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Significance: Since the introduction of the first commercial negative pressure wound therapy (NPWT) system nearly three decades ago, several key technological innovations have led to the wide adoption of the therapy. This is a review of the history and innovation of commercial NPWT systems for adjunctive management of open wounds. Recent Advances: Technical modifications have broadened NPWT options to include innovative dressing interfaces, tubing configurations, power sources, capability of topical wound solution instillation or irrigation, canister versus canister-free configurations, smart technology, and disposable versus larger reusable therapy units. While these options complicate product selection, they have greatly expanded the potential to manage a wide variety of wounds in patients who previously may not have been candidates for NPWT. Critical Issues: Basic yet mandatory requirements of NPWT include delivering an accurate level of negative pressure to the wound bed, maintaining a seal, removing wound surface exudate through the dressing interface, and patient adherence to prescribed therapy. Meeting these requirements is challenging in the face of variable wound types, wound locations, exudate levels, and exudate viscosity. While there are a growing number of marketed NPWT systems, each may have different characteristics and performance. Evaluating the functionality of each system and relevant accessories is complicated, especially as additional manufacturers enter the market. Understanding the key innovations and specific challenges they are intended to solve may aid health care providers in selecting appropriate NPWT technologies for patients. Future Directions: Evolving technology, including artificial intelligence, will likely play a major role in redefining NPWT safety, simplicity, and reliability.

Background: Surgical site complication (SSC) rates in breast surgery have been reported between 2.25% and 53%. Use of incision management may help reduce the risk of SSCs. The potential of 2 closed incision negative pressure therapy (ciNPT) systems to mitigate surgical site complications (SSC) and surgical site infections (SSI) in breast surgery were assessed., Methods: A systematic literature review for breast surgery studies was conducted comparing ciNPT use against standard of care (SOC). SSC, SSI, and dehiscence rates were examined. SSCs were defined as all surgical site complications including SSI, dehiscence, seroma, hematoma, and necrosis. Risk ratios and random effects models were used to assess the effect of ciNPT with multilayer absorbent dressing (ciNPT-MLA) and ciNPT with foam dressing (ciNPT-F) compared with SOC., Results: Eight articles were included in the meta-analysis. No significant differences in SSC rates ( P = .307) or SSI rates ( P = .453) between ciNPT-MLA and SOC were observed. ciNPT-MLA use was associated with a reduction in dehiscence compared with SOC (RR = 0.499, 95% CI = 0.303, 0.822; P = .006). A significant reduction in SSC rates (RR = 0.498, 95% CI = 0.271, 0.917; P = .025) was observed with ciNPT-F use. Similarly, dehiscence rate reduction was associated with ciNPT-F use (RR = 0.349, 95% CI= 0.168, 0.725; P = .005). A trend towards reduction of SSI rates with ciNPT-F use compared with SOC was also noted ( P = .053)., Conclusions: Compared with SOC, ciNPT-MLA significantly reduced rates of dehiscence, while ciNPT-F use resulted in significantly reduced SSC and dehiscence rates with a trend toward reducing SSI., (© 2024 HMP Global. All Rights Reserved. Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.)

Background: Surgical site complications (SSCs) pose a significant risk to patients, potentially leading to severe consequences or even loss of life. While previous research has shown that closed incision negative pressure therapy (ciNPT) can reduce wound complications in various surgical fields, its effectiveness in abdominal incisions remains uncertain. To address this gap, a systematic review and meta-analysis were conducted to assess the impact of ciNPT on postsurgical outcomes and health care utilization in patients undergoing open abdominal surgeries., Methods: A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT with standard of care dressings for patients undergoing abdominal surgical procedures between January 2005 and August 2021. Characteristics of study participants, surgical procedures, dressings used, duration of treatment, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Dichotomous outcomes were summarized using risk ratios and continuous outcomes were assessed using mean differences., Results: The literature search identified 22 studies for inclusion in the analysis. Significant reductions in relative risk (RR) of SSC (RR: 0.568, P = .003), surgical site infection (SSI) (RR: 0.512, P < .001), superficial SSI (RR: 0.373, P < .001), deep SSI (RR: 0.368, P =.033), and dehiscence (RR: 0.581, P = .042) were associated with ciNPT use. ciNPT use was also associated with a reduced risk of readmission and a 2.6-day reduction in hospital length of stay ( P < .001)., Conclusions: These findings indicate that use of ciNPT in patients undergoing open abdominal procedures can help reduce SSCs and associated hospital length of stay as well as readmissions.A previous version of this abstract was presented at the 2023 Conference of the European Wound Management Association (EWMA) in Milan, Italy and posted online at the site listed below. EWMA permits abstracts to be republished with the complete manuscript. https://journals.cambridgemedia.com.au/application/files/9116/8920/7316/JWM&#95;Abstracts&#95;LR.pdf., (© 2024 HMP Global. All Rights Reserved. Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.)

Retinopathy of prematurity (ROP) is a disorder affecting low birthweight, preterm neonates. In the preterm eye, the retina is not fully developed and neovascularization may occur at the margin between the developed vascular retina and undeveloped avascular retina. Without timely treatment by laser or intravitreal anti-vascular endothelial growth factor (VEGF) therapy, this can lead to tractional retinal detachment and blindness. Visualization of the retina in regular examinations by indirect ophthalmoscopy is hence the current standard of care, but the exams are stressful and interpretation of images is subjective. The upregulation of VEGF in ROP would suggest an increase in ocular blood flow. In this report, we evaluate the potential of ultrafast plane-wave Doppler ultrasound (PWU) to detect increased flow velocities in the orbital vessels supplying the eye in a gentle exam with objective findings. We imaged both eyes of 50 low-birthweight preterm neonates using 18 MHz PWU. Flow velocity in the central retinal artery (CRA) and vein (CRV), and the short posterior ciliary arteries were determined and values at each ROP Stage compared. We found significantly increased velocities in the CRA and CRV in Stage 3 ROP eyes, where intervention would be considered. We compared multivariate models for identifying Stage 3 eyes comprised solely of clinical factors, solely of Doppler parameters, and clinical plus Doppler parameters. The respective models provided areas under their respective ROC curves of 0.760, 0.812, and 0.904. PWU Doppler represents a gentle, objective means for identifying neonates at risk for ROP that could complement ophthalmoscopy., (© 2024. The Author(s).)

