBJECTIVE Our objective was to measure adipogenic and lipogenic gene expression in abdominal and gluteal SAT depots and determine their relationships with insulin sensitivity (S(I)) in South African women. PARTICIPANTS AND DESIGN Fourteen normal-weight [body mass index (BMI) <25 kg/m(2)] Black, 13 normal-weight White, 14 obese (BMI >30 kg/m(2)) Black, and 13 obese White premenopausal South African women participated in this cross-sectional study. MAIN OUTCOMES S(I) (frequently sampled i.v. glucose tolerance test) in relation to expression of adipogenic and lipogenic genes in abdominal and gluteal SAT depots. RESULTS With increasing BMI, Black women had less visceral fat (P = 0.03) and more abdominal (P = 0.017) and gynoid (P = 0.041) SAT but had lower S(I) (P < 0.01) than White women. The expression of adipogenic and lipogenic genes was proportionately lower with obesity in Black but not White women in the gluteal and deep SAT depots (P < 0.05 for ethnicity × BMI effect). In Black women only, the expression of these genes correlated positively with S(I) (all P < 0.05), independently of age and fat mass. CONCLUSIONS Obese Black women have reduced SAT expression of adipogenic and lipogenic genes compared with White women, which associates with reduced S(I). These findings suggest that obesity in Black women impairs SAT adipogenesis and storage, potentially leading to insulin resistance and increased risk of type 2 diabetes.

Intralesional bleomycin injection in management of low flow vascular malformations in children

Abstract Low flow vascular malformations are challenging to manage, particularly with their propensity to grow, and can lead to severe disfigurement and dysfunction. Traditional surgical excision is fraught with tedious dissection and complications, particularly in the head and neck region. Trends toward less invasive techniques, such as intralesional sclerotherapy, are proving to be successful independent treatments or adjuncts in management in low flow vascular malformations. This study was a retrospective case note review, over an 8-year period, reporting the outcomes of 32 children (mean = 5.8 years, range = 5 months–11.5 years) with radiologically confirmed low flow vascular malformations, treated with serial intralesional bleomycin injection (IBI) therapy. Patient demographics, lesion characteristics, imaging findings, treatment course, radiological and clinical response to treatment were recorded. An overall 91% (n = 29) response rate was achieved, with 28% obtaining complete resolution for low flow vascular malformations. Lesions were sub-categorized into venous malformation, including mixed venous-capillary (n = 27) or lymphatic malformation (LM) (n = 5). Twenty-seven of 32 children experienced no complications. Local complications included superficial skin infection (n = 2), skin necrosis (n = 1), hyperpigmentation, and minor contour deformity. There was no recurrence and no systemic side-effects to bleomycin. Mean follow-up was 38 months (range = 6–95 months). In conclusion, serial intralesional bleomycin injections can be effective and also safe in a paediatric population for the successful management of symptomatic or disfiguring low flow vascular malformations.

Autologous Dermal Graft in Breast Reconstruction

Introduction:The role of allogenic dermis is well established in reconstructive breast surgery, where it acts as a hammock between the detached inferior border of pectoralis major and the inframammary fold. Method:The study reports on the outcome of 19 women (21 breasts as 2 were bilateral) in which autologous dermis was used rather than allogenic material. The autologous dermis was harvested from the abdomen, as a miniabdominoplasty in 15 patients, and from the contralateral breast in 4 patients having simultaneous breast reduction/mastopexy. In all, 15 women underwent immediate reconstruction (7 with tissue expanders, 8 with immediate prosthesis), whereas 4 patients underwent delayed reconstruction (with expanders). Results:Two patients developed infection requiring explantation. There were no abdominal complications after the miniabdominoplasty. The coverage of the prosthesis or tissue expander by the dermal graft was achieved on average in three-quarters of cases (range, just under two-thirds to 100%). The mean follow-up was 17 months (range, 6–36 months). Conclusions:Autologous dermis is a useful alternative to allogenic dermis. It is cheap and readily available. In patients having a contralateral breast reduction, there is no donor site. The risk of complications is not dissimilar to allogenic dermis.

