Category: National Laser Institute

Intra-articular Osteotomy for Malunited Proximal Interphalangeal Joint Fracture

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imageBackground
Intra-articular malunion of the proximal interphalangeal joint is challenging. Multiple treatment options vary from arthrodesis to different types of osteotomy procedures. The aim of this study was to evaluate the effectiveness of intra-articular osteotomy in treating malunited proximal interphalangeal (PIP) joint fractures.
Materials and Methods
Fifty-nine consecutive patients with chronic PIP joint fractures were presented to us from May 2007 to December 2017. Sixteen joints of 15 patients were malunited PIP fracture without severe cartilage damage and underwent intra-articular osteotomy. The average interval from injury to operation was 4 (1–48) months. The mean duration of follow-up was 9 (2–43) months. Radiographic evidence of bone healing, joint alignment, range of motion of PIP, and distal interphalangeal joints were documented and assessed.
Result
Fifteen patients underwent intra-articular osteotomy. The average age was 32 (15–54) years. Fourteen of them were males. Fractures affect 9 middle phalangeal bases and 7 proximal phalangeal heads. Bony union was obtained in all patients by 6 to 10 weeks after surgery. Pain was relieved in 14 patients and the deformity was corrected in 12 joints of 11 patients. The average arc of motion for involved PIP joints was improved from 30.3 (10.0–39.1) degrees to 68.4 (7.2–75.6) degrees. One patient arose painful degenerative arthritis after surgery. Ten patients were satisfied or very satisfied.
Conclusions
For malunited PIP joint fracture without severe cartilage damage, intra-articular osteotomy provides predictable functional recovery and minimal donor site sacrifice.

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A Drain-free Technique for Female-to-Male Gender Affirmation Chest Surgery Decreases Morbidity: Outcomes From 306 Consecutive Masculoplasties

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imagePurpose
One of the most common surgical procedures for gender affirmation surgery of the chest is mastectomy. The aims of this article are to review the outcomes of a single surgeon’s experience with a drainless technique, which we named “masculoplasty” and compare morbidity in this group to previously published outcomes where drains were used.
Methods
A retrospective chart review was undertaken of all patients presenting to a single surgeon for gender-affirming chest surgery. A literature review was completed, compiling data from previously published studies of mastectomy with free nipple graft for the transgender patient. Outcomes of this drain-free group were compared with historical data, where drains were known to have been used.
Results
One hundred fifty-three patients underwent 306 masculoplasties in a university teaching hospital. The mean age of patients was 30 years (17–66 years). Sixty-five (42%) had 1 or more chronic medical comorbidities with 17 diabetic patients (11%). The mean body mass index was 32 kg/m2 (18–57 kg/m2), and 83 (54%) were obese. Forty-two (27%) of the patients had a history of smoking. Mean operative time was 136 minutes (74–266 minutes).
Hematoma occurred in 1 patient (0.3%). Infections occurred in 7 masculoplasties (2%) with wound dehiscence in 3 (1%). Two masculoplasties (0.7%) had partial nipple necrosis. Two patients (0.7%) developed a symptomatic pneumothorax. There were 0 seromas, and no procedures were performed to drain fluid. Eight masculoplasties (3%) underwent secondary corrections. Median follow-up was 9 months.
Outcomes from this drain-free technique were compared with previously published outcomes of mastectomy where drains were known to be used. When compared with previously published series (n = 1334), the drain-free group had statistically significantly lower rates of hematoma (1/306 vs 39/1334, P = 0.0036) and acute reoperation (1/306 vs 42/1334, P = 0.0024). There was a shorter length of hospital stay in the drain-free group with a statistically significantly lower revision rate (8/306 vs 116/1334, P = 0.0001).
Conclusions
Gender affirmation chest surgery can be safely offered using a drain-free or “masculoplasty” technique. Compared with historical data, the use of progressive tension sutures decreases the incidence of hematoma, the need for acute reoperation, and other complications.

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Effects of Dressing Materials on Donor Site Morbidity: A Comparative Study at a Tertiary Hospital in Kenya

