Stefan Danilla

Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial

Objectives:To determine the effectiveness of the negative pressure closure (NPC) technique in the integration of split-thickness skin grafts (STSG) to the recipient site. Methods:Randomized, double-masked, controlled trial. Setting: A tertiary burn unit. Patient characteristics: Between May 2003 and October 2004, 60 patients having wounds with skin loss which hindered primary closure, were incorporated to this study. We excluded patients with ≥20% of total body surface burns, polytraumatized, surgical contraindications, those who were enlisted in other clinical trials, and those who rejected the informed consent. Interventions: In all the patients, surgical cleaning of the recipient site and STSG were performed after which they were randomly assigned between 2 groups: a group that received a NPC dressing and were connected to the central aspiration system at −80 mm Hg versus a control group with similar dressing but without connection to negative pressure. Loss of STSG area at the fourth postoperative day, days of hospital stay. Results:Sixty patients were included. The median loss of the STSG in the NPC group was 0.0 cm2 versus 4.5 cm2 in the control group (P = 0.001). The median hospital stay was of 13.5 days in the NPC group versus 17 days in the control group (P < 0.001). Conclusions:The use of NPC significantly diminishes the loss of STSG area, as well as shortens the days of hospital stay. Therefore, it should be routinely used for these kinds of procedures.

A Prospective, Randomized, Double-blind, Controlled Clinical Trial Comparing Laser-assisted Lipoplasty with Suction-assisted Lipoplasty

Background: The authors randomized and prospectively analyzed their clinical experience with the use of internal neodymium:yttrium-aluminum-garnet low-level laser-assisted lipoplasty compared with suction-assisted lipoplasty. Methods: Suction-assisted lipoplasty was generated through a SmartLipo machine and delivered into the subcutaneous tissues through 2-mm solid optical probes. Ipsilateral suction-assisted lipoplasty and contralateral laser-assisted lipoplasty were performed on one or more comparable topographic areas of the body in the same patient. Laser-assisted lipoplasty and suction-assisted lipoplasty sides of 25 patients were compared with preoperative and postoperative photographs at 3 to 5 days, 12 to 15 days, and 6 to 11 months. Statistical analysis considered surgeon and patient satisfaction, time used in the procedures, learning curves, lipocrits, operative technique, postoperative pain, edema, ecchymosis, time of recovery, body mass index, DNA proteins, free fatty acids, and cytologic patterns of post–laser-assisted lipoplasty and suction-assisted lipoplasty adipocyte architecture. Photographs were sent to the patients (blinded to the operated sides) and two plastic surgeons unfamiliar with the cases for evaluation of results. Results: All patients completed the preestablished follow-ups. No complications were observed. Less pain, lower lipocrits, higher triglycerides, and DNA cellular membrane traces were detected in the laser-assisted lipoplasty sides. All other considerations studied showed no differences with either technique in the three periods of the follow-up controls. Cytologic studies showed more damage of the adipocytes in the laser-assisted lipoplasty sides. Conclusions: No major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty were found. Higher concentrations of free-fatty acids after laser-assisted lipoplasty must alert us to possible hepatic and renal toxicity.

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction.

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.

Measuring common outcome measures and their concepts using the International Classification of Functioning, Disability and Health (ICF) in adults with burn injury: A systematic review

PURPOSE To identify and quantify the health related concepts contained in the most common outcome instruments used in adult burn care, and to compare the content of these instruments based on their linkage to the International Classification of Functioning, Disability and Health (ICF). The ICF has been validated as a reference tool by the World Health Organization and is a framework that incorporates physical, emotional, environmental and social aspects of daily functioning. METHODS Electronic searches of MEDLINE, EMBASE CINAHL, PsychINFO and the Cochrane Library from 2003 onwards were carried out using a predetermined search strategy. Specific characteristics of the included studies and data pertaining to the outcome instruments were extracted. Two reviewers independently categorised the underlying concepts contained in the most commonly used outcome measures and linked them to ICF categories using standardised linkage rules. RESULTS Out of a total 132 included studies, 151 outcome instruments were identified. Of these, 14 frequently used generic and burn-specific instruments were selected for linkage to the ICF. From the 381 items contained in the 14 instruments, 356 concepts were extracted and subsequently linked to 99 ICF categories. Nearly 46% of the concepts were linked to body function and 20% to activities and participation, whereas only a few concepts were formally linked to health condition, body structures and personal or environmental factors. CONCLUSION The ICF proved highly useful for the content comparison of frequently used generic and burn-specific instruments. The results may provide clinicians and researchers with new insights when selecting health-status measures for clinical studies in those with burn injury.

Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: A systematic review

INTRODUCTION Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians. METHODS Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients. RESULTS The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain. CONCLUSION The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.

Methodological quality of randomised controlled trials in burns care. A systematic review

OBJECTIVE To evaluate the methodological quality of published randomised controlled trials (RCTs) in burn care treatment and management. METHODS Using a predetermined search strategy we searched Ovid MEDLINE (1950 to January 2008) database to identify all English RCTs related to burn care. Full text studies identified were reviewed for key demographic and methodological characteristics. Methodological trial quality was assessed using the Jadad scale. RESULTS A total of 257 studies involving 14,535 patients met the inclusion criteria. The median Jadad score was 2 (out of a best possible score of 5). Information was given in the introduction and discussion sections of most RCTs, although insufficient detail was provided on randomisation, allocation concealment, and blinding. The number of RCTs increased between 1950 and 2008 (Spearmans rho=0.6129, P<0.001), although the reporting quality did not improve over the same time period (P=0.1896) and was better in RCTs with larger sample sizes (median Jadad score, 4 vs. 2 points, P<0.0001). Methodological quality did not correlate with journal impact factor (P=0.2371). CONCLUSIONS The reporting standards of RCTs are highly variable and less than optimal in most cases. The advent of evidence-based medicine heralds a new approach to burns care and systematic steps are needed to improve the quality of RCTs in this field. Identifying and reviewing the existing number of RCTs not only highlights the need for burn clinicians to conduct more trials, but may also encourage burn health clinicians to consider the importance of conducting trials that follow appropriate, evidence-based standards.

Full-face carbon dioxide laser resurfacing: a 10-year follow-up descriptive study.

Background: The purposes of this study were to retrospectively compare the 1-, 5-, and 10-year cosmetic outcomes of full-face carbon dioxide laser resurfacing using the SilkTouch technology, and analyze its advantages, disadvantages, and long-term results. Methods: Photographic results of full-face carbon dioxide laser resurfacing were evaluated after 1, 5, and 10 years. Statistical analysis considered surgeon and patient satisfaction based on a predetermined cosmetic visual analogue scale. Patients and two plastic surgeons unfamiliar with the cases evaluated objective postresurfacing results using Beausang’s grading system and a modified wrinkle assessment scale. Results: One hundred fifty-nine patients were treated and 46 patients completed 1-, 5-, and 10-year follow-up. Combined aesthetic procedures to the full-face carbon dioxide resurfacing were transcutaneous upper lid/lower lid transconjunctival blepharoplasty and endoscopic brow lifts in 15 patients. After 1 year, some relapse occurred, but the overall aesthetic result remained very good. At 5 and 10 years, respectively, 32 and 20 percent of the sample maintained good-quality skin texture; 22 and 19 percent achieved correction of skin pigmentation without scars; and 88 and 98 percent needed correction of recurrent rhytides, jowling, and redundant skin. Permanent hypopigmentation was found in four cases (8.7 percent). Conclusions: The authors’ early experience with the carbon dioxide laser was excellent, but after 1 year, they noticed lines of demarcation between treated and nontreated skin or persistent erythema. After 5 and 10 years, advantages were maintenance of good skin texture, ablation of fine wrinkles, and long-term correction of skin pigmentation. Disadvantages included permanent hypopigmentation of the mandible-neck junction, telangiectasia, and possible accentuation of skin redundancy.

Nonresective shrinkage of the septum and fat compartments of the upper and lower eyelids: a comparative study with carbon dioxide laser and Colorado needle.

