Simon H. Wood

A prospective, randomized, double-blind trial of the use of fibrin sealant for face lifts.

Fibrin sealant imitates the final phase of the blood coagulation process. Fibrinogen is converted into fibrin on a tissue surface by the action of thrombin, which is then cross-linked by factor XIIIa, creating a mechanically stable fibrin network. This fibrin network is thought to reduce the amount of postoperative bleeding by sealing capillary vessels and allowing raw operative surfaces to adhere. The authors conducted a prospective, double-blind, randomized, controlled trial on the use of fibrin sealant in 20 consecutive patients undergoing bilateral face lifts by the same surgeon. Each patient was randomized for the use of fibrin sealant on either the right or the left side with the contralateral side acting as the control. Total drainage was recorded on each side for 24 hours before drains were removed. The age range of the patients in the trial (all of whom were women) was 44 to 70 years (mean, 55). The side treated with fibrin glue had a median drainage of 10 ml and the control side 30 ml. The Wilcoxon signed rank test shows a significant difference in drainage between sides (p = 0.002). The reduction in postoperative drainage could also reduce pain and bruising, increasing patient satisfaction with this procedure. The need for drains may also be obviated.

A prospective investigation of the healing of grafted pretibial wounds with early and late mobilisation.

The aims of this study were to determine whether early mobilisation delays wound healing after meshed split skin graft repair of pretibial wounds and to identify other factors delaying the healing of these wounds. A prospective randomised controlled trial was conducted to compare the time to complete healing of patients mobilised early (the first postoperative day) against those who mobilised late (the tenth postoperative day). There was no difference in time to complete healing. Patients with a history of oral steroid therapy had a mean delay in wound healing of approximately 8 days (p < 0.02). The severity of tissue damage, as indicated by undermining of the skin margins, damage to the fascia and exposure of the periosteum, correlated with delayed wound healing (p < 0.05).

Objective assessment of keloid scars with three-dimensional imaging: quantifying response to intralesional steroid therapy.

Background: Treatment of keloid scars poses a significant challenge. Assessment of treatment response and research in this area depend on the availability of objective, accurate, and reproducible outcome measures. At present, scars are assessed using subjective grading systems, or with cumbersome investigations such as direct casting. The authors assessed the feasibility of objectively monitoring response to intralesional steroid treatment in routine clinical practice with quantitative three-dimensional imaging. Methods: Scar volume was quantified using a validated three-dimensional speckle-pattern stereophotogrammetry before and for a minimum of 8 weeks after intralesional steroid therapy in 12 patients with keloid scars. Results: Mean scar volume at the start of treatment was 0.73 ± 0.701 cc (range, 0.12 to 2.15 cc); this was reduced to 0.14 ± 0.302 cc (range, 0.007 to 1.08 cc) after monthly intralesional injections of triamcinolone acetate (p < 0.001; analysis of variance). The majority of patients achieved a greater than 50 percent response within 8 weeks of the start of therapy, but poor treatment response was noted and quantified in a minority of patients. Conclusions: Three-dimensional stereophotogrammetry is a rapid and noninvasive method of scar volume assessment that could allow accurate and objective monitoring of treatment response to be incorporated into clinical practice. Therefore, it can be of considerable value in assessing treatment efficacy and evaluating new therapeutic strategies.

Investigation of nuclear factor‐κB inhibitors and interleukin‐10 as regulators of inflammatory signalling in human adipocytes

The poor prognosis of obesity is now known to involve a proinflammatory state associated with elevated circulating levels of cytokines and with macrophage infiltration of adipose tissue. In particular, Toll‐like receptor (TLR)‐4‐driven adipose inflammation has been implicated recently in obesity and the development of diabetes. Adipocytes are now recognized as an important source of cytokine and chemokine production, including interleukin (IL)‐6 and monocyte chemotractant protein (MCP)‐1, and this appears to be a key step in the development of the obesity‐associated inflammatory state. Interventions targeted at adipocyte inflammation may therefore form novel therapies to treat or prevent medical complications of obesity. We set out to explore whether anti‐inflammatory interventions which are effective in conventional immune cells would operate on primary human cultures of in‐vitro differentiated adipocytes. IL‐10 was ineffective against TLR‐4‐induced cytokine secretion due to lack of IL‐10 receptor on human adipocytes, in contrast to the widely used murine 3T3‐L1 adipocyte model, which is known to respond to IL‐10. Adenoviral delivery of an IL‐10 receptor construct to the cells restored IL‐10 responsiveness as assessed by signal transducer and activator of transcription‐3 (STAT‐3) phosphorylation. However, the small molecule nuclear factor (NF)‐κB inhibitors 2‐[(aminocarbonyl)amino]‐5‐(4‐fluorophenyl)‐3‐thiophenecarboxamide (TPCA)‐1 and carbobenzoxyl‐Ile‐Glu(O‐t‐butyl)‐Ala‐leucinal (PSI) as well as adenovirally delivered dominant negative inhibitor of IkappaB kinase 2 (IKK2) and wild‐type IκBα were effective inhibitors of TLR‐4‐driven IL‐6 and MCP‐1 induction. These data identify a central role for canonical NF‐κB signalling in adipocyte cytokine induction and indicate that small molecule inhibitors of NF‐κB may form the basis of future treatments for obesity‐related conditions where adipocyte inflammatory signalling is implicated.

TLR signalling and adapter utilization in primary human in vitro differentiated adipocytes.

