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Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest.

Background: Circumferential deep burns on the limb lead to a constrictive, tourniquet-like effect causing critical limb ischaemia. The treatment, escharotomy, is a time-critical procedure that sometimes is required before the patient arrives at a burn centre. At present, no practical method of teaching this procedure is incorporated into formal educational courses., Methods: The feasibility of a comprehensive education package to teach upper limb escharotomy was assessed in a group of plastic and general surgery trainees in Wales. Small group workshops focused on the clinical presentation of patients requiring escharotomy. Participants then executed this on a custom-made high-fidelity simulation upper limb model. The articulated limb has subcutaneous silicone fat which bulges upon decompression and a finger-tip which turns pink indicating satisfactory reperfusion. A before and after five-point Likert scale was used to evaluate changes in participants' self-assessed confidence in the surgical management of escharotomy. Statistical significance between scores was assessed using the Wilcoxon signed-rank test., Results: A total of 34 participants took part. Following completion of the course, general surgery trainees' confidence in executing the procedure increased from a median score of 1.00 "not confident at all" (IQR 1.00-2.00) to 4.00 "fairly confident" (IQR 4.00-5.00, p < 0.01). Plastic surgery trainees' confidence increased from a median score of was 3.00 "somewhat confident" (IQR 1.75-4.00) to 4.00 "fairly confident" (IQR 3.00-4.25, p < 0.01)., Discussion: We developed a comprehensive simulator course that has been demonstrated to improve candidate's confidence in performing escharotomy. The next stage in the course development is to confirm the results in a larger cohort. By developing this simulator course we aim to improve emergency burn care education in the UK and globally., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Introduction: Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy., Patients and Methods: We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed., Results: Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy., Conclusion: While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients., Competing Interests: Declaration of Competing Interest Nicole Lindenblatt acts as a symposium speaker and clinical advisor for Medical Microinstruments (MMI). The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In most breast reduction techniques, the pedicle of the nipple-areola complex (NAC) is de-epithelialized to preserve the subdermal plexus, thereby decreasing the risk of NAC necrosis. However, deskinning the pedicle is faster and makes it more pliable, which potentially improves the aesthetic outcome. There is no scientific evidence regarding the beneficial effects of de-epithelialization. In this study, we present data from patients undergoing breast reduction with deskinning of a superomedial pedicle., Methods: In the period June 2013 to March 2019, a single surgeon performed all breast reductions using a superomedial glandular pedicle. The patients were included retrospectively and data were collected by reviewing the medical records. The NAC necrosis rate was compared with data from the literature through a systematic review., Results: The cohort consisted of 142 consecutive patients. The median resection weight was 287 g (interquartile range (IQR), 197-399) per breast. No complete NAC necroses occurred during the follow-up period, but two patients (1.4%) developed partial NAC necrosis. In the literature, the rate of NAC necrosis (complete or partial) was 1.5% of patients undergoing breast reduction with de-epithelialization., Conclusion: The rate of NAC necrosis after breast reduction with deskinning of the pedicle was comparable with breast reductions with de-epithelialization that has been reported in the literature. Our findings support that the pedicle in breast reduction surgery can be deskinned safely in patients with low resection weights., Competing Interests: Conflicts of Interest Statement None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results., Materials and Methods: This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up., Results: The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months)., Conclusion: Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity., Competing Interests: Declaration of Competing Interest Conflicts of Interest and Sources of Funding: There are no conflicts of interest to disclose for all authors and the Department of Orthopaedic Surgery for the University of Missouri provided funding for the biomechanical aspect of this study. Level of Evidence: Level V, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: The incidence of head and neck melanoma is increasing. Various factors influence prognosis., Objective: We sought to investigate the subgroup of patients with head and neck melanoma who fail primary treatment and to define the patterns of failure., Methods: The database of a tertiary medical center was reviewed for patients diagnosed and surgically treated for cutaneous head and neck melanoma in 1995-2014. Regional disease failure was defined as disease confirmed in positive SLNB at first assessment or at recurrence., Results: The cohort included 141 patients followed for a median duration of 6.8 years (range 1-20 years). Median tumor thickness was 2.1 mm (range 0.5-12 mm). Ulceration was documented in 38 patients (26.9%). Sentinel lymph node biopsy (SLNB) was positive in 18 patients (12.8%). Total disease failure rate was 32.6% with similar rates of regional (n = 26, 18.4%) and distal (n = 22, 15.6%) failure. Most patients (86.3%) with systemic recurrence had a negative SNLB as did 6/26 patients (23%) with regional failure. Forty-three patients (30.4%) died during follow-up, half of them (23 patients, 16.3%) of melanoma. On multivariate analysis, Breslow thickness was the only significant predictor of outcome., Conclusions: The pattern of treatment failure in patients with head and neck melanoma relate predominantly to Breslow thickness. The high false-negative rate of SNLB and the relatively high rate of systemic failures in patients with negative SNLB indicate a low predictive value of this procedure. Efforts to detect systemic disease during follow-up need to be intensified., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Backgrounds: Recently a flood of new techniques and studies have been released for prepectoral reconstruction, following strict criteria for selection of patients undergoing skin or nipple sparing mastectomy. Nevertheless a big population of patients that would otherwise benefit from prepectoral techniques has been excluded so far., Patients and Methods: Between January 2016 and February 2017, patients undergoing skin reducing mastectomy (SRM) were enrolled at our Institution. We selected patients with large and ptotic (grade II-III) breasts undergoing SRM, followed by a new technique, which involves placement of the implant, wrapped by acellular dermal matrix, in a prepectoral pocket under a dermal flap. Data of all the surgeries were prospectively collected and contracture grade was assessed by Baker scale. Complication rate and cancer recurrence were reported and health related quality of life (HRQOL) measurement was recorded using BREAST-Q questionnaire. At early follow-up, postoperative pain was assessed through VAS scale., Results: 29 patients underwent SRM and 10 patients, meeting inclusions criteria, were enrolled, with a total of 13 operated breasts. Postoperative average pain was assessed as low as 4.1. The median follow-up was 2.6 (range 2.1-3.2) years. Post-operative complications occurred in 1 case of minimal wound dehiscence. No patient reported breast seroma or severe capsular contracture grade. Patient scored high level of satisfaction with breast, psychosocial well-being, sexual well-being, physical impact and overall satisfaction with outcome, at BREAST-Q questionnaire., Conclusions: In this study we present a modified prepectoral technique for patients undergoing SRM, reporting satisfactory outcomes. These results might support the rationale for expanding the population target of prepectoral reconstruction., Competing Interests: Declaration of Competing Interest None of the authors has any conflict of interest or financial interest in any of the products, devices, or drugs mentioned in this manuscript. The study followed the ethical standards of human experimentation, according to the Declaration of Helsinki., (Copyright © 2019. Published by Elsevier Ltd.)

Purpose: Treatment package time (TPT) prolongation is associated with lower overall survival and locoregional control in mucosal head and neck squamous cell carcinoma (SCC), but there are few reports in cutaneous HNSCC (cHNSCC). We sought to test the effect of TPT in a cohort of patients with cHNSCC., Methods: This is a single institution retrospective study of node-positive cHNSCC patients involving either the parotid or cervical nodes treated with curative intent surgery with macroscopic tumor clearance followed by standard fractionation postoperative radiation therapy (PORT) from 2001 to 2014. We assessed the effect of TPT and other prognostic variables on overall survival (OS), cHNSCC specific survival (CSS) progression free survival (PFS), and freedom from locoregional failure (FFLRF)., Results: In the present study, 152 patients met the inclusion criteria. The 5-year OS, CSS, PFS, and FFLRF were 62% (95% confidence interval [CI], 54-71), 78% (95% CI, 71-87), 54% (95% CI, 46-64), and 76% (95% CI ,68-85), respectively. In a multivariable model, TPT ≥14 weeks was associated with worse outcomes in all endpoints (OS [hazard ratio (HR) 4.93; 95% CI, 2.54-9.56, P < .001], CSS [HR 6.09; 95% CI, 2.33-15.92; P = .001], PFS [HR 4.29; 95% CI, 2.21-8.34; P < .001], and FFLRF [HR 4.63; 95% CI, 1.71-12.51; P = .007]). Immunosuppression and the presence of ≥2 pathologically involved lymph nodes were also significant adverse factors for both OS and FFLRF, although extracapsular extension was also associated with lower FFRLF. Delays to commencing PORT rather than treatment breaks accounted for the majority of cases with prolonged TPT., Conclusions: Prolongation of TPT to 14 weeks or longer may confer a lower probability of locoregional control and survival in patients with lymph node-positive cHNSCC treated with surgery and PORT. Timely referral and commencement of PORT is necessary to maximize long-term disease outcomes., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery leads to sustained weight loss and resolution of obesity-associated co-morbidities in severely obese adolescents. However, one consequence of massive weight loss is excess skin and soft tissue. Many details regarding the timing, outcomes, and barriers associated with body contouring surgery (BCS) in youth who have undergone bariatric surgery are unknown., Objectives: Describe the incidence and effect of BCS following bariatric surgery among adolescents., Setting: University Hospitals., Methods: Teen-Longitudinal Assessment of Bariatric Surgery is a prospective multi-institutional study of 242 adolescents who underwent bariatric surgery from 2007 to 2012. Utilization of BCS was analyzed in this population with comparison of anthropometrics and excess skin-related symptoms between those who did and those who did not undergo BCS., Results: Among the 198 study participants with BCS data available, 25 (12.6%) underwent 41 body contouring procedures after bariatric surgery. The most common BCS was panniculectomy (n = 23). Presence of pannus-related symptoms at baseline and the magnitude of weight loss within the first year after bariatric surgery were independently associated with subsequent panniculectomy (P = .04 and P = .03, respectively). All adolescents who underwent panniculectomy experienced resolution of pannus-related symptoms. At 5 years after bariatric surgery, 74% of those who did not undergo panniculectomy reported an interest in the procedure, and 58% indicated that cost/insurance coverage was the barrier to obtaining BCS., Conclusion: Few adolescents who underwent bariatric surgery later underwent BCS procedures. Panniculectomy effectively treated pannus-related symptoms. Disparities in access to surgical care for adolescents who desire BCS warrants further investigation., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The abdominoplasty (AP) is a common type of plastic surgery procedure that removes unsightly and uncomfortable cutaneous and fatty excess from the anterior abdominal wall. In 30% of the cases, the results prove to be insufficient and motivate a request for reintervention which goes from the simple cicatricial revision under local anesthesia to the complete recovery of the procedure. The defects at the origin of the secondary abominoplasty are persistent skin excess, residual fat deposits, scarring malpositions or abnormalities of the umbilicus. The respect of certain technical rules during the primary AP are likely to limit the postoperative defects at the origin of these surgical revisions. When an imperfection of result is found postoperatively, the methodical clinical analysis of the defect will allow in determining the cause and to choose the most adapted corrective solution in order to obtain finally the satisfaction of the patient., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Insufficient blood supply is associated with high levels of necrosis in reconstructive surgery. Restoring blood flow to undersupplied ischemic tissue is the most important impact factor determining skin flap viability. Dietary nitrate, a significant source of nitric oxide, has multiple physiological functions, including regulator of blood flow, angiogenesis, and vasodilatation. However, the effects of dietary nitrate on ischemic skin flap remain unknown. The present study evaluated whether dietary nitrate supplementation altered blood flow of ischemic skin flap in rats. Our results showed that nitrate treatment significantly enhanced ischemic tissue survival. Mechanistically, nitrate therapy significantly increased serum nitrate and nitrite levels, blood perfusion, and angiogenesis. In addition, the circulating levels of Inflammatory mediators were decreased by nitrate supplementation. In conclusion, we demonstrated that dietary nitrate supplementation protected ischemic skin flap by enhancing ischemia-induced revascularization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This essay describes the potential for using ethnographic evidence and mummified tattooed skin to reflect on past therapeutic tattoo practice in the Arctic. It also considers the ways in which circumpolar concepts of disease emerged in relation to the agency of nonhuman entities. I argue that specific forms of curative tattooing offer interpretive models for the paleopathological and bioarchaeological study of care through an ontological framework of analysis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Skin tumors surgery is common and well established. There is discrepancy between recommendations on macroscopic margins to apply and therapeutic decisions taken on histological margins. The purpose of this study is to examine skin shrinkage upon exeresis, then in formalin, to understand the anatomo-clinical discrepancy, which is often found., Material and Methods: It was a prospective study, lasting a month, including patients receiving skin surgery. For each tumor, the surgeon carried out 4 margins measurements before and after exeresis ; margins measured again in histology. The evaluation criterion was the difference between preoperative, postoperative and histological margins measurement. These data was weighting according to factors linked to the patient and the tumor., Results: Seventy-nine tumors for 61 patients had been studied. The study showed a significant shrinkage between preoperative measurements and postoperative, from 0.4 to 0.6mm. It is correlated with no one tested factors. Significant shrinkage between 0.4 and 0.5mm was also established between preoperative and histological measurements. However, there is a significant augmentation between postoperative and histological measurements., Conclusion: This last result could be linked to the inflammatory peri-wound skin that surgeon consider as tumoral process so exclude of his margin, while histology could show a healthy area. In front of these results, an expert committee leading a more important study could include histological margins recommendations to the actual clinical