Glucocorticoid receptor gene expression in adipose tissue and associated metabolic risk in black and white South African women

Background:Black women have lower visceral adipose tissue (VAT) but are less insulin sensitive than white women; the mechanisms responsible are unknown.Objective:The study aimed to test the hypothesis that variation in subcutaneous adipose tissue (SAT) sensitivity to glucocorticoids might underlie these differences.Methods:Body fatness (dual energy X-ray absorptiometry) and distribution (computerized tomography), insulin sensitivity (SI, intravenous and oral glucose tolerance tests), and expression of 11β-hydroxysteroid dehydrogenase-1 (11HSD1), hexose-6-phosphate dehydrogenase and glucocorticoid receptor-α (GRα), as well as genes involved in adipogenesis and inflammation were measured in abdominal deep SAT, superficial SAT and gluteal SAT (GLUT) depots of 56 normal-weight or obese black and white premenopausal South African (SA) women. We used a combination of univariate and multivariate statistics to evaluate ethnic-specific patterns in adipose gene expression and related body composition and insulin sensitivity measures.Results:Although 11HSD1 activity and mRNA did not differ by ethnicity, GRα mRNA levels were significantly lower in SAT of black compared with white women, particularly in the GLUT depot (0.52±0.21 vs 0.91±0.26 AU, respectively, P<0.01). In black women, lower SAT GRα mRNA levels were associated with increased inflammatory gene transcript levels and abdominal SAT area, and reduced adipogenic gene transcript levels, VAT/SAT ratio and SI. Abdominal SAT 11HSD1 activity associated with increased VAT area and decreased SI in white, but not in black women.Conclusions:In black SA women, downregulation of GRα mRNA levels with obesity and reduced insulin sensitivity, possibly via increased SAT inflammation, is associated with reduced VAT accumulation.

Ethnic-Specific Associations between Abdominal and Gluteal Fat Distribution and the Metabolic Complications of Obesity: Implications for the Use of Liposuction

Adipose tissue is now considered to be an endocrine organ. Ever since this realization, there has been much debate on the effectiveness of liposuction to improve insulin sensitivity (IS) and the metabolic profile. To examine the ethnic and physiological differences of abdominal and gluteal fat compartments and their relationship to IS. Body composition, fat distribution, IS and serum; lipids, adipokines and inflammatory mediators were measured in fifty-four healthy, premenopausal women. Biopsies were taken from subcutaneous fat depots to measure leptin, adiponectin and IL-18 mRNA levels. Obese black women had more superficial subcutaneous abdominal (SAT) (p<0.01) and gluteal (p=0.043), but less visceral adipose tissue (VAT) (p<0.05) than their white counterparts. Nonetheless, black women were less insulin-sensitive than white women (p<0.01). IS correlated with deep and superficial SAT (p<0.01) in both ethnic groups but gluteal fat was inversely associated with IS only in black women (black p=0.033, white p=0.22). IL-18 mRNA (p<0.001) and leptin mRNA levels (p<0.001) were highest in gluteal fat than abdominal fat depots in both ethnic groups. Obese black women had more SAT than obese white women. SAT area correlated inversely with IS in both races, whereas the gluteal fat mass in black women and VAT in white women were associated with decreasing IS, respectively. Both lean and obese black South African women were more insulin resistant than their white counterparts. We therefore hypothesize that reduction in SAT (in both races) and gluteal fat mass (only in black women) may beneficially improve the IS and metabolic profile.

Tissue Expansion: Further Attempts to Improve Results in Breast Reconstruction

Tissue expansion, is a simple method of breast reconstruction. Method. A prospective study of 27 patients treated over a 43 month period is described. At the first stage the expander is inserted in the dual plane, and the medial pectoral nerve is divided. The tissue expander is over-expanded. Second stage: a de-epithelialized vertical triangle is used to aid anterior projection, an inframammary fold is created and a silicone gel prosthesis inserted. Z-plasties are added to the transverse scar. The contralateral breast can be treated or left alone. Complications were recorded and the results were assessed by 4 plastic surgeons using a visual analogue scale. Results. 19 patients had expanders inserted at mastectomy (2 bilateral) and 8 underwent delayed reconstruction, with a mean age of 47 years (range 30–65 years). A single prosthesis was inserted in 15 patients (mean size 320 mL) and two prosthesis were stacked in 12 patients (mean volume of 400 mL). The mean delay from full expansion to the second stage was 10 weeks (range 3 weeks–11 months). A contralateral augmentation was performed in 5 patients, pexy in 10, a reduction in 2 and in 8 patients no procedure was performed. One patient required explantation. The mean visual analogue assessment was 7. Conclusion. This technique should be considered enhance the cosmetic results in tissue expansion.