Toll‐like receptors (TLRs) are central to innate immunity and yet their expression is widespread and not restricted to professional inflammatory cells. TLRs have been reported on adipocytes and have been implicated in obesity‐associated pathologies such as diabetes. Why TLRs are found on adipocytes is not clear although one hypothesis is that they may coordinate energy utilization for the energy intensive process of an immune response. We have explored TLR signalling in primary human in vitro differentiated adipocytes and investigated the specific adapter molecules that are involved. Only lipopolysaccharide (LPS), poly(I:C), Pam3CSK4 and MALP‐2 could induce the production of IL‐6, IL‐8 and MCP‐1 by adipocytes. Poly(I:C) alone caused a strong induction of type I interferons, as assessed by IP‐10 production. Using siRNA, it was confirmed that LPS‐dependent signalling in adipocytes occurs via TLR4 utilizing the adapter molecules MyD88, Mal and TRIF and caused rapid degradation of IκBα. Pam3CSK4 signalling utilized TLR2, MyD88 and Mal (but not TRIF). However, the response to poly(I:C) observed in these cells appeared not to require TRIF, but MyD88 was required for induction of NFκB‐dependent cytokines by Poly(I:C). Despite this, IκBα degradation could not be detected in poly(I:C) stimulated adipocytes at any time‐point up to 4 h. Indeed, IL‐6 transcription was not induced until 8–16 h after exposure. These data suggest that Pam3CSK4 and LPS signal via the expected routes in human adipocytes, whereas poly(I:C)/TLR3 signalling may act via a TRIF‐independent, MyD88‐dependent route.

Role of reconstructive surgery in the management of head and neck cancer: A national outcomes analysis of 11,841 reconstructions

BACKGROUND The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis. METHODS An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003-2013 national activity. RESULTS The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site (n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision (n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm (n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days (P < 0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66-3.38; P < 0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed. CONCLUSIONS Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes.

Caustic ingestion injury of the upper aerodigestive tract in adults.

Adult ingestion of caustic substances is an unusual but serious surgical problem, with injuries likely to be more extensive than those in the corresponding paediatric population. After initial stabilisation and airway management, clinicians are presented with a complex multisystemic problem, frequently requiring a multidisciplinary approach involving several surgical disciplines and associated therapies. A new multidisciplinary team was convened to discuss complex ingestion injury in adults and established techniques were used to bring forward a proposed treatment algorithm. An algorithm may potentially improve clinical efficacy and risk in the management of these complex patients.

PET-CT imaging in patients with chronic sternal wound infections prior to reconstructive surgery: A case series

Late presenting and recurrent sternal wound infections post-sternotomy are difficult to treat, with the clinical picture not necessarily reflecting the underlying problem. As a result of our experience, we suggest that these chronic cases should be managed using a different algorithm to acute sternal wound infection. Positron emission tomography combined with computerized tomography (PET-CT) imaging may be potentially useful in enabling accurate localization of disease sites, which guides adequate debridement prior to definitive reconstruction. It may also allow for disease surveillance and monitoring of the response to antimicrobial treatment. We present three cases which support the need for pre-operative imaging using PET-CT.

A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty: Have we improved over 15 years?

In 1996 we published a study evaluating the difference between patient and surgeon opinion on the aesthetic outcome of reduction mammaplasty (see Ref. 1). The patients rated the aesthetic outcome of their surgery as significantly higher than the consultant panel. The surgical panel suggested scope for improvement. Areas of dissatisfaction were poor scarring, high placement of the nipple areola complex and high rates of revision surgery. Fifteen years on, the same team has regrouped to repeat this assessment. In 1996 the consultants scored their own patient results. In 2011 they graded the results of their former trainee who has modified her operative technique to address aesthetic problems highlighted in the first study. Forty-four patients attended a review clinic at least one year post reduction mammaplasty. Patient scored their satisfaction using the original questionnaire employed in 1996. The cohort were photographed and their images graded blindly by the original surgical panel. Statistical analysis was performed by the original statistician. The patients graded aesthetic aspects of body harmony, breast mound appearance, nipple areolar complex appearance and post-operative scarring significantly more positively (p<0.01) than both the 1996 patient cohort and surgical panel. The consultant panel showed a trend for more positive grades for all aesthetic features assessed versus their previous views but this was only significant for breast mound symmetry. They expressed that there was a decrease in post-operative breast ptosis (p<0.04) and improvement in the nipple areolar complex position (p=0.02). The rate of revision surgery has decreased from 53% to 16% between the studies. In keeping with clinical audit, outcomes have been assessed and modifications implemented to address aesthetic concerns. Assessment of outcomes following the modifications demonstrates a trend for increased patient and surgeon satisfaction. Patient satisfaction however still exceeds that of the surgeons.

Preserving a patent DIEP pedicle to facilitate salvage breast reconstruction with a second free flap: A case report

Surgeons performing free flap breast reconstruction need to have a range of techniques in their armamentarium to successfully salvage cases of flap failure. We present a case of 47‐year‐old patient who suffered near‐total right breast deep inferior epigastric perforator (DIEP) flap failure 3 days post‐bilateral immediate breast reconstruction with DIEP flaps. At debridement, the DIEP pedicle was noted to be patent with preserved perfusion to a small segment of tissue around the origin of the pedicle. This tissue and the DIEP pedicle itself were therefore preserved to facilitate subsequent breast reconstruction using stacked transverse upper gracilis flaps anastomosed end‐to‐end to the original DIEP pedicle. Post‐operatively, both flaps remained viable with no further complications and symmetrical aesthetic result maintained at 2 months follow‐up post‐salvage procedure. This case emphasizes the importance of exercising caution during initial debridement for free flap failure to preserve viable tissue in the flap and pedicle, particularly in circumstances where vascular flow in the pedicle is maintained, to facilitate successful salvage reconstruction.