recommendations., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Regenerative medicine is a burgeoning field that is important to combat challenging diseases and functional impairments. Compared with traditional cell therapies with evident shortcomings (e.g., cell suspension injection or tissue engineering with scaffolds), scaffold-free cell sheet technology enables transplanted cells to be grafted and fully maintain their viability on target sites. Clinical and experimental studies have advanced the application of cell sheet technology to numerous tissues and organs (e.g., liver, cornea and bone). However, previous reviews have failed to discuss vital aspects of this rapidly developing technology, and many new challenges are gradually emerging. This review aims to provide a comprehensive introduction to cell sheet technology from cell selection to the ultimate applications of cell sheets, and challenges and future visions are also described., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Gamat (sea-cucumber) is a natural occurring fauna which is popularly used as traditional medication in Southeast Asian countries. There have been many animal studies done on its' biochemical properties and its' effects in vivo. The effect of gamat on human cutaneous wounds was studied using a split-skin graft donor site wound., Methods: This was a comparative case-control study done on patients in Hospital Universiti Sains Malaysia (Hospital USM), requiring split-thickness skin grafting, whereby, the skin graft donor site was divided to almost equal halves, and applied with both gamat-based gel on one side, with Duoderm ® hydrogel on the other side. The epithelialization of the wounds was observed and compared on days 10, 14 and 21. Pain score, and pruritus score were also observed. Repeated measure analysis of variance (ANOVA) test and Paired t-test was used to test statistical significance accordingly., Results: No significant differences were seen in rates of epithelialization of wounds on days 10, 14 and 21 (p > 0.01). No significant difference was also seen in the pain score and pruritus score (p > 0.01)., Conclusions: A gamat-based gel is comparable to conventional hydrogels in treatment of split-skin graft donor site. No adverse effects were observed in either group., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: The technique of meshed skin grafting is known since 1960s. It was shown that there is a difference between the declared and real expansion ratio of the skin meshed graft. We hypothesize that the orientation of the Langer's lines in a split thickness skin graft is a key parameter in the resulting expansion ratio., Methods: The skin graft meshing process was analyzed in two steps. In the first step, ex vivo uniaxial tests of human skin were performed. This served as an input for the constitutive model used for numerical simulations. In the second step, finite element analyses were performed so that stress distributions and expansion ratios could be determined., Results: It was shown that peaks of true stress tended to be concentrated around the vertex of the mesh pattern region for all cases. The declared expansion was impossible to obtain for all expansion ratios having the meshing incision perpendicular to the Langer's lines. The highest difference between declared and real expansion ratio reaches 37%., Conclusions: With regard to literature dealing with expansion of skin grafts by meshing, a high scatter amongst data results is observed. This finding was also explained by our research, demonstrating the significance of Langer's lines and their relative orientation to the direction of meshing., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Background: Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor shown to improve survival in advanced solid cancers. We evaluated the role of adjuvant bevacizumab in melanoma patients at high risk of recurrence., Patients and Methods: Patients with resected AJCC stage IIB, IIC and III cutaneous melanoma were randomised to receive either adjuvant bevacizumab (7.5 mg/kg i.v. 3 weekly for 1 year) or standard observation. The primary end point was detection of an 8% difference in 5-year overall survival (OS) rate; secondary end points included disease-free interval (DFI) and distant metastasis-free interval (DMFI). Tumour and blood were analysed for prognostic and predictive markers., Results: Patients (n=1343) recruited between 2007 and 2012 were predominantly stage III (73%), with median age 56 years (range 18-88 years). With 6.4-year median follow-up, 515 (38%) patients had died [254 (38%) bevacizumab; 261 (39%) observation]; 707 (53%) patients had disease recurrence [336 (50%) bevacizumab, 371 (55%) observation]. OS at 5 years was 64% for both groups [hazard ratio (HR) 0.98; 95% confidence interval (CI) 0.82-1.16, P = 0.78). At 5 years, 51% were disease free on bevacizumab versus 45% on observation (HR 0.85; 95% CI 0.74-0.99, P = 0.03), 58% were distant metastasis free on bevacizumab versus 54% on observation (HR 0.91; 95% CI 0.78-1.07, P = 0.25). Forty four percent of 682 melanomas assessed had a BRAFV600 mutation. In the observation arm, BRAF mutant patients had a trend towards poorer OS compared with BRAF wild-type patients (P = 0.06). BRAF mutation positivity trended towards better OS with bevacizumab (P = 0.21)., Conclusions: Adjuvant bevacizumab after resection of high-risk melanoma improves DFI, but not OS. BRAF mutation status may predict for poorer OS untreated and potential benefit from bevacizumab., Clinical Trial Information: ISRCTN 81261306; EudraCT Number: 2006-005505-64.