Closed incision negative pressure therapy (ciNPT) system use compared with standard of care dressings (SOC) on surgical site infection (SSI) in cardiac surgery was assessed. A systematic literature review was conducted. Risk ratios (RR) and random effects models were used to assess ciNPT with foam dressing (ciNPT-F) or multilayer absorbent dressing (ciNPT-MLA) versus SOC. Health economic models were developed to assess potential per patient cost savings. Eight studies were included in the ciNPT-F analysis and four studies were included in the ciNPT-MLA analysis. For ciNPT-F, a significant reduction in SSI incidence was observed (RR: 0.507, 95% confidence interval [CI]: 0.362, 0.709; p < 0.001). High-risk study analysis reported significant SSI reduction with ciNPT-F use (RR: 0.390, 95% CI: 0.205, 0.741; p = 0.004). For ciNPT-MLA, no significant difference in SSI rates were reported (RR: 0.672, 95% CI: 0.276, 1.635; p = 0.381). Health economic modelling estimated a per patient cost savings of $554 for all patients and $3242 for the high-risk population with ciNPT-F use. Health economic modelling suggests ciNPT-F may provide a cost-effective solution for sternotomy incision management. However, limited high-quality literature exists. More high-quality evidence is needed to fully assess the impact of ciNPT use following cardiac surgery., (© 2024 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Objectives: Preeclampsia (PE) is a severe complication of pregnancy characterized by hypertension, proteinuria and compromised fetal blood supply. The eye, like other end organs, is affected by this systemic condition, but unlike in other organs, ocular media transparency allows high-resolution optical visualization of the vascular structure of the retina. Our aim was to assess how ultrasound-determined ocular blood-flow correlates with vascular structure of the retina and choriocapillaris determined by optical coherence tomography angiography (OCTA)., Methods: Plane-wave ultrasound and OCTA were performed on both eyes of 40 consecutive subjects consisting of normal controls (n = 11), mild PE (n = 5), severe PE (n = 17) and chronic or gestational hypertension (n = 7) within 72 hours following delivery. From ultrasound, we measured pulsatile flow velocity and resistance indices in the central retinal artery (CRA) and vein, the short posterior ciliary arteries (SPCAs) and choroid. From OCTA, we measured vascular density (VD) in the superficial, deep retina and choriocapillaris. We determined differences in Doppler and OCTA parameters among groups and correlations between ultrasound and OCTA., Results: In severe PE, flow resistance was reduced with respect to controls. Flow velocity and resistance in the and SPCA were moderately correlated with VD in the choriocapillaris and peripapillary retina, but VD in PE did not differ significantly from controls., Conclusions: Although OCTA parameters were moderately correlated with Doppler ultrasound, OCTA did not demonstrate significant differences between PE and controls postpartum., (© 2023 American Institute of Ultrasound in Medicine.)

Purpose: To establish a quantitative metric of posterior eyewall deformability in different directions of gaze in highly myopic eyes with and without posterior staphyloma., Methods: A prospective study was performed on 53 highly myopic patients (106 eyes). Ultrasound scans were acquired in primary, up, downward, nasal, and temporal gazes. A validated intensity-based segmentation algorithm was used to quantify the posterior eyewall geometry on digitalized B-scan images. Posterior eyewall local curvature (K) and distance (L) to the transducer were calculated. The associations between directions of gaze, axial length (AL), and presence of staphyloma with the K and L parameters were assessed., Results: A total of 53 participants (106 eyes) were studied. Multivariate regression analysis demonstrated that, after accounting for longer AL, and presence of staphyloma, eccentric gaze was often independently associated with various K and L parameters. Specifically, downward gaze was associated with increased posterior eyewall concavity as reflected in the maximum of K (KMax) (β = 0.050, P < 0.001) and absolute value of KMax (β = 0.041, P = 0.011). Both downward gaze and upgaze were independently associated with increase in the derivative of absolute KMax (which is consistent with more apparent, steeper staphyloma ridges), local KMax (which detects KMax at smaller intervals), and Kstd (which represents likelihood of staphyloma presence) and decrease in maximum of L (which represents movement of the staphyloma apex) with all P < 0.05. The β coefficients for downward gaze were consistently greater in magnitude compared with those in upgaze. After accounting for AL and presence of staphyloma, horizontal gazes were independently associated only with decrease in the standard deviation of L (which also represents likelihood of staphyloma presence) and maximum of L., Conclusions: Downward gaze results in a significant increase in posterior eyewall concavity in highly myopic eyes after accounting for AL and staphyloma presence. In comparison with downward gaze, upgaze resulted in a lower magnitude, but significant changes in staphyloma ridge steepness and the likelihood of staphyloma presence. Horizontal gazes seemed to be associated with less posterior eyewall geometric parameters. Studies are required to further assess the association between downward gaze during near work on posterior eyewall concavity and possible effects on myopia development and progression.

Background: Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known., Methods: The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41., Results: In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r 2  = 0.51, p < 0.0001; HM3 "continuous-flow," r 2  = 0.32, p = 0.0009; HM3 "artificial pulse," r 2  = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients., Conclusions: The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs., (Copyright © 2023 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Negative pressure wound therapy (NPWT) is commonly used in wound management of both acute and chronic wounds. As wound care has advanced, traditional NPWT has evolved to include instillation and dwell time (NPWTi-d). To better understand the potential clinical benefits of NPWTi-d, an assessment of the available literature focusing on NPWTi-d mechanisms of action in wound management was conducted. Methods. A literature search was performed for abstracts and articles published between 2010 and 2023. Published studies in English that discussed NPWTi-d mechanisms of action and included a study population larger than 10 patients were examined., Results: A total of 1878 articles were identified through the literature search. After removal of duplicates and article reviews, 29 studies discussing the mechanisms of action for NPWTi-d were found. Study types included case series (n = 20), comparative study (n = 6), randomized controlled trial (n = 2), and retrospective study (n = 1). These studies included approximately 1108 patients who received NPWTi-d as part of a wound care treatment plan. NPWTi-d use was associated with improved wound and clinical outcomes through wound cleansing, removal of exudate and infectious materials, and promotion of granulation tissue development., Conclusions: The mechanisms of action for NPWTi-d helps provide wound management through wound cleansing, removal of exudate and infectious materials, and promoting the development of granulation tissue. Additional studies are warranted to fully assess the potential clinical and health economic benefits of NPWTi-d use., (© 2023 HMP Global. All Rights Reserved. Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.)

Closed incision negative pressure therapy (ciNPT) has been adopted into practices of diverse surgical specialties to help reduce postsurgical complication risks. There are two primary commercially available systems that deliver ciNPT through different mechanisms. The purpose of this meta-analysis is to compare the potential effects of two different ciNPT systems on clinical outcomes following hip and knee arthroplasty. A systematic literature search was conducted to identify hip and knee arthroplasty studies comparing the incidence of surgical site infections (SSIs) and surgical site complications (SSCs) versus standard of care (SOC) following the use of two different ciNPT systems. Four meta-analyses were performed by calculating risk ratios (RR) to assess the effect of (1) ciNPT with foam dressing (ciNPT-F) versus SOC and (2) ciNPT with multilayer absorbent dressing (ciNPT-MLA) versus SOC. Comprehensive Meta-Analysis Version 3.0 (Biostat Inc., Englewood, NJ) software was used to perform the analyses. Twelve studies comparing ciNPT-F to SOC and six studies comparing ciNPT-MLAto SOC were analyzed. SSI rates were reported in seven of 12 studies involving ciNPT-F. In those, ciNPT-F significantly reduced the incidence of SSI (RR = .401, 95% confidence interval (CI) = .190, .844; p = .016). Across four of six studies that reported SSI rates, there was no significant difference in SSI rates between ciNPT-MLAvs SOC (RR = .580, 95% CI = .222, 1.513; p = .265). SSC rates were evaluated in eight of 12 ciNPT-F studies that reported SSC rates. This meta-analysis of the eight ciNPT-F studies showed significantly reduced SSC rates with ciNPT-F vs SOC (RR = .332, 95% CI = .236, .467; p < 0.001). For ciNPT-MLA, five of six studies reported SSC rates. In those, there was no significant difference in SSC rates between ciNPT-MLA vs SOC (RR = .798, 95% CI = .458, 1.398; p = .425). These meta-analyses results showed a significant reduction in SSI and SSC rates in the ciNPT-F group vs SOC and no difference in SSI and SSC rates in the ciNPT-MLA group vs SOC. The reasons for these observed differences were not evaluated as part of this study. Future controlled clinical studies comparing outcomes between different ciNPT systems over closed orthopedic incisions would help to validate these study results., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Cooper et al.)

