Saad Dibo

Wound cleansing, topical antiseptics and wound healing

Atiyeh BS, Dibo SA, Hayek SN. Wound cleansing, topical antiseptics and wound healing.

Metabolic implications of severe burn injuries and their management: a systematic review of the literature.

BackgroundSevere burn patients are some of the most challenging critically ill patients, with an extreme state of physiologic stress and an overwhelming systemic metabolic response. A major component of severe burn injury is a hypermetabolic state associated with protein losses and a significant reduction of lean body mass. The second prominent component is hyperglycemia. Reversal of the hypermetabolic response by manipulating the patient’s physiologic and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacologic doses, is emerging as an essential component of the state of the art in severe burn management. The present review aims at summarizing the new treatment modalities established to reduce the catabolic burden of severe burn injuries, for which there is some evidence-based support.MethodsA systematic review of the literature was conducted. Search tools included Elsevier ScienceDirect, EMBASE.com, Medline (OVID), MedlinePlus, and PubMed. Topics searched were Nutrition and Burns, Metabolic Response and Burns, Hypermetabolism and Burns, Hyperglycemia and Burns, and several more specific topics when indicated. With a focus on the most recently published articles, abstracts were reviewed and, when found relevant, were included as references. Full text articles, whenever available, were retrieved.ResultsMany issues remain unanswered. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined, and these will certainly have some practical applications but above all will dictate future research in the field.

Nonsurgical Nonablative Treatment of Aging Skin: Radiofrequency Technologies Between Aggressive Marketing and Evidence-Based Efficacy

The gold standard treatment for the many aesthetic aspects of aging has for many years been surgery in its many forms. However, with increasing patient demand for cosmetic rejuvenation and with the strong desire and drive by patients to attain aesthetic enhancement with minimal risk and rapid recovery, there has been a strong surge inspiring the field of nonsurgical skin rejuvenation. Traditionally, most of the nonsurgical methods have centered around those that destroy the epidermis and cause a dermal wound, with resultant dermal collagen remodeling and secondary skin tightening and rhytid improvement. Currently, there is growing interest in a wide range of nonablative interventions that, predictably, are claimed to rejuvenate skin and subcutaneous tissue “safely and effectively.” Although several nonablative systems have been cleared by the U.S. Food and Drug Administration (FDA) for the purpose of skin rejuvenation and despite significant reported improvement in the appearance of signs and symptoms of photoaging by relatively noninvasive means, the clinical results have been generally less than impressive, with most subjects showing only mild improvement. The current review aims at summarizing the various nonablative methods currently in use for skin rejuvenation and to evaluate the evidence-based efficacy of a particular nonablative radiofrequency (NARF) method: monopolar radiofrequency.

Cosmetic Mesotherapy: Between Scientific Evidence, Science Fiction, and Lucrative Business

Mesotherapy, originally conceived in Europe, is a minimally invasive technique that consists of the intra- or subcutaneous injection of variable mixtures of natural plant extracts, homeopathic agents, pharmaceuticals, vitamins, and other bioactive substances in microscopic quantities through dermal multipunctures. Its application in cosmetic medicine and surgery is gaining in popularity and acceptance and is rapidly growing in profile at an alarming rate. Despite their attraction as purported rejuvenating and ‘‘fat-dissolving’’ injections, the safety and efficacy of these novel cosmetic treatments remain ambiguous, making mesotherapy vulnerable to criticism by the generally more skeptical medical community. The technique is shrouded in mystery and the controversy surrounding it pertains to its efficacy and potential adverse effects that are subject of much concern. As with any new technology, it is important to assess the benefits, safety, experience, and standardization of mesotherapy. More studies are necessary before it can be advocated as a safe and effective treatment for body contouring and facial rejuvenation. Although the claims made about mesotherapy may be hard to believe at face value, we must be cautious about rejecting new ideas. Just as absence of proof is not proof of absence, lack of scientific validation is not proof that it does not work.

Barbed sutures lunch time lifting: evidence-based efficacy

There is a growing trend nowadays for patients to seek the least invasive treatments possible with less risk of complications and downtime to correct rhytides and ptosis characteristic of aging. Nonsurgical face and neck rejuvenation has been attempted with various types of interventions. Suture suspension of the face, although not a new idea, has gained prominence with the advent of the so called “lunch‐time” face‐lift. Although some have embraced this technique, many more express doubts about its safety and efficacy limiting its widespread adoption. The present review aims to evaluate several clinical parameters pertaining to thread suspensions such as longevity of results of various types of polypropylene barbed sutures, their clinical efficacy and safety, and the risk of serious adverse events associated with such sutures. Early results of barbed suture suspension remain inconclusive. Adverse events do occur though mostly minor, self‐limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect, and the long‐term effects of the sutures themselves. The popularity of barbed suture lifting has waned for the time being. Certainly, it should not be presented as an alternative to a face‐lift.