Objective: Permanent hypopigmentation of burn scars is a common consequence after partial and full thickness burns that heal by secondary intent, and they can cause severe aesthetic issues. The surgical goals for effective treatment of postburn hypopigmentation are to remove scar tissues, and to produce healthy melanocytes, with minimal donor site morbidity. This article reviews the current literature about the different ways to treat hypopigmentation following burn injuries and discusses the indications., Methods: The PubMed database was searched for articles published from 1985 and up to 2016. Papers with regards to the management of hypopigmented lesions were included only if scars were following burn injuries. The treatments were assessed according to body region treated, surface involved, skin color, effectiveness on restoring skin pigmentation., Results: Sixteen studies were included in this review. Non-surgical treatments like makeup and tattooing, and surgical treatments including thin skin grafting, chip skin grafting, punch grafting, non-cultured keratinocyte-melanocyte cell suspension, and cultured epidermal cells were all compared., Conclusion: Thin skin grafting is a reliable treatment especially for patient who suffer from small hypopigmented lesions as this method requires a donor skin of the same size. The cell suspension procedure may be beneficial for larger scars. Moreover demarcation between skin graft and normal skin may exist and when a precise color match is required, particularly in the head, tattooing and chip skin grafting produce a good pigmentation outcome., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Anticoagulant and antiplatelet (AC/AP) use is common and practice surrounding AC/AP continuation or cessation peri-operatively for minor cutaneous surgery lacks evidence-based consensus., Objective: To determine the risks of haemorrhagic and thromboembolic complications associated with the continuation or cessation of AC/AP therapy in minor cutaneous surgery., Methods: A systematic literature search was conducted using PubMed, MEDLINE, Embase and CENTRAL, to identify all articles involving the use of AC/AP in patients undergoing minor cutaneous surgery, including skin grafts and local flaps. Eligible studies were randomised control trials, prospective studies and retrospective studies in the English language. Studies investigating free-flap repairs, oculoplastic surgery and hand surgery were excluded., Results: 30 studies included data from over 14,000 patients, of which more than 5000 took regular AC/AP therapy. Thromboembolic events were rare but carry high morbidity and even mortality, and in these studies three events were associated with cessation of AC/AP. There was no increase in haemorrhagic complications in patients taking aspirin monotherapy, but evidence is conflicting regarding warfarin and clopidogrel monotherapy, which shows a small increase in rate of bleeding complications. However, no increase in wound dehiscence, graft failure, wound infection or cosmetic outcome was seen. Too few studies investigated DOAC use to draw reliable conclusions. Data are sparse in comparing multiple versus single AC/AP regimens. Use of skin grafts or local flaps may have a greater complication rate than direct closure in patients on one or more AC/AP, but evidence is limited., Conclusion: A case-by-case risk assessment is warranted in all patients but where possible, clinicians should prioritise meticulous haemostasis over cessation of agents., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Purpose: To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap., Methods: We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications., Results: The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications., Conclusions: The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The combination of acellular dermal matrix (ADM) and split-thickness skin graft (STSG) has been widely adopted to overcome functional and cosmetic limitations of conventional STSG. In this study, we evaluated the efficacy of this combination using 2 types of ADM: cadaveric acellular dermal matrix (CDM) and bovine acellular dermal matrix (BDM)., Methods: We recruited 72 patients undergoing autologous STSG to cover radial forearm free flap donor sites. They were included in 1 of 3 therapeutic groups: group 1, STSG using CDM (n = 29); group 2, STSG using BDM (n = 20); and group 3, STSG only (n = 23). Functional skin values for skin elasticity, humidification, transepidermal water loss, and color were determined. Values were compared between graft sites and adjacent normal (control) skin, and between grafted areas of each group., Results: All skin defects were successfully reconstructed without graft loss. Groups 1 and 2 demonstrated better elasticity than did group 3, based on the analysis using the ratio of grafted area to control. Grafted areas in all 3 groups exhibited less moisture than did control normal skin. There was less transepidermal water loss in group 1 than in group 3, which implied that CDM application had better barrier capacity against water evaporation. Graft sites of groups 1 and 3 exhibited darker and redder color compared with control areas., Conclusions: Composite forearm defects were successfully restored and exhibited