Tomás Gómez-Cía

Digital imaging in remote diagnosis of burns

Images are capable of giving an accurate representation of skin color and have been used extensively in teaching about and researching burn therapy. The advance from analogue to digital imaging allows the remote transmission of the clinical information contained in the digital image of a burn, using a suitable system. The large size of these image files reduces transmission speed and makes data compression desirable. Compression, by means of the JPEG algorithm, of up to 50 times the original size of 38 digital images of burns suffered by 22 consecutive patients did not lessen its great usefulness in determining the depth of burn injuries, according to a group of experts in burn care. The success rate was close to 90%, both for non-compressed images in original BMP format (mean size:1500 Kb) and for compressed images with a Q index of 50 (30 Kb files), when compared with the clinical diagnoses confirmed one week after the accident.

Reconstruction of a Severe Facial Defect by Allotransplantation in Neurofibromatosis Type 1: A Case Report

BACKGROUND On January 26, 2010, our team performed a facial transplant for a patient with neurofibromatosis type 1. We detail the perioperative surgical strategies for the composite tissue allograft (CTA) of the lower parts of the face to restore a severe defect after excision of bilateral massive plexiform neurofibromas. The main distinctive feature included an innovative provisional heterotopic transplantation (PHT) technique of the facial allograft to the femoral vessels before its final orthotopic transplantation. CASE REPORT A 35-year-old Caucasian man received a CTA of the lower two-thirds of the face, including a chin osseous segment. The face was obtained from a non-heart-beating donor. The sequence of microsurgical procedures began by performing a PHT of the CTA to the recipients femoral vessels in the right thigh. Intraoperatively, he experienced considerable blood loss that required transfusion of 24 units of packed cells. Surgical revision was required at day 7 to remove an extensive hematoma in the right side of the CTA. The maintenance immunosuppressive regimen included steroids, mycophenolate mofetil, and tacrolimus. CONCLUSION We have reported a case of successful provisional transplantation of a human facial allograft onto the thigh as an alternative technique in human face transplantation. PHT was a reliable alternative procedure to obtain the facial allograft from a cadaveric donor.

Analysis of burn injury by digital simulation

A non-linear mathematical model for digital simulation of fluid distribution in burn patients during the first 48 h after injury is presented. The technique employed in the model construction is the system dynamic approach. A five-compartment model has been considered. The control mechanisms incorporated are adequate for describing the interactions between plasma and interstitial fluid and between the extra- and intracellular compartments. With the model we are able to analyse the dynamic behaviour of many variables, for example the plasma, interstitial, extra- and intracellular fluid volumes and the plasma and interstitial proteins in burn and non-burn areas. These values are very difficult to measure in daily clinical practice, although they indicate the actual state of a burn patient. The simulation results are compared with measured values in a series of patients from a burn unit in a general hospital.

Use of a three-dimensional virtual reality model for preoperative imaging in DIEP flap breast reconstruction.

BACKGROUND The significant variation in the vascular anatomy of the abdominal wall makes preoperative imaging essential when raising a deep inferior epigastric artery perforator (DIEP) flap due to the potential for maximizing operative success, reducing intraoperative error and minimizing operative complications. Computerized models and virtual reality applications are being used to facilitate teaching and preoperative evaluation in a number of other complex anatomical regions. The variability in perforator anatomy makes DIEP flap surgery a suitable candidate for application of such technology. In this context, a study was undertaken to determine the feasibility of computed tomography angiography (CTA)-guided VirSSPA three-dimensional (3D) software for virtual reality navigation in DIEP flap surgery and to compare findings with operative measurements. MATERIALS AND METHODS We recruited 12 consecutive patients planned for an elective DIEP flap for breast reconstruction. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and VirSSPA 3D reconstruction. Imaging findings were compared with operative findings. RESULTS In all cases, the major perforators were accurately localized using both methods. 3D reconstruction of the abdominal wall with VirSSPA demonstrated a significant good correlation with perforator location compared with operative findings, showing an average error rate of 0.23cm (95% CI, 0.17-0.30). CONCLUSION In short, the main advantage of VirSSPA, when used in conjunction with an image assessment such as CTA, is to provide additional and potentially more accurate data over conventional CTA with regard to the site of the best perforators and its course through the muscle.

A three-dimensional virtual reality model for limb reconstruction in burned patients.

Electrical burns are a common cause of injuries. Despite many developments in the treatment of high-tension electrical burns, this type of injury still shows high-morbidity rates. Recently, the use of free flaps for reconstruction in burned patients has increased due to advances in the field of microvascular free tissue transplantation [1]. Free flaps have reached a high level of sophistication. For instance, reexpanded flaps, composite tissue flaps, fascial flaps, multiple autologous flap transplantations and combined flaps (‘‘chimeric flaps’’) based on a single vascular pedicle have been performed in patients with severe burns and large defects in extremities [2]. Traditional methods of learning have helped generations of surgeons to familiarize themselves with flaps anatomy. Nevertheless, even texts with the highest level of accuracy and image quality are limited by the two-dimensional nature of printed material, which cannot impart three-dimensional (3D) views. Video material is similarly limited as to deliver a 3D experience. Another restriction of most traditional methods for the study of anatomy relates to the lack of interactivity and feedback. As a supplement to the knowledge gained from books and observation, cadaver dissections can play an

First Face Composite-Tissue Transplant Recipient Successfully Treated for Cytomegalovirus Infection with Preemptive Valganciclovir Treatment

ABSTRACT Little is known about cytomegalovirus (CMV) infection after face transplantation, since only two of the 11 cases of face transplantation reported worldwide have documented a CMV infection after transplantation. Herein, we present the first report of a composite-tissue face allotransplant recipient at high risk for CMV infection (D+/R− [CMV serpositive donor positive/CMV seronegative receptor]) undergoing preemptive treatment. Preemptive treatment was safe and effective for controlling CMV infection and thus promoting early acquisition of a CMV-specific immune response that protected the patient from late-onset CMV disease.