Background: Scleral cross-linking is a potential method to inhibit axial elongation of the eye, preventing the progression of pathological myopia. Formaldehyde releasers, which are common preservatives found in cosmetics and ophthalmic solutions, have been shown to be not only effective in cross-linking corneal collagen in vitro and in vivo, but also have minimal toxicity effects on the eye. The present study aims to evaluate the efficacy of scleral cross-linking using sodium hydroxymethylglycinate (SMG) to inhibit eye growth using an in vivo rabbit model., Methods: A cross-linking solution containing 40 mM SMG was delivered to the sub-Tenon's space behind the equator. The application regimen included a two-quadrant injection performed five times over 2 weeks on New Zealand White rabbits (n=5, group 1), and one-time injection followed for up to 5 days on Dutch-Belted rabbits (n=6, group 2). Group 1 was monitored serially for axial length changes using B-scan ultrasound for 5-6 weeks. Group 2 was injected with a higher viscosity solution formulation. Both groups were evaluated for thermal denaturation temperature changes of the sclera postmortem., Results: Axial growth was limited by 10%-20% following SMG treatment as compared with the untreated eye. Thermal denaturation analysis showed increased heat resistance of the treated eyes in the areas of injection. Overall, the SMG treatment inhibited eye growth with few side effects from the injections., Conclusions: Cross-linking solutions delivered via sub-Tenon injection provide a potential method for limiting axial length growth in progressive myopia and could be used as a potential treatment for myopia., Competing Interests: Competing interests: Patents issued through Columbia University: US Patent Nos. 8,466,203; 9,125,856; 10,105,350; and 10,292,967., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate the posterior and equatorial scleral thickness in patients with autosomal dominant Best disease, a condition that has chronic subretinal fluid., Methods: Retrospective study involving patients with Best disease and age-matched controls. Participants were evaluated with contact B-scan ultrasonography and enhanced depth imaging optical coherence tomography to evaluate scleral thickness in the posterior pole and equator. Univariate analysis and generalized estimating equations were used., Results: Of 9 patients with genetically proven Best disease and 23 age-matched controls, there was no significant difference in the age or the gender proportion between groups. Subfoveal choroidal thickness and axial length were not significantly different between groups. Both posterior scleral (OD; 1.38mm vs. 0.89mm, P<.001 and OS; 1.39mm vs. 0.83mm, P<.001) and equatorial scleral (OD; 0.61mm vs. 0.42mm, P=.003, and OS; 0.55mm vs. 0.41mm, P=.017) thicknesses were much greater in cases as compared with controls. Multivariate analysis showed male sex and having Best disease were each significant predictors of posterior scleral thickness and Best disease was the sole significant predictor for equatorial scleral thickness., Conclusion: BEST1 gene may have a developmental role leading to having a thicker sclera, influencing disease manifestation, and contributing to the accumulation of subretinal fluid in Best disease.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common surgical procedures but carry a risk of harmful and costly surgical site complications (SSCs). This systematic review and meta-analysis examined the impact of closed incision negative pressure therapy (ciNPT) on the risk of SSCs following THA and TKA., Methods: A systematic literature review identified studies published between January 2005 and July 2021 comparing ciNPT (Prevena Incision Management System) to traditional standard-of-care dressings for patients undergoing THA and TKA. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national database., Results: Twelve studies met the inclusion criteria. Eight studies evaluated SSCs, where a significant difference was seen in favor of ciNPT (relative risk [RR]: 0.332, P < .001). Significant benefits in favor of ciNPT were also observed for surgical site infection (RR: 0.401, P  = .016), seroma (RR: 0.473, P  = .008), dehiscence (RR: 0.380, P  = .014), prolonged incisional drainage (RR: 0.399, P  = .003), and rate of return to the operating room (RR: 0.418, P  = .001). The estimated cost savings attributed to ciNPT use was $932 per patient., Conclusions: The use of ciNPT after TKA and THA was associated with a significant reduction in the risk of SSCs, including surgical site infections, seroma, dehiscence, and prolonged incisional drainage. The risk of reoperation was reduced as were the costs of care in the modeled cost analysis, suggesting a potential for both economic and clinical advantages for ciNPT over standard-of-care dressings, particularly in high-risk patients., (© 2023 The Authors.)

Background: Surgical site complications (SSCs) are not uncommon in plastic surgery procedures due to characteristics of the incisions and the patients undergoing such procedures. Closed incision negative pressure therapy (ciNPT) has been used to manage surgical incisions across surgical specialties. This systematic review and meta-analysis examined the impact of ciNPT on risk of SSCs following plastic surgery., Methods: A systematic review was conducted to identify studies published between January 2005 and July 2021 comparing ciNPT versus traditional standard of care (SOC) dressings for patients undergoing plastic surgery. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national hospital database., Results: Sixteen studies met the inclusion criteria. In the 11 studies that evaluated the effect of ciNPT on of SSCs, ciNPT use was associated with a significant reduction in risk of SSC ( P < .001). ciNPT use was also associated with reduced risk of dehiscence ( P = .001) and skin necrosis ( P =.002) and improved scar quality ( P = .014). Hospital length of stay was decreased by an average of 0.61 days for patients receiving ciNPT ( P < .001). There were no differences in observed risk of SSIs ( P = .113) and seromas ( P = .143). While not statistically significant, a decrease in rate of reoperations ( P = .074), fluid volume removed from the drains ( P = .069) and drain days (-1.97 days, P = .093) was observed with ciNPT use. The estimated cost savings attributed to ciNPT use was $904 (USD) per patient., Conclusions: The findings suggest that ciNPT may reduce the incidence of SSCs and related health care utilization and costs in plastic surgery procedures.

Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes., Methods: A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments., Results: The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use ( P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT ( P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay ( P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use ( P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT ( P < 0.05)., Discussion: For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients., Competing Interests: Disclosure: Drs. H. J. Cooper, D. P. Singh, A. Gabriel, and C. Mantyh are consultants for 3M. Dr. R. Silverman and L. Griffin are employees of 3M., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: Ultrasound imaging of the eye was introduced over 50 years ago. While the physical principles of ultrasound imaging have not changed, technology has undergone tremendous and ongoing development., Areas Covered: The fundamentals of ultrasound physics, biometry (A-scan), structural imaging (B-scan) and blood-flow imaging and measurement (Doppler) will be described. Emphasis will be placed on technological development and potential future advances., Expert Opinion: While A- and B-scan ultrasound of the eye has traditionally been performed with focused single-element transducers, the introduction of annular and linear arrays has enhanced clinical utility. Future advances, especially in multielement arrays, and point-of-care systems promise amazing new capabilities for diagnostic imaging of the eye and orbit., Competing Interests: Declaration of interest R H Silverman has a financial interest in Arcscan, Inc. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