acceptable quality after treatment with an ADM plus STSG. Applying either CDM or BDM under a STSG was a suitable procedure, as verified by objective measurements. Elasticity was well preserved in CDM and BDM groups. However, both ADMs revealed functional impairment of humidification., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Not only has tattooing been socially performed for thousands of years, but it has also been part and parcel of medical practice since antiquity. In our day and age, plastic surgeons are ever more frequently compelled to deal with tattooing - and with tattoo removal procedures, as well. While the process itself may appear harmless, it is not without risk and necessitates use of suitable tools and management by expert hands., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Dexmedetomidine has been proposed as a novel anesthetic adjuvant. However, it remains unclear whether peripheral administration of dexmedetomidine is safe and effective to reduce acute postoperative pain. This study aimed to examine the effects of dexmedetomidine on neuropathic pain., Methods: Adult male Sprague-Dawley rats were anaesthetized and randomly allocated into four groups (n = 8): Groups S, R, RD 1 , and RD 5 were injected with saline, 0.5% ropivacaine, 0.5% ropivacaine combined with 1 μg dexmedetomidine, and 0.5% ropivacaine combined with 5 μg dexmedetomidine, respectively, around the saphenous nerve. Then, the rats were subjected to skin/muscle incision and retraction (SMIR) surgery in the medial thigh. Mechanical and heat sensitivity was evaluated and morphology of the dorsal root ganglion (DRG) neurons was observed by electron microscopy., Results: Some 62.5%, 50%, 12.5%, and 25% of rats developed mechanical hypersensitivity in Groups S, R, RD 1 , and RD 5 , respectively. The number of swollen mitochondria in DRG neurons was significantly more in Group S (257.2 ± 60.9) and Group R (291.6 ± 82.1) than in Group RD 1 (97.2 ± 33.3) and Group RD 5 (13.6 ± 17.9). In addition, the edema in endoplasmic reticulum and Golgi apparatus was decreased in Group RD 1 and Group RD 5 compared with Group S and Group R., Conclusion: Peripheral administration of dexmedetomidine improves mechanical and heat hyperalgesia and mitigates postoperative pain., (Copyright © 2016. Published by Elsevier Taiwan.)

Introduction: Non-melanoma skin cancer is the most common type of skin cancer of the nasal dorsum and the medial canthal region, which is caused by chronic sun exposure. Limited adjacent tissue and the need for aesthetically pleasing result make the reconstruction of these regions very challenging. To overcome this challenge, we designed a perforator propeller flap based on the central artery., Methods: Between January 2014 and November 2015, we covered the nasal or medial canthal defects of 22 patients with central artery perforator propeller flaps., Results: The mean age of the patients was 60.4 years (range: 47-81 years). The median follow-up period was 7.5 months (range: 2-23 months). The pathological diagnoses were basal cell carcinoma for 14 patients and squamous cell carcinoma for the remaining eight patients. The size of the defects ranged from 2 × 2 to 3.5 × 4 cm, and that of the flaps ranged from 2 × 3.5 to 3.2 × 6 cm. We did not observe any major complications requiring surgery, such as total flap loss, hematoma, or dog-ear deformity. However, venous congestion was seen in five patients and partial flap necrosis (that healed without intervention) in two patients., Conclusion: The central artery perforator propeller flap is a reliable and versatile flap for the reconstruction of the nasal dorsum and medial canthal region. Reconstruction with this flap is a single-stage procedure that can cover large defects without causing dog-ear deformity or eyebrow asymmetry compared with other local flap options., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In recent years, transorbital endoscopic approaches are increasing in popularity as they provide several corridors to reach lateral areas of the ventral skull base through the orbit. The aim of this study is to investigate the feasibility of the inferolateral transorbital endoscopic approach (ILTEA) by detailing the step-by-step dissection, anatomic landmarks, and target anatomic areas., Methods: Seven cadaveric specimens (14 sides) were dissected in the Laboratory of Endoscopic Anatomy of the University of Brescia. Step-by-step dissection of ILTEA was performed to identify the main anatomic landmarks and corridors. Skin incision, dural incision, and boundaries of craniectomy were measured. Neuronavigation was used to check landmarks, track boundaries of surgical volumes, and measure orbital dislocation., Results: The study on the 14 ILTEAs defined 1 anatomic area ("waterline door") that leads to 4 corridors: Meckel's cave corridor, carotid foramen corridor, petrous corridor, and transdural middle fossa corridor. Crucial anatomic landmarks were identified and analyzed. Orbital dislocation was <10 mm., Conclusions: ILTEA provides the surgeon with a direct route to the region of the "waterline door," lateral areas of the ventral skull base, and middle cranial fossa. In addition, it allows an optimal view of the intracranial and extracranial portions of the maxillary and mandibular nerves. Further