Background: The purpose of this article is to describe an alternative nonresective treatment of the fat-septum component of the eyelids during blepharoplasty, using shrinkage desiccation with two low-energy modalities: a carbon dioxide laser and a low-range grid of electrocautery with a Colorado microdissection needle. Methods: Thirty-six patients underwent a four-lid blepharoplasty. During surgery, after exposure (not opening) of the septum and assessment of the amount of bulging by gentle globe compression, a grid spray of electrocautery (right eye) and carbon dioxide laser (left eye) was applied over the entire septum until shrinkage and correction of the bulging was achieved. Preoperative, postoperative day 15, and 1-year follow-up photographs were evaluated using an objective grading system by blinded surgeons. For statistical analysis, the Wilcoxon matched-pairs signed-ranks test was used, with p < 0.05 indicating statistical significance. Results: All the patients completed the 15-day evaluation, but only 32 completed the 1-year follow-up. No major eye or eyelids complications were observed. There were no statistical differences in surgical time and postoperative pain on either side. In this study, laser fat-septum shrinkage achieved substandard results compared with electrocautery when analyzed as a continuous variable, but it did not influence the categorical Strasser scale final result in the short- and long-term follow-up. Conclusions: The method described is simple and safe, and provides a subtle but long-lasting, adequate result. No statistical clinical differences were observed between the electrocautery and laser fat-septum shrinkage techniques.

Suction-assisted lipectomy fails to improve cardiovascular metabolic markers of disease: a meta-analysis.

BACKGROUND The purpose of this study was to determine whether suction-assisted lipectomy (SAL) decreases the incidence of early cardiovascular disease risk factors or its biochemical and clinical risk indicators. METHODS A systematic review of the literature was performed by conducting a predefined, sensitive search in MEDLINE without limiting the year of publication or language. The extracted data included the basal characteristics of the patients, the surgical technique, the amount of fat extracted, the cardiovascular risk factors and the biochemical and clinical markers monitored over time. The data were analysed using pooled curves, risk ratios and standardised means with meta-analytical techniques. RESULTS Fifteen studies were identified involving 357 patients. In all of the studies, measurements of predefined variables were recorded before and after the SAL procedure. The median follow-up was 3 months (interquartile range (IQR) 1-6, range 0.5-10.5). The mean amount of extracted fat ranged from 2063 to 16,300 ml, with a mean ± standard deviation (SD) of 6138 ± 4735 ml. After adjusting for time and body mass index (BMI), leptin and fasting insulin were the only markers that were significantly associated with the amount of aspirated fat. No associations were observed for high sensitive C-reactive protein (hCRP), interleukin-6 (IL-6), adiponectin, resistin, tumour necrosis factor-α (TNF-α), Homeostasis Model of Assessment (HOMA), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, free fatty acids or systolic blood pressure. CONCLUSIONS Based on the results of our analysis, we conclude that there is no evidence to support the hypothesis that subcutaneous fat removal reduces early cardiovascular or metabolic disease, its markers or its risk factors.

A new technique of "double-A" bilateral flaps based on perforators for the treatment of sacral defects.

Background: Myocutaneous and fasciocutaneous flaps can provide stable coverage of sacral defects. For neurologically intact patients, sensate innervated gluteal artery perforator flaps are the ideal solution. For patients with spinal cord injury, soft-tissue coverage can be performed with a variety of noninnervated flaps. Methods: Between 1997 and 2004, the authors operated on 30 patients, 21 men and nine women, using bilateral gluteal distal fasciocutaneous and proximal musculocutaneous vertical vector rotation-advancement flaps, based on perforators with V-Y closures. The ages of the patients ranged from 32 to 74 years. Twenty-five patients had spinal cord injuries and all had sacral pressure sores extending to the bone. Three patients had low-grade malignant tumors (sacral chordomas); one had a sacral radiation-induced necrosis and two senile patients with large sacral defects had chronic renal failure and multiple sclerosis. No comorbidities were found in the sample. Results: All the lesions were closed successfully. After follow-up of 1 to 8 years, 27 patients never required repeated surgery after wound complications. Three patients had infection and partial dehiscence of the flaps that healed after reoperation with V-Y readvancement; three died as a result of their primary diseases. Conclusions: This flap design has been used only in selected cases because, after its elevation, use of other gluteal-based flaps for future sacral reconstructions may not be possible. Five neurologically intact patients were found to have good sensitive protection of the flaps and adequate cushion contour after surgery because the authors conserved the gluteal arteries, perforators, and their corresponding sensory nerves.