The aim of this study was to develop an eyewall curvature- and axial length (AxL)-based algorithm to automate detection (clinician-free) of staphyloma ridge and apex locations using ultrasound (US). Forty-six individuals (with emmetropia, high myopia or pathologic myopia) were enrolled in this study (AxL range: 22.3-39.3 mm), yielding 130 images in total. An intensity-based segmentation algorithm automatically tracked the posterior eyewall, calculating the posterior eyewall local curvature (K) and distance (L) to the transducer and the location of the staphyloma apex. By use of the area under the receiver operator characteristic (AUROC) curve to evaluate the diagnostic ability of eight local statistics derived from K, L and AxL, the algorithm successfully quantified non-uniformity of eye shape with an AUROC > 0.70 for most K-based parameters. The performance of binary classification (staphyloma absence vs. presence) was assessed with the best classifier (the combination of AxL, standard deviation of K and standard deviation of L) yielding a diagnostic validation performance of 0.897, which was comparable to the diagnostic performance of junior clinicians. The staphyloma apex was localized with an average error of 1.35 ± 1.34 mm. Combined with the real-time data acquisition capabilities of US, this method can be employed as a screening tool for clinician-free in vivo staphyloma detection., Competing Interests: Conflict of interest disclosure The authors report no competing financial interests nor conflicts of interest., (Copyright © 2022 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: The PROMISES (Post-market, Randomized, Open-Label, Multicenter, Study to Evaluate the Effectiveness of Closed Incision Negative Pressure Therapy Versus Standard of Care Dressings in Reducing Surgical Site Complications in Subjects With Revision of a Failed Total Knee Arthroplasty) randomized controlled trial compared closed incision negative pressure therapy (ciNPT) to standard of care (SOC) after revision total knee arthroplasty in high-risk patients. We assessed the costs associated with 90-day surgical site complications (SSCs) to determine the cost-benefit of ciNPT., Methods: A health economic model was used to determine mean per-patient costs to manage the surgical site, including the costs of postoperative dressings, surgical and non-surgical interventions, and readmission. A subanalysis was performed to examine cost-benefit in "lower risk" (Charlson Comorbidity Index < 2) and "higher risk" (Charlson Comorbidity Index ≥ 2) patients., Results: Patients with ciNPT experienced fewer SSCs (3.4% vs 14.3%; P = .0013) and required fewer surgical (0.7% vs 4.8%; P = .0666) and non-surgical (2.7% vs 12.9%; P = .0017) interventions compared to those with SOC. Readmission rates were significantly higher when patients experienced SSC (31% vs 4%; P = .0001). Using the economic model, respective per-patient costs for the ciNPT and SOC groups were $666 and $52 for postoperative dressings, $135 and $994 for surgical interventions, $231 and $970 for readmissions, and $15 and $70 for non-surgical interventions. Total per-patient costs for surgical site management were $1,047 for ciNPT and $2,036 for SOC. Among the lower risk population, mean per-patient cost was $1,066 for ciNPT and $1,474 for SOC. Among the higher risk population, mean per-patient cost was $676 for ciNPT and $3,212 for SOC., Conclusion: Despite higher upfront costs for postoperative dressings, ciNPT was cost-effective in this health economic model, decreasing the costs of surgical site management after revision total knee arthroplasty by 49% in this study population and 79% in higher risk subgroup., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Ocular ultrasound is an invaluable tool for the evaluation of the eye and orbit. However, the eye and orbit are potentially sensitive to the thermal and mechanical effects of ultrasound. When performing B-mode imaging, dedicated ocular settings should be used. If these settings are not available, limiting the acoustic output to Food and Drug Administration (FDA) recommended maximum levels is strongly advised. Especially important is the acoustic output in spectral (pulsed) and color Doppler modes, which can exceed the FDA's maximum recommended levels for the eye. Adjusting settings to decrease acoustic output and limiting the time of the examination should be done when performing a Doppler examination. The acoustic output of shear wave elastography is significantly higher than FDA guidelines for the eye and should be considered experimental., (© 2021 American Institute of Ultrasound in Medicine.)

Elevated intraocular pressure (IOP) is the most prevalent risk factor for initiation and progression of neurodegeneration in glaucoma. Ocular hypertension results from increased resistance to aqueous fluid outflow caused by reduced porosity and increased stiffness of tissues of the outflow pathway. Acoustic activation and resulting bioeffects of the perfluorocarbon (PFC) nanodroplets (NDs) introduced into the anterior chamber (AC) of the eye could potentially represent a treatment for glaucoma by increasing permeability in the aqueous outflow track. To evaluate the potential of NDs to enter the outflow track, 100-nm diameter perfluoropentane (PFP) NDs with a lipid shell were injected into the AC of ex vivo pig eyes and in vivo rat eyes. The NDs were activated and imaged with 18- and 28-MHz linear arrays to assess their location and diffusion. NDs in the AC could also be visualized using optical coherence tomography (OCT). Because of their higher density with respect to aqueous humor, some NDs settled into the iridocorneal angle where they entered the outflow pathway. After acoustic activation of the NDs at the highest acoustic pressure, small gas bubbles were observed in the AC. After two days, no acoustic activation events were visible in the AC of the rats and their eyes showed no evidence of inflammation.

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full-coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full-coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full-coverage dressings. High-quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues., (© 2021 3M Company. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Objective: Wide surgical excision is the standard treatment for severe hidradenitis suppurativa (HS). Because of the nature of HS, these wounds are often nonsterile, located in moist intertriginous regions, and closed under tension, increasing the risk for surgical site complications. Although uncommon, absorbable sutures may confer benefits over nonabsorbable material for skin closure. Accordingly, the authors evaluated the use of absorbable, braided, transcutaneous polyglactin sutures after wide surgical excision of HS., Methods: The authors performed a retrospective chart review for all consecutive patients who underwent wide surgical excision of HS at a tertiary university hospital between January 2009 and March 2020., Results: Sixty consecutive patients with 174 operative sites were included in the study. The surgical site complication rate was 17.8%. Postoperative complications included wound dehiscence (n = 18), surgical site infection (n = 2), and scar contracture (n = 1). Sutures were removed from 12 (6.9%) operative sites. Factors influencing complications were Hurley grade and area of excision. Complications did not differ significantly among disease locations (P = .6417)., Conclusions: The results support the growing evidence that absorbable sutures are an appropriate option after wide surgical excision of HS., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