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imageSkin graft donor wounds should heal with rapid epithelialization resulting in good aesthetic and minimal donor site morbidity. Several dressing materials are now available for the dressing of the donor sites. Few studies have, however, been done to compare the efficacy of these dressing materials.
This study compared the effectiveness of paraffin gauze, hydrocolloid, antimicrobial biguanide foam, and silver hydrofiber dressings on donor site wounds at a tertiary hospital in Kenya.
Patients who underwent split-thickness skin graft were recruited and randomized into 4 arms. The donor site wound was dressed with either of the 4 dressing material mentioned earlier. The patient and observers were blinded. Outcome variables that were assessed were donor site pain on days 1, 3, and 10, and infection and percentage epithelialization on day 10.
Wounds dressed with hydrocolloids were the least painful on all the 3 postoperative days assessed. Those dressed with paraffin gauze were the most painful on day 1, whereas those with antimicrobial foam were the most painful on the 10th day. The mean (SD) percentage epithelialization of the wounds on the 10th day were as follows; hydrocolloids, 92.2% (20.9%); silver hydrofiber, 91.4% (18.8%); paraffin gauze, 73.4% (24.9%); and antimicrobial biguanide foam, 11.0% (10.3%). Paraffin gauze dressed wounds were the most infected at 22%.
In conclusion, all the 4 dressing materials had different scores among the factors assessed. Hydrocolloids dressings and silver hydrofiber dressing would, however, be the preferred dressing materials for the donor site based on these study findings as reflected by the high epithelialization low infection rates and less pain.

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The Management and Prognosis of Facial and Scalp Angiosarcoma: A Retrospective Analysis of 15 Patients

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imageBackground
Angiosarcomas are extremely aggressive malignant tumors that arise from vascular endothelial cells. The risk factors, etiology, prognostic factors, and optimal management strategies for angiosarcomas are as yet unknown.
Methods
We retrospectively analyzed data from 15 patients who were treated in Asan Medical Center, Seoul, Republic of Korea, in the past 12 years, to assess the effect of different treatment modalities and reconstructive methods on the locoregional recurrence, metastasis, and overall survival.
Results
A total of 15 patients were identified (median age at diagnosis, 72 years; range, 61–82 years). Median tumor size was 6 cm. Median follow-up was 287 days. The median overall survival was 14.96 months; a total of 13 (87%) patients had died by the end of the study.
The median locoregional recurrence, metastasis, and overall survival were 7.3, 6.5, and 16.7 months, respectively. On univariate analysis, the use of adjuvant therapy after surgery (vs surgery without adjuvant therapy) was associated with delayed median time to detection of recurrence (7.9 months vs 3.1 months, respectively; P = 0.825), delayed median time to metastasis (8.7 months vs 3.1 months, respectively; P = 0.191), and better median overall survival (7.3 months vs 3.1 months, respectively; P = 0.078).
The use of flap versus skin graft as a reconstructive method was associated with delayed median recurrence (8.75 vs 7.32 months, respectively; P = 0.274) and earlier median metastasis (3.75 vs 6.53 months, respectively; P = 0.365), but the same median overall survival of 16.7 months (P value: 0.945) and tumor smaller or bigger than 5 cm show earlier median time to detection of recurrence (4.17-7.32 months; P = 0.41), earlier median time to metastasis (3.75-6.53 months; P = 0.651), but better median overall survival of 18.21 versus 16.7 months, respectively (P = 0.111).
Conclusions
Multimodal treatment that combines surgery with adjuvant therapy is the best management strategy that influences survival positively in patients with angiosarcoma. The study shows that the reconstructive method does not affect the prognosis in these patients. So it is better to choose the simplest suitable resection and reconstructive method with the least complications and to avoid unnecessary procedures.

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Clinical Utility of Postoperative Computed Tomography Imaging in Orbital Floor Fracture Management

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imageBackground
Surgical repair of orbital floor fractures aims to improve visual function and appearance. Postoperative care often involves computed tomography (CT) imaging in addition to physical examination. It has yet to be investigated whether postoperative CT imaging influences treatment of orbital floor fractures.
Methods
A retrospective chart review was conducted for all patients who underwent orbital floor fracture repair at University of California, Irvine, from 2008 to 2017. Demographics, injury characteristics, and presurgical and postsurgical management were retrospectively extracted for 217 cases. Patients who experienced a change of care following postoperative CT (n = 6) were compared with the entire patient cohort.
Results
Postoperative CT imaging influenced orbital floor fracture management in 6 patients (7.2% of patients with imaging). The positive predictive value of a postoperative CT scan was 10.3%, compared with 17.6% for a physical examination. An estimated $2013.76 was spent to obtain a postoperative CT scan that revealed 1 additional patient who needed reoperation (number needed to treat = 14). A multivariate regression model demonstrated no association between postoperative CT scans and change in management (P = 0.995).
Conclusions
In this patient cohort, postoperative CT imaging and its associated costs did not significantly benefit management of orbital floor fracture repair. Careful clinical physical examination should be emphasized over postoperative CT imaging to reliably determine the necessity for reoperation in orbital floor fracture management.