De-epithelialized dermal barrier for a safe immediate prosthetic breast reconstruction post circumvertical skin sparing/reducing mastectomy (SSM/SRM)

BackgroundSkin-sparing mastectomy (SSM) and skin-reducing mastectomy (SRM) with immediate breast reconstruction (IBR) is oncologically safe and has become increasingly popular as an effective treatment for patients with early stage breast cancer requiring mastectomy. Cosmetic appearance following IBR depends largely on the location of the skin incision, the quantity of breast skin left as well as the pocket for prosthetic placement, whether submuscular, subcutaneous, or both. SRM with Le Jour pattern skin excision has already been described in conjunction with autogenous tissue reconstruction. This technique is not recommended for implant-based IBR because any compromise of skin viability can result in exposure of the implant or expander.MethodsWe propose SRM with a circumvertical skin excision pattern and IBR comprising a de-epithelialized dermal barrier to reinforce the vertical suture line. We performed this technique on 10 breast cancer patients.ResultsEight patients underwent SSM with IBR using textured anatomical cohesive gel implants. One patient had Becker tear drop implants for both breasts (right SSM with IBR, and delayed left breast reconstruction); and the last patient had completion mastectomies with IBR using Becker tear drop implants. None of the patients developed complications.ConclusionThis technique is reliable and safe for implant-based IBR, ensuring minimal scarring and pleasing aesthetic results.Level of Evidence: Level IV, therapeutic study.

Modulation of wound contracture α-smooth muscle actin and multispecific vitronectin receptor integrin αvβ3 in the rabbit's experimental model

The myofibroblast, a major component of granulation tissue, is a key cell during wound healing, tissue repair and connective tissue remodelling. Persistence of myofibroblasts within a fibrotic lesion leads to excessive scarring impairing function and aesthetics. Various wound‐healing cytokines can be modulated by topical application of active agents to promote optimal wound healing and improve scar quality. Thus, the myofibroblast may represent an important target for wound‐healing modulation to improve the evolution of conditions such as hypertrophic scars. The purpose of this work is to study the modulation of myofibroblasts and integrin αvβ3 in a full thickness wound performed on rabbits treated with different topical agents using: (1) saline, (2) Tegaderm occlusive dressing (3) silver sulfadiazine and (4) moist exposed burn ointment (MEBO). The reepithelialisation was 4 days faster in the MEBO group compared with the other therapies with less oedema formation, delayed contraction, less inflammatory cells and the lowest transepidermal water loss (TEWL) resulting in a soft scar. Although α‐smooth muscle actin (α‐SMA) was the highest around day 12 in the MEBO group, wound contraction and myofibroblasts activity were the least for the same period probably because of a downregulation of the integrin αvβ3. It seems that the effect of MEBO could be more pronounced on force transmission rather then on force generation. Greater insight into the pathology of scars may translate into non surgical treatments in the future and further work in myofibroblast biology will eventually result in efficient pharmacological tools, improving the evolution of healing and scar formation.

Vertical and Horizontal Coordinates of the Nipple-Areola Complex Position in Males

After massive weight loss, male breasts in particular are one of the most disturbing body regions and can be a difficult area to treat often requiring nipple-areola repositioning. The need for bilateral repositioning of the nipple-areola complex is also increasing in other surgical fields such as in female-to-male transsexual patients with large breasts and in patients with severe forms of gynecomastia. Proper configuration and localization of the nipple-areola complex requires both meticulous planning and a thorough understanding of the male anatomy and is essential in determining final aesthetic outcome. Currently available guidelines create areolas that are too large, place the nipple-areola complex too high and too far medially, and/or require complex abstract mathematical calculations. Relying on the recently appreciated aesthetic value of the golden number Phi (ϕ) we propose an easy and reliable method to determine the horizontal and vertical coordinates of the male nipples. With only 2 easily measurable distances, umbilicus-anterior axillary fold apex and umbilicus-suprasternal notch, the internipple distance and the position of the horizontal nipple plane relative to the suprasternal notch can be calculated. The internipple distance can be determined with 95% accuracy and the distance from the suprasternal notch can be determined in 80% of cases within a range of 3.33 ± 1.25 cm.

Preoperative Assessment Tool for the Planning of Inframammary Incision and Implant Profile in Breast Augmentation

AbstractWhen using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN–IMF1 (simplified evaluation system), SN–IMF2 (High Five System), and SN–IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Functional and Therapeutic Indications of Liposuction: Personal Experience and Review of the Literature.

AbstractLiposuction is the most common cosmetic surgical procedure worldwide. It has evolved from being designed primarily for body contouring to becoming essential adjunct to various other aesthetic procedures, greatly enhancing their outcome. Despite its hard clear differentiation between an aesthetic and therapeutic indication for some pathologic conditions, liposuction has been increasingly applied to a gamut of disorders as a therapeutic tool or to improve function. In fact, liposuction has ceased to define a specific procedure and became synonymous to a surgical technique or tool same as the surgical knife, laser, electrocautery, suture material, or even wound-dressing products. At present, there seems to be an enormous potential for the application of the basic liposuction technique in ablative and reconstructive surgery outside the realm of purely aesthetic procedures. The present review contemplates the various nonaesthetic applications of liposuction, displaying the enormous potentials of what should be considered a basic surgical technique rather than a specific aesthetic procedure. Implications of this new definition of liposuction should induce third-party public payers and insurance companies to reconsider their remuneration and reimbursement policies.