In cases of significant prematurity, neonates born with eyelid fusion can undergo spontaneous eyelid disjunction. Here, the authors present such a case, along with ultrasound findings shortly before eyelid separation. All protected patient information extracted for this report was done so in accordance with the Health Insurance Portability and Accountability Act. This report was prepared in accordance with the tenants of the Declaration of Helsinki., Competing Interests: L.R.D.G. - Royalties from Thieme Medical Publishers. The other authors have no conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up., Methods: This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs., Results: Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05)., Conclusion: ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Most studies of the effect of acute elevation of intraocular pressure (IOP) on ocular blood-flow have utilized optical coherence tomography (OCT) to characterize retinal and choroidal flow and vascular density. This study investigates the effect of acute IOP elevation on blood flow velocity in the retrobulbar arteries and veins supplying and draining the eye, which, unlike the retinal and choroidal vasculature, are not directly compressed as IOP is increased. By cannulation of the anterior chamber of 20 Sprague-Dawley rats, we increased IOP in 10 mmHg steps from 10 to 60 mmHg and returned to 10 mmHg. After 1 min at each IOP (and 3 min after return to 10 mmHg), we acquired 18 MHz plane-wave ultrasound data at 3000 compound images/sec for 1.5 s. We produced color-flow Doppler images by digital signal processing of the ultrasound data, identified retrobulbar arteries and veins, generated spectrograms depicting flow velocity over the cardiac cycle and characterized changes of vascular density and perfusion in the orbit overall. Systolic, diastolic and mean velocities and resistive and pulsatile indices were determined from arterial spectrograms at each IOP level. Baseline mean arterial and mean venous velocities averaged 30.9 ± 10.8 and 8.5 ± 3.3 mm/s, respectively. Arterial velocity progressively decreased and resistance indices increased at and above an IOP of 30 mmHg. Mean arterial velocity at 60 mmHg dropped by 55% with respect to baseline, while venous velocity decreased by 20%. Arterial and venous velocities and resistance returned to near baseline after IOP was restored to 10 mmHg. Both vascular density and orbital perfusion decreased with IOP, but while perfusion returned to near normal when IOP returned to 10 mmHg, density remained reduced. Our findings are consistent with OCT-based studies showing reduced perfusion of the retina at levels comparable to retrobulbar arterial flow velocity change with increased IOP. The lesser effect on venous flow is possibly attributable to partial collapse of the venous lumen as volumetric venous outflow decreased at high IOP. The continued reduction in orbital vascular density 3 min after restoration of IOP to 10 mmHg might be attributable to persisting narrowing of capillaries, but this needs to be verified in future studies., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: Prior color-flow Doppler ultrasound studies of the eye have been performed with systems that exceed US Food and Drug Administration permissible ophthalmic ultrasonic energy limits. The authors report a study of orbital vascular malformations using a novel, Food and Drug Administration compliant, ultrafast compound coherent plane-wave ultrasound device to produce power Doppler images., Methods: Using a Verasonics Vantage 128 ultrasound engine and a user-developed MATLAB program with a 5-MHz linear-array probe, compound coherent plane-wave ultrasound data were collected on patients with orbital vascular malformations. Real-time color-flow Doppler visualized orbital blood flow. Power Doppler images were produced by post-processing compound coherent plane-wave ultrasound data acquired continuously for 2 seconds., Results: Compound coherent plane-wave ultrasound was performed on 3 orbital vascular malformations (1 venolymphatic malformation, 1 infantile hemangioma, and 1 arteriovenous malformation). Compound coherent plane-wave ultrasound produced a high-resolution depiction of orbital blood flow for orbital vascular malformations with high sensitivity to slow flow., Conclusions: Analysis of blood flow within orbital lesions informs treatment planning. Compound coherent plane-wave ultrasound is an emerging ultrasound modality that falls within the Food and Drug Administration guidelines for use in the orbit and provides information to characterize orbital vascular malformations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Retinopathy of prematurity (ROP) is a vision-threatening complication occurring in pre-term neonates. The standard of care entails regular monitoring by dilated ophthalmoscopy examinations, which entail stress and potential morbidity. In this pilot study, we used plane-wave ultrasound (PWUS) to image, measure, and assess the association of blood-flow velocities in the retrobulbar vessels with ROP stages ranging from stage 0 (immature vessels without ROP) to stage 3., Methods: Both eyes of 14 preterm neonates at risk for ROP were examined by 18 MHz PWUS. All but two subjects had a follow-up examination. PWUS was acquired for 1.5 seconds at 3000 compound B-scans/sec. Data were postprocessed to form color-flow images and spectrograms depicting flow velocity in the central retinal artery (CRA), central retinal vein (CRV), and the short posterior ciliary arteries (SPCA). Flow parameters derived from spectrograms were compared by ROP stage., Results: ROP stage was found to correlate with flow velocities. Velocities were significantly elevated with respect to non-ROP eyes in all vessels at stage 3 and in the SPCAs at stage 2., Conclusions: PWUS measurement of blood flow may provide a quantitative, clinically important, and easily tolerated means for detecting and assessing the risk of ROP in preterm neonates. We speculate that the observed increase in flow velocity results from elevated vascular endothelial growth factor (VEGF) in ROP eyes., Translational Relevance: PWUS offers a gentle, nonmydriatic method for monitoring neonates at risk for ROP that would complement ophthalmoscopy.

Introduction: Differences in academic qualifications are cited as the reason behind the documented gender gap in industry sponsorship to academic plastic surgeons. Gendered imbalances in academic metrics narrow among senior academic plastic surgeons. However, it is unknown whether this gender parity translates to industry payments., Methods: We conducted a cross-sectional analysis of industry payments disbursed to plastic surgeons in 2018. Inclusion criteria encompassed (i) faculty with the rank of professor or a departmental leadership position. Exclusion criteria included faculty (i) who belonged to a speciality besides plastic surgery; (ii) whose gender could not be determined; or (iii) whose name could not be located on the Open Payment Database. Faculty and title were identified using departmental listings of ACGME plastic surgery residency programs. We extracted industry payment data through the Open Payment Database. We also collected details on H-index and time in practice. Statistical analysis included odds ratios (OR) and Pearson's correlation coefficient (R)., Results: We identified 316 senior academic plastic surgeons. The cohort was predominately male (88%) and 91% held a leadership role. Among departmental leaders, women were more likely to be an assistant professor (OR 3.9, p = 0.0003) and heads of subdivision (OR 2.1, p = 0.0382) than men. Industry payments were distributed equally to male and female senior plastic surgeons except for speakerships where women received smaller amounts compared to their male counterparts (median payments of $3,675 vs $7,134 for women and men respectively, p<0.0001). Career length and H-index were positively associated with dollar value of total industry payments (R = 0.17, p = 0.0291, and R = 0.14, p = 0.0405, respectively)., Conclusion: Disparity in industry funding narrows at senior levels in academic plastic surgery. At higher academic levels, industry sponsorship may preferentially fund individuals based on academic productivity and career length. Increased transparency in selection criteria for speakerships is warranted., Competing Interests: The authors of this paper have read the journal's policy and have the following competing interests: RPS is a paid employee of Acelity Corporation. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Purpose: Pre-eclampsia (PE) is a serious complication of pregnancy characterized by high blood pressure, proteinuria, compromised fetal blood supply, and potential organ damage. The superficial location of the eye makes it an ideal target for characterization hemodynamics. Our aim was to discern the impact of PE on ocular blood flow., Methods: 18 MHz plane-wave ophthalmic ultrasound scanning was performed on subjects with PE (n = 26), chronic or gestational hypertension (n = 8), and normal controls (n = 19) within 72 hours of delivery. Duplicate three-second long scans of the posterior pole including the optic nerve were acquired at 6000 images/sec for evaluation of the central retinal artery and vein and the short posterior ciliary arteries. The choroid was scanned at 1000 images/sec. Doppler analysis provided values of pulsatile flow velocity and resistance indexes., Results: End diastolic velocity was higher, and pulsatility and resistive indexes were significantly lower in the choroid, central retinal artery and short posterior ciliary arteries in PE than in controls. Blood pressure was elevated in PE with respect to controls and was negatively correlated with resistance., Conclusions: Although vasoconstriction is considered characteristic of PE, we found reduced resistance in the orbital vessels and choroidal arterioles, implying vasodilation at this level. Future studies incorporating optical coherence tomography angiography for characterization of the retina and choriocapillaris in conjunction with plane-wave ultrasound scanning, particularly in late pregnancy, might address this conundrum., Translational Relevance: Use of plane-wave ultrasound scanning for evaluation ocular blood flow in women at risk for PE may offer an avenue towards early detection and clinical intervention., Competing Interests: Disclosure: R.H. Silverman, None; R. Urs, None; R.J. Wapner, None; S. Bearelly, None, (Copyright 2020 The Authors.)

Background  Negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) includes periodic instillation of topical solution into the wound followed by a negative pressure. Our objective was to evaluate potential differences in wound outcomes in patients receiving NPWT and those receiving NPWTi-d using saline. Methods An analysis was performed using two previously published independent studies from a single investigator and hospital to compare patient characteristics and clinical outcomes of infected wounds from 74 NPWT-treated patients with 42 NPWTi-d-treated patients. Results  Patient demographics and comorbidities, wound etiologies, and anatomical locations of wounds were similar between groups, although a significantly higher percentage of NPWT-treated patients had end-stage renal disease (P = 0.0119). Compared with patients treated with standard NPWT, NPWTi-d-treated patients had a significantly lower number of operations (P = 0.0048), shorter length of hospital stay (P = 0.0443), shorter time to final surgical procedure (P = 0.0001), higher percentage of closed wounds (P = 0.0004), and a higher percentage of wounds that remained closed at one month (P = 0.0001). Conclusions The results of this analysis suggest that management of infected wounds with NPWTi-d using saline leads to favorable wound outcomes when compared to those managed with NPWT., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Kim et al.)

Wide local excision offers a potential cure for severe axillary hidradenitis suppurativa. However, the gold standard for reconstruction has yet to be defined. Here, we describe our rotation advancement flap technique, which allows for one-stage closure of large axillary defects, with minimal functional morbidity to the axilla. We performed a retrospective review of all patients who underwent one-stage surgical management for axillary hidradenitis suppurativa at a single-centre tertiary care hospital from 2009 to 2018. We identified 34 patients, with a total of 53 operative sites. The majority were female (85%) with a mean age of 31 years and body mass index 35 kg/m 2 . The median defect size was 84 cm 2 and the majority were treated using the rotation advancement flap technique (86%). A quarter of operative sites experienced minor complications with only one requiring re-operation. At a median follow-up of 32 months, two (4%) sites showed decreased range of motion. However, all patients had achieved remission without any further recurrence of disease. We describe a one-stage rotation advancement flap technique for management of moderate to severe hidradenitis suppurativa that achieves a high local cure rate, minimal functional morbidity, and acceptable wound complication rates., (© 2020 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Hidradenitis suppurativa (HS) is a chronic and physically debilitating condition. Achieving long-term remission is difficult and sometimes remains elusive despite use of multiple pharmacological agents. However, surgery remains underused in the pediatric population., Methods: We conducted a retrospective review for a 10-year period of all patients younger than 18 years who had undergone surgery for HS at a tertiary university hospital. In addition, we performed a literature review for English language articles related to the surgical management of pediatric HS patients., Results: Eleven patients with a total of 23 operative sites were included in the study. The cohort was predominantly female (10:1) with an average age of 15.4 years and mean body mass index 31.9 kg/m. Lesion size ranged from 12.6 to 400 cm. Overall complication rate was 87% with a 7% reoperation rate to manage complications. Remission was achieved after a single procedure in 57% of sites. Three articles met our inclusion criteria for the literature review., Conclusions: Our article adds to the sparse literature and represents the largest study on surgical management of pediatric HS patients. Although surgery is not without its challenges, it presents a safe option and for pediatric HS patients with extensive scar or sinus tract formation.

Multipulse (MP) ultrasound contrast agent (UCA) imaging is a method to increase the contrast-to-background (CBR) ratio in regions of blood flow. Plane-wave imaging allows high frame rates, and with high-frequency ultrasound, fine-spatial and temporal resolution. MP and plane-wave imaging have not been applied to high-frequency ultrasound. Here, an 18-MHz linear array was employed to implement the MP methods of pulse inversion (PI) and amplitude modulation (AM) using high-speed, multiangle, compound plane-wave imaging. A flow of the UCA DEFINITY © at a dilution ratio of 2000:1 circulating through a 2-mm-diameter flow channel in a tissue-mimicking phantom was used to characterize CBR and compared with cases of standard, multiangle compound plane-wave imaging. The relative improvement of PI and AM versus standard plane-wave imaging ranged from 5 to 10 dB. The CBR was observed to be stable over a 60-min time duration for a 2000:1 dilution ratio and a 2000:1 dilution ratio provided an optimal CBR.

Preclinical imaging, especially of rodent models, plays a major role in experimental ophthalmology. Our aim was to determine if ultrasound can be used to visualize and measure flow dynamics in the retrobulbar vessels supplying and draining the eye and the potential of contrast microbubbles to provide image and measurement enhancement. To accomplish this, we used a 128-element, 18 MHz linear array ultrasound probe and performed plane-wave imaging of the eyes of Sprague Dawley rats. Compound images were acquired by emitting unfocused wavefronts at multiple angles and combining echo data from all angles to form individual B-scans. Multiple imaging sequences were utilized, compounding up to six angles, with imaging rate of up to 3000 compound B-scans per second and sequence durations from 1.5 to 180 s. Data were acquired before and after intravenous introduction of contrast microbubbles. We found the total power of the Doppler signal in the image plane to increase approximately 20 fold after injection of contrast, followed by an exponential decay to baseline in about 90 s, The best-fit time constant of the decay averaged 41 s. While major vessels and the retinal/choroidal complex were evident pre-contrast, they were dramatically enhanced with contrast present, with details such as choroidal arterioles seen only with contrast. Ocular arteriovenous transit time determined from comparative enhancement curves in arteries and veins was approximately 0.2 s. In conclusion, plane wave ultrasound, especially with enhancement by contrast microbubbles, offers a means for the study of ocular hemodynamics using the rat eye as a model., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Despite increasing representation in surgery, women continue to lag behind men in important metrics. Little is known on how industry funding may also contribute to this ongoing disparity. This article seeks to quantify industry payments to academic plastic surgeons (APSs) by sex and examine the relationship between funding and academic achievement., Methods: We conducted a cross-sectional analysis of industry payments disbursed to APSs in 2017. Faculty were identified using departmental listings of Accreditation Council for Graduate Medical Education plastic surgery residency programs. Payments were identified via the Center for Medicare and Medicaid Services open payment database. Academic achievement was assessed using rank (eg, assistant professor), leadership designation (eg, division head), and Scopus H-index and then controlled for time in practice., Results: Of the 805 APSs, the majority were male (82% male vs 18% female, P < 0.0001). Significant sex differences emerged in average yearly industry contributions (men, US $3202, vs women, US $707; P < 0.0001). Across all academic ranks, men received significantly higher payments than women (P < 0.0500). Men constituted 93% of full professors and were almost twice as likely to hold additional leadership positions compared with women (odds ratio, 1.82; P = 0.0143). After adjustment for time in practice, there was no difference in H-indices between male and female APSs, although payment disparity persisted (P < 0.0001)., Conclusions: Substantial sex-based disparities exist among APSs' academic rank and leadership attainment, which is not attributed to differences in academic qualifications or experience. To better elucidate the sources of this disparity, future studies should assess sexed differences in payment types. Furthermore, we urge for increased transparency in the selection process for industry payments.

Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post-surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African-American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence., (© 2019 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Purpose: Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser treatment is performed on vitreous floaters, but studies of structural and functional effects with objective outcome measures are lacking. This study evaluated Nd:YAG laser effects by comparing participants with vitreous floaters who previously underwent laser treatment with untreated control participants and healthy persons without vitreous floaters using quantitative ultrasonography to evaluate vitreous structure and by measuring visual acuity and contrast sensitivity function to assess vision., Design: Retrospective, comparative study., Participants: One eye was enrolled for each of 132 participants: 35 control participants without vitreous floaters, 59 participants with untreated vitreous floaters, and 38 participants with vitreous floaters previously Nd:YAG-treated. Of these, 25 were dissatisfied and sought vitrectomy; 13 were satisfied with observation., Methods: The 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-39) to assess participant visual well-being, quantitative ultrasonography (QUS) to measure vitreous echodensity, and best-corrected visual acuity (BCVA) and contrast sensitivity function (CSF) to evaluate vision., Main Outcome Measures: Results of NEI-VFQ-39, QUS, BCVA, and CSF., Results: Compared with control participants without vitreous floaters, participants with untreated vitreous floaters showed worse NEI-VFQ-39 results, 57% greater vitreous echodensity, and significant (130%) CSF degradation (P < 0.001 for each). Compared with untreated eyes with vitreous floaters, Nd:YAG-treated eyes had 23% less vitreous echodensity (P < 0.001), but no differences in NEI-VFQ-39 (P = 0.51), BCVA (P = 0.42), and CSF (P = 0.17) results. Of 38 participants with vitreous floaters who previously were treated with Nd:YAG, 25 were dissatisfied and seeking vitrectomy, whereas 13 were satisfied with observation. Participants seeking vitrectomy showed 24% greater vitreous echodensity (P = 0.018) and 52% worse CSF (P = 0.006). Multivariate linear regression models confirmed these findings., Conclusions: As a group, participants previously treated with Nd:YAG laser for bothersome vitreous floaters showed less dense vitreous, but similar visual function as untreated control participants with vitreous floaters. Because some treated eyes showed less dense vitreous and better visual function than those of untreated control participants, a prospective randomized study of Nd:YAG laser treatment of vitreous is warranted, using uniform laser treatment parameters and objective quantitative outcome measures., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Closed incision negative pressure therapy (ciNPT) is an emerging approach to managing closed incisions of patients at risk of postoperative complications. There are primarily 2 different commercially available ciNPT systems. Both systems consist of a single-use, battery-powered device and foam- or gauze-based peel-and-place dressing designed for closed incisions. These systems vary in design, and there are no data comparing outcomes between the 2 systems., Methods: We performed 2 separate meta-analyses to compare surgical site infection (SSI) rates postuse of (1) ciNPT with foam dressing (FOAM) versus conventional dressings and (2) ciNPT with multilayer absorbent dressing (MLA) versus conventional dressings., Results: Seven articles and 2 abstracts met inclusion criteria in the FOAM group (n = 489) versus the control group (n = 489) in meta-analysis 1; 7 articles and 1 abstract met inclusion criteria in the MLA group (n = 532) versus the control group (n = 540) in meta-analysis 2. Meta-analysis 1 showed that patients in the control group were 3.17 times more likely to develop an SSI compared with patients in the FOAM group [weighted mean odds ratios of FOAM group versus control group was 3.17 ( P < 0.0001) with the 95% confidence intervals of 2.17-4.65]. Meta-analysis 2 showed no significant difference in SSI rates between patients in the MLA group and patients in the control group [weighted mean odds ratios of MLA group versus control group was 1.70 ( P = 0.08) with the 95% confidence intervals of 0.94-3.08]., Conclusions: Comparing outcomes of two different ciNPT systems with a common comparator (conventional dressings) may provide an interim basis for comparing ciNPT systems until further comparative evidence is available. More comparative research is required to determine outcomes in clinical practice., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone., Methods: An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups., Results: A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair-only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention., Conclusions: The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy., Clinical Question/level of Evidence: Therapeutic, III.

Background: Hidradenitis suppurativa (HS) is a physically debilitating disease that greatly impairs the quality of life of affected individuals. Advanced disease is often difficult to treat with topical and systemic therapies. Surgical resection of diseased skin has become paramount in HS management but proposes challenges of wound care and closure., Methods: Four patients with a total of 12 complex wounds were treated over a three year period. All of the patients were males between the ages of 28 and 61 years. The lesions were located on the buttocks (n=5), chest (n=1), perianal (n=2), perineal (n=2), and axillary regions (n=2). A protocol of wide local excision, followed by negative pressure wound therapy with instillation and dwell time (NPWTi-d) to decrease bioburden and promote angiogenesis of the exposed base, and subsequent skin grafting was used. Patients remained hospitalized between procedures., Results: The original wound area ranged from 210-540 cm 2 . Skin grafts of comparable sizes were taken from donor sites. The average duration of NPWTi-d placement was 3.5 days and the average time from excision to wound coverage was 4.3 days. The percent of graft uptake ranged from 70%-90%. All patients were resolved of their local disease with no complications., Conclusions: Surgical management of HS can be complicated by difficult closures. This case series demonstrates that wide local excision followed by NPWTi-d and skin grafting is able to achieve local resolution of disease in HS patients who have failed multiple minimally invasive therapies., Competing Interests: The authors have declared financial relationships, which are detailed in the next section.

Purpose: The choroid is a vascular network providing the bulk of the oxygen and nutrient supply to the retina and may play a pivotal role in retinal disease pathogenesis. While optical coherence tomography angiography provides an en face depiction of the choroidal vasculature, it does not reveal flow dynamics. In this report, we describe the use of plane-wave ultrasound to image and characterize choroidal blood flow., Methods: We scanned both eyes of 12 healthy subjects in a horizontal plane superior to the optic nerve head using an 18-MHz linear array. Plane-wave data were acquired over 10 transmission angles that were coherently compounded to produce 1000 images/sec for 3 seconds. These data were processed to produce a time series of power Doppler images and spectrograms depicting choroidal flow velocity. Analysis of variance was used to characterize peak systolic, and end diastolic velocities and resistive index, and their variability between scans, eyes, and subjects., Results: Power Doppler images showed distinct arterioles within a more diffuse background. Choroidal flow was moderately pulsatile, with peak systolic velocity averaging approximately 10 mm/sec and resistive index of 0.55. There was no significant difference between left and right eyes, but significant variation among subjects., Conclusions: Plane-wave ultrasound visualized individual arterioles and allowed measurement of flow over the cardiac cycle. Characterization of choroidal flow dynamics offers a novel means for assessment of the choroid's role in ocular disease., Translational Relevance: Characterization of choroidal flow dynamics offers a novel means for assessment of the choroid's role in ocular disease.

A frequency-domain, non-contact approach to photoacoustic microscopy (PAM) that employs amplitude-modulated (0.1-1 MHz) laser for excitation (638-nm pump) in conjunction with a 2-wave mixing interferometer (532-nm probe) for non-contact detection of photoacoustic waves at the specimen surface is presented. A lock-in amplifier is employed to detect the photoacoustic signal. Illustrative images of tissue-mimicking phantoms, red-blood cells and retinal vasculature are presented. Single-frequency modulation of the pump beam directly provides an image that is equivalent to the 2-dimensional projection of the image volume. Targets located superficially produce phase modulations in the surface-reflected probe beam due to surface vibrations as well as direct intensity modulation in the backscattered probe light due to local changes in pressure and/or temperature. In comparison, the observed modulations in the probe beam due to targets located deeper in the specimen, for example, beyond the ballistic photon regime, predominantly consist of phase modulation., (© 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Purpose: Mapping of epithelial thickness (ET) is useful for detection of keratoconus, a disease characterized by corneal thinning and bulging in which epithelial thinning occurs over the apex. In prior clinical studies, optical coherence tomography (OCT) measurements of ET were systematically thinner than those obtained by 40-MHz high-frequency ultrasound (HFU) where a constant speed of sound ( c ) of 1636 m/s was used for all corneal layers. The purpose of this work was to study the acoustic properties, that is, c , acoustic impedance ( Z ), and attenuation ( α ) of the corneal epithelium and stroma independently using a scanning acoustic microscope (SAM) to investigate the discrepancy between OCT and HFU estimates of ET., Methods: Twelve unfixed pig corneas were snap-frozen and 6-μm sections were scanned using a custom-built SAM with an F-1.08, 500-MHz transducer and a 264-MHz bandwidth. Two-dimensional maps of c , Z , and α with a spatial resolution of 4 μm were derived., Results: SAM showed that the value of c in the epithelium (i.e., 1548 ± 18 m/s) is substantially lower than the value of c in the stroma (i.e., 1686 ± 33 m/s)., Conclusion: SAM results demonstrated that the assumption of a constant value of c for all corneal layers is incorrect and explains the prior discrepancy between OCT and HFU ET determinations., Translational Relevance: The findings of this study have important implications for HFU-based ET measurements and will improve future keratoconus diagnosis by providing more-accurate ET estimates.

Objective: To evaluate PDE5/6 inhibition with sildenafil to reduce choroidal ischemia and treat age-related macular degeneration., Methods: Sildenafil was prescribed to treat participants with macular degenerations or macular dystrophies measured by spectral-domain optical coherence tomography, color fundus photography, enhanced depth imaging, and best-corrected visual acuity., Results: No change in calcified drusen was noted. Vitelliform-type soft drusen were not substantially changed. A participant with Best vitelliform macular dystrophy had a significant improvement in vision as well as in photoreceptor and ellipsoid layers., Conclusions: Our research supports sildenafil as a safe treatment for age-related and vitelliform macular degenerations. Thickened Bruch's membrane reduces the beneficial effect of perfusion increase, but all eyes appear to benefit from PDE6. Notably, maintenance or improvement in the photoreceptor layer may be the most significant result of sildenafil and is consistent with PDE6 inhibition. Thus, sil-denafil treatment of macular degeneration offers significant potential for vision retention and recovery., (© 2018 S. Karger AG, Basel.)

Purpose: We used acoustic radiation force optical coherence elastography (ARF-OCE) to map out the elasticity of retinal layers in healthy and diseased in vivo rabbit models for the first time., Methods: A healthy rabbit eye was proptosed and imaged using ARF-OCE, by measuring the tissue deformation after an acoustic force is applied. A diseased retinal inflammation model was used to observe the contrast before and after disease formation. Retinal histologic analysis was performed to identify layers of the retina corresponding with the optical images., Results: The general trend of the retinal layer elasticity is increasing stiffness from the ganglion side to the photoreceptor side, with the stiffest layer being the sclera. In a healthy rabbit model, the mechanical properties varied from 3 to 16 kPa for the five layers that were identified via optical imaging and histology (3.09 ± 0.46, 3.82 ± 0.88, 4.53 ± 0.74, 6.59 ± 2.27, 16.11 ± 5.13 kPa). In the diseased model, we have induced optical damage in a live rabbit and observed a change in the stiffness trend in its retina., Conclusions: High sensitivity elasticity maps can be obtained using the ARF-OCE system to differentiate different retinal layers. Subtle changes in the mechanical properties during the onset of diseases, such as retinal degeneration, can be measured and aid in early clinical diagnosis. This study validates our imaging system for the characterization of retinal elasticity for the detection of retinal diseases in vivo.

Real-time imaging of the embryonic murine cardiovascular system is challenging due to the small size of the mouse embryo and rapid heart rate. High-frequency, linear-array ultrasound systems designed for small-animal imaging provide high-frame-rate and Doppler modes but are limited in regards to the field of view that can be imaged at fine-temporal and -spatial resolution. Here, a plane-wave imaging method was used to obtain high-speed image data from in utero mouse embryos and multi-angle, vector-flow algorithms were applied to the data to provide information on blood flow patterns in major organs. An 18-MHz linear array was used to acquire plane-wave data at absolute frame rates ≥10 kHz using a set of fixed transmission angles. After beamforming, vector-flow processing and image compounding, effective frame rates were on the order of 2 kHz. Data were acquired from the embryonic liver, heart and umbilical cord. Vector-flow results clearly revealed the complex nature of blood-flow patterns in the embryo with fine-temporal and -spatial resolution.

Hyperopia (farsightedness) is a common and significant cause of visual impairment, and extreme hyperopia (nanophthalmos) is a consequence of loss-of-function MFRP mutations. MFRP deficiency causes abnormal eye growth along the visual axis and significant visual comorbidities, such as angle closure glaucoma, cystic macular edema, and exudative retinal detachment. The Mfrp rd6 /Mfrp rd6 mouse is used as a pre-clinical animal model of retinal degeneration, and we found it was also hyperopic. To test the effect of restoring Mfrp expression, we delivered a wild-type Mfrp to the retinal pigmented epithelium (RPE) of Mfrp rd6 /Mfrp rd6 mice via adeno-associated viral (AAV) gene therapy. Phenotypic rescue was evaluated using non-invasive, human clinical testing, including fundus auto-fluorescence, optical coherence tomography, electroretinography, and ultrasound. These analyses showed gene therapy restored retinal function and normalized axial length. Proteomic analysis of RPE tissue revealed rescue of specific proteins associated with eye growth and normal retinal and RPE function. The favorable response to gene therapy in Mfrp rd6 /Mfrp rd6 mice suggests hyperopia and associated refractive errors may be amenable to AAV gene therapy.

Quantitative assessment of the material properties of ocular tissues can provide valuable information for investigating several ophthalmic diseases. Quantitative acoustic microscopy (QAM) offers a means of obtaining such information, but few QAM investigations have been conducted on human ocular tissue. We imaged the optic nerve (ON) and iridocorneal angle in 12-µm deparaffinized sections of the human eye using a custom-built acoustic microscope with a 250-MHz transducer (7-µm lateral resolution). The two-dimensional QAM maps of ultrasound attenuation (α), speed of sound ( c), acoustic impedance ( Z), bulk modulus ( K), and mass density (ρ) were generated. Scanned samples were then stained and imaged by light microscopy for comparison with QAM maps. The spatial resolution and contrast of scanning acoustic microscopy (SAM) maps were sufficient to resolve anatomic layers of the retina (Re); anatomic features in SAM maps corresponded to those seen by light microscopy. Significant variations of the acoustic parameters were found. For example, the sclera was 220 MPa stiffer than Re, choroid, and ON tissue. To the authors' knowledge, this is the first systematic study to assess c, Z, K, ρ, and α of human ocular tissue at the high ultrasound frequencies used in this study.

Management of chronic wounds remains challenging in terms of prevalence and complexity. Considerable progress has been made in understanding the science of wound healing during the past decade, sparking volumes of publications and the development of hundreds of dressing and therapy options. There is a need for a simpli ed overview of evidence-based criteria to assist in the accurate diagnosis and appropriate management of chronic wounds in all care settings. An expert panel of 11 wound healing specialists experienced in various care settings convened to discuss best practices and recommended guidelines for managing major chronic wound types. Prior to the meeting, panel members reviewed 8 preselected peer-reviewed articles and 1 white paper containing treatment algorithms for all major chronic wound types. During the meeting, each panelist presented current evidence-based guidelines regarding a specific chronic wound type and case studies to illustrate concepts in the guidelines. This publication is a result of the panel discussion and presents an overview of literature- and experience- based criteria to help guide chronic wound diagnosis, assessment, treatment, and follow-up. A cycle of steps is presented as a framework to guide holistic care for all patients with chronic wounds, including de- hisced surgical wounds, diabetic foot ulcers, venous leg ulcers, arterial insu ciency ulcers, and pressure ulcers/injuries. Emphasis is placed on criteria to assist accurate diagnosis and dressing/therapy selection, holistic elements of patient and wound bed preparation, interventions to achieve patient adherence to a care plan, and follow-up to help prevent wound recurrence.