anatomic and clinical studies are needed to validate ILTEA in surgical practice., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Sacrococcygeal pilonidal sinus is common in young men and may recur over time after surgery. We investigated whether a factor exists that can aid in the determination of the preferred technique between the early Limberg flap and Karydakis flap techniques for treating recurrent pilonidal sinus., Materials and Methods: This prospective and randomized study enrolled 71 patients with recurrent pilonidal sinus in whom the Limberg flap or Karydakis flap techniques were applied for reconstruction after excision. Patients were divided into two groups as follows: 37 patients were treated with the Limberg flap technique and 34 patients were treated with the Karydakis flap technique. Fluid collection, wound infection, flap edema, hematoma, partial wound separation, return to daily activities, pain score, complete healing time, painless seating and patient satisfaction were compared between the groups. ClinicalTrial.gov: NCT02287935., Results: The development rates of total fluid collection, wound infection, flap edema, hematoma, and partial wound separation were 9.8%, 16%, 7%, 15% and 4.2%, respectively; total flap necrosis was not observed in any patient (p<0.001). During the average follow-up of 28 months, no patients (0%) developed recurrent disease. The two groups differed with respect to early surgical complications (p<0.001)., Conclusion: In this study, use of the Limberg flap was associated with lower complication rates, shorter length of hospital stay, early return to work, low pain score, high patient satisfaction and better complete healing duration. Therefore, we recommend the Limberg flap for treatment of recurrent pilonidal sinus.

Background: Photodynamic therapy (PDT) is a successful treatment for non-melanoma skin cancers in clinical practice. More and more doctors use PDT to cure the patients with skin cancer, especially in the elder. The purpose of this study was to evaluate the efficacy and safety of topical PDT using aminolevulinic acid (5-ALA) in the treatment of Extramammary Paget's disease (EMPD) and its role in surgical improvements., Methods: A total of 38 cases were included in this study. Lesions were located in the scrotum and the penis. Thirty-one cases had surgical resection of the lesions followed by ALA-PDT (combination of PDT and surgery group). Seven cases received ALA-PDT without receiving surgical resection because the surgery is extremely difficult or the patients refused surgery (simple PDT group). Each tumor lesion was irradiated with 120J/cm(2) using a 635-nm laser for 15min. A total of 3 times of assisted ALA-PDT was applied after surgery., Results: In the combination group, there was no recurrence in 6 months after treatment. In another group, recurrence occurred in 1 case in 6 months. All patients were able to complete the treatment protocol, with well cosmetic results and no moderate adverse reactions., Conclusions: As an assistive therapy after tumor resection, ALA-PDT can reduce the excision range of the tumor lesions and will play more important role in the treatment of EMPD., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background and Aim: The surgical treatment of microcystic lymphatic malformations (LMs) has historically been difficult and frustrating because of a high recurrence rate due to incomplete resection. However, complete removal of the multifocal and extensive lesions rely on accurate imaging diagnosis and effective repair methods for the resulting large defect. The purpose of this study was to repair large skin defects due to complete resection of microcystic LMs using lateral intercostal artery perforator (LICAP) flap., Patients and Methods: Between January 2009 and June 2012, tissue defects in the axillary chest wall region of eight patients aged 13-22 years after microcystic LMs resections were closed using the LICAP flap. Flap donor sites in all patients were closed primarily except in one patient who underwent skin grafting. Before surgery, ultrasound and magnetic resonance imaging (MRI) examination were used to confirm the diagnosis and determine the scope and level of the abnormality for complete resection., Results: All defects after microcystic LM excision were successfully closed using LICAP flaps. The follow-up period ranged from 1 to 3 years (mean 2.1 years). All flaps survived postoperatively. No recurrence occurred. Ultrasound and MRI follow-up also demonstrated flap survival without recurrence of microcystic LMs. No functional loss attributable to the LICAP flap harvest was identified in any case., Conclusions: Surgical resection is necessary for microcystic LMs. Imaging assists in the diagnosis and identification of the scope and level of lesions. The LICAP flap provides good coverage for the large defects and achieves acceptable morphology without functional deficits at flap donor sites. Ultrasound and MRI are safe and accurate diagnostic imaging methods for the pre- and postoperative evaluation of microcystic LMs in patients undergoing surgery., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade malignant tumor. It is characterized by aggressive local infiltration, leading to a propensity for recurrence. In children, DFSP is even less