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Abnormal Presentation of Aggressive Fibromatosis After Radiotherapy for Keloids: Case Report and Brief Literature Review

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imageRationale
Keloids, dermal fibroproliferative lesions, often occur secondary to skin injury and extend beyond the margins of the original lesion. Aggressive fibromatosis (AF) is a rare condition arising from fibroblasts and is characterized clinically as a nonmetastasizing but locally invasive tumor. In this work, we present the case of a patient who developed AF in the chest 3 years after surgery and postoperative radiotherapy for keloids.
Patient Concerns
A 15-year-old female patient who underwent surgery and postoperative radiotherapy for keloids presented with AF in the chest 3 years after intervention.
Diagnoses and Outcomes
Physical examination revealed a fan-shaped scar on the manubrium sterni with a radius of 7 cm, as well as a 9 (L) × 2-cm (W) longitudinal reddish and irregularly surfaced scar arising from previous incisions. By comparing this case with similar cases reported previously, we infer that a history of exposure to radiation is the main factor that contributes to the development of AF in patients suffering from keloid scars. We also discussed the clinical characteristics of AF and treatment options and suggest factors that should be considered when using radiotherapy in patients with keloids.
Lessons
To our knowledge, this is the first reported case of AF developing in a patient after radiotherapy for keloids. Radiotherapy may be a causal factor of AF.

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Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines

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imageIntroduction
Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery.
Methods
This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included.
Results
Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days.
Conclusions
Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

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Diagnostic Criteria for Symptomatic Neuroma: Erratum

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No abstract available

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Clinical Application of a Specific Simulation Software for 3-Dimensional Orbital Volume Modeling for Orbital Wall Reconstruction

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imageIn this study, we developed a new 3-dimensional (3D) preoperative planning software and investigated its effectiveness by measuring orbital volume change. Fifty-six patients who underwent unilateral orbital wall reconstruction between December 2015 and February 2018 in our institute were recruited. We developed an orbit-specific automatic 3D modeling software (Osteopore CMF 3D) that can automatically detect orbital fracture site, process mirroring, measure volume, and then produce a customized orbital implant. Using preoperative and postoperative 3D computed tomography, orbital volume was measured and compared between Osteopore CMF 3D and the widely used Mimics. Intraclass correlation coefficient between Osteopore CMF 3D and Mimics showed 90.6% concordance for preoperative injured site orbital volume and 86.7% concordance for postoperative orbital volume, both being statistically significant (preoperative intraclass correlation coefficient, 0.906 [confidence interval {CI}, 0.840–0.945; P < 0.000]; postoperative intraclass correlation coefficient, 0.867 [CI, 0.773–0.922; P < 0.000]). For uninjured sites, the 2 software packages showed 76.6% preoperative concordance and 83.9% postoperative concordance, both being statistically significant (preoperative intraclass correlation coefficient, 0.766 [CI, 0.600–0.863; P < 0.000]; postoperative intraclass correlation coefficient, 0.839 [CI, 0.725–0.905; P < 0.000]). This study introduces our newly developed 3D surgical planning software specialized for orbital wall reconstruction and demonstrates its performance to be comparable with that of a widely used software.

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Postural Changes After Abdominoplasty in Morbid Obese Patients

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Skin Care news and information found at www.SpaTreatmentTraining.com brought to you by National Laser Institute. Are you interested in a career that can train you to be a Med Spa technician? Want to become a certified Laser Hair Removal Specialist, Laser Tattoo Removal Specialist, Botox Injections or many more exciting Medical Spa courses? Enroll in the National Laser Institute and find yourself on the fast track to success.

imageBackground
In the multidisciplinary treatment of obesity, the role of a plastic surgeon is to remove the excess of skin after weight loss to obtain cosmetic, functional, and psychological benefits. Obesity modifies body geometry, increases the mass of different segments, and imposes functional limitations in life activities that may predispose the obese to injury. The authors evaluated the postural conditions of obese patients, before and 12 months after surgery.
Methods
The study included 15 obese patients of both genders affected by class II obesity. Postural function was evaluated preoperatively and 12 months postoperatively. Patients underwent conventional abdominoplasty surgical procedure. In all patients, plantar pressure distribution and balance (stabilometric test) were evaluated before and 3 months after surgery.
Results
The static pedobarographic revealed a significant reduction in forefoot peak pressure; total plantar force; rearfoot plantar force percentage; midfoot plantar force percentage; and forefoot, midfoot, and rearfoot plantar contact areas percentage 3 months after surgery; the dynamic’s one showed a reduction in the first metatarsal peak pressure and plantar contact. The stabilometric values showed a reduction in the range of center of foot pressure (CP) displacement along y axis, the average displacement of the CP speed from the mean (RMS y velocity), and CP mean peak in the condition of vision.
Conclusions
Our study demonstrates the beneficial effect of dermolipectomies and the consequential weight loss on postural stability of obese men. Such findings may support the hypothesis that dermolipectomy may improve postural stability with and without vision. The data demonstrate that the benefits are related to the magnitude of the resected tissue.

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