Facial transplantation: A concise update

Objectives: Update on clinical results obtained by the first worldwide facial transplantation teams as well as review of the literature concerning the main surgical, immunological, ethical, and follow-up aspects described on facial transplanted patients. Study design: MEDLINE search of articles published on “face transplantation” until March 2012. Results: Eighteen clinical cases were studied. The mean patient age was 37.5 years, with a higher prevalence of men. Main surgical indication was gunshot injuries (6 patients). All patients had previously undergone multiple conventional surgical reconstructive procedures which had failed. Altogether 8 transplant teams belonging to 4 countries participated. Thirteen partial face transplantations and 5 full face transplantations have been performed. Allografts are varied according to face anatomical components and the amount of skin, muscle, bone, and other tissues included, though all were grafted successfully and remained viable without significant postoperative surgical complications. The patient with the longest follow-up was 5 years. Two patients died 2 and 27 months after transplantation. Conclusions: Clinical experience has demonstrated the feasibility of facial transplantation as a valuable reconstructive option, but it still remains considered as an experimental procedure with unresolved issues to settle down. Results show that from a clinical, technical, and immunological standpoint, facial transplantation has achieved functional, aesthetic, and social rehabilitation in severely facial disfigured patients. Key words:Face transplantation, composite tissue transplantation, face allograft, facial reconstruction, outcomes and complications of face transplantation.

Fast parameter-free region growing segmentation with application to surgical planning

In this paper, we propose a self-assessed adaptive region growing segmentation algorithm. In the context of an experimental virtual-reality surgical planning software platform, our method successfully delineates main tissues relevant for reconstructive surgery, such as fat, muscle, and bone. We rely on a self-tuning approach to deal with a great variety of imaging conditions requiring limited user intervention (one seed). The detection of the optimal parameters is managed internally using a measure of the varying contrast of the growing region, and the stopping criterion is adapted to the noise level in the dataset thanks to the sampling strategy used for the assessment function. Sampling is referred to the statistics of a neighborhood around the seed(s), so that the sampling period becomes greater when images are noisier, resulting in the acquisition of a lower frequency version of the contrast function. Validation is provided for synthetic images, as well as real CT datasets. For the CT test images, validation is referred to manual delineations for 10 cases and to subjective assessment for another 35. High values of sensitivity and specificity, as well as Dice’s coefficient and Jaccard’s index on one hand, and satisfactory subjective evaluation on the other hand, prove the robustness of our contrast-based measure, even suggesting suitability for calibration of other region-based segmentation algorithms.

Psychological Effects Observed in Child Burn Patients During the Acute Phase of Hospitalization and Comparison With Pediatric Patients Awaiting Surgery

The main aim of this article is to examine, first, the emotional and behavioral reactions in children who have suffered burns, during their first days of hospitalization (N = 103) (ages, 1–17 years and average TBSA%, 12.84). In addition, in relationship to this question, the article compares a group of 33 of these children hospitalized for burns, with children awaiting surgery (N = 36), taking into account that all were awaiting surgery and all were from the same age group (6–14 years). The authors used the State-Trait Anxiety Inventory for Children (STAIC) and the Child Behavior Checklist (CBCL). For the population of 103 burn patients, the authors also used the Scale for Anxiety Behavior Observation during Hospitalization for the parents. The majority of children who suffer from burns are younger than 5 years. All present high levels of state anxiety and lower than average levels in trait anxiety. The older children suffer flame burns, which are greater in gravity and pain, require greater hospitalization time, and cause greater emotional and behavioral effects. The results of the comparison group show that the group awaiting minor surgery registered higher state anxiety (STAIC) levels and somatic complaints (CBCL). Where behavior is concerned, the children suffering from burns showed problems of attention and behavior (CBCL). The authors may conclude that the differences with respect to anxiety among child patients suffering from burns and those awaiting minor surgery are linked to the reason for hospital admission.

A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital

BACKGROUND Postmastectomy breast reconstruction involves the use of large amounts of hospital resources. This study provides comparative data on the clinical results and long-term economic costs of two methods of breast reconstruction in a public hospital. METHODS A prospective cohort study was performed to evaluate the costs incurred by delayed unilateral breast reconstruction performed using either the two-stage sequence expander/prosthesis (E-P) or autologous deep inferior epigastric flap (DIEP) method during 2005-2013 in 134 patients. The major evaluated variables included previous clinical records, history of radiotherapy, and number of surgical procedures. Total costs accounted for both direct intra- and extra-hospital costs derived from the initial reconstruction and those resulting from associated reoperations due to aesthetic retouches and/or complications. RESULTS Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction (3.07 vs. 2.32, p < 0.001) and showed higher rates of surgery-related complications (40.29% vs. 32.82%). No statistically significant differences were found between the two surgical methods in terms of total costs (€18857.77 DIEP vs. €20502.08 E-P; p = 0.89). In the E-P cohort, active smoking and history of radiotherapy were statistically significant risk factors of complications. In the DIEP group, only active smoking was significantly associated with complications. CONCLUSIONS Compared to the E-P method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable aesthetic results. E-P reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.