common and likely misdiagnosed or underdiagnosed. This study is a review of DFSP in the pediatric population and aims to identify factors for successful treatment., Materials and Methods: From July of 1986 to 2011, a total of 159 patients were diagnosed with dermatofibrosarcoma protuberans at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Subject to the age classification of our institution, patients under the age of 18 are defined in the pediatric category, of which159 cases were identified as our research subjects. Detailed data, including demographic data, imaging studies, pathology, treatment methods, and outcomes, of these identified patients were collected, reviewed, and analyzed., Results: A total of 13 patients, consisting of six male and seven female patients, were identified based on our criteria. Two had the lesions noticed at birth. Most patients experienced a variable period of quiescence, followed by a rapid growth phase. All 13 patients underwent wide excisions. Post-excision reconstruction included direct closure in three cases, skin grafting in three cases, and local or free flap reconstruction in seven cases. Of 13 patients, four received postoperative radiotherapy. All patients survived without recurrence up to July 2011, with follow-up periods ranging from 20 months to 19 years., Conclusion: Clinicians should be aware that DFSP is known to occur among children. Owing to its relatively low incidence, its presence may be confused with commoner lesions such as hemangioma, fibroma, or atrophic plaques without nodule. The confusing situation, as a result, frequently leads to delayed diagnosis. Vigilance in its diagnosis allows for treatment at manageable sizes as well as ensures complete excision. Reconstructive options, such as skin grafting, and modalities, such as adjuvant postoperative radiotherapy, are suggested to best complement each other. The former minimizes disfigurement while the latter minimizes recurrences., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Closure of a large myelomeningocele requires stable durable coverage of the dural reconstruction., Methods: Twenty-seven cases of myelomeningoceles have been treated in the department of pediatric neurosurgery at the Timone Children's Hospital in the last 17 years. Six children have undergone plastic and reconstructive surgery. Among these six children, four were received several months after birth with a large myelomeningocele and underwent cutaneous expansion prior to closure. One child received lateral discharge incisions during the neonatal period. The sixth child, received at 15 years of age for persistent CSF leak despite numerous attempts to close the dura, was treated by rotational dorsal fasciocutaneous flap with dural plastic surgery., Results: In all of the cases, these techniques provided stable and durable closure with a maximum follow-up of 11 years. An expansion complication was observed with exposure of the prosthesis without secondary infection., Conclusions: Cutaneous expansion is the technique of choice for late closure of large myelomeningoceles. It makes it possible to limit wound-healing problems and preserve muscle and skin resources in children who risk pressure sores., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Subcutaneous emphysema is often a symptom of a serious pathologic condition but rarely requires direct treatment. Subcutaneous emphysema itself occasionally may interfere with effective cardiopulmonary resuscitation and require direct intervention., Objective: The aim of this article is to present a case of subcutaneous emphysema during cardiac arrest and to describe a therapeutic technique that we call the "gills" procedure, as well as the background and rationale for this and other similar techniques., Case Report: A 56-year-old man sustained cardiac arrest in the setting of a perforated duodenal ulcer with massive subcutaneous emphysema and pneumomediastinum that interfered with effective cardiopulmonary resuscitation. A "gills" procedure consisting of bilateral skin incisions over the clavicles was performed, with the return of spontaneous circulation., Conclusion: Subcutaneous emphysema and pneumomediastinum can cause tension physiology, impairing normal cardiovascular and pulmonary function. Only with release of this tension can normal cardiopulmonary function return. The gills procedure is one of several possible therapeutic options., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Nail surgery is a special branch of hand and dermatologic surgery. It is not widely performed, and many physicians do not feel at ease to perform it. The objective of this contribution is to give a short overview of the most important surgical procedures in clinical practice. References from the literature and the author's own experiences are condensed to describe what a dermatologic practitioner with knowledge of the nail and some surgical skills can perform. Nail surgery is a precise technique that requires careful administration and attention to details. Proper patient preparation starts with a patient history to identify potential contraindications and to prevent unnecessary complications. The author recommends isopropyl alcohol scrub and chlorhexidine for disinfection and ropivacaine 1% for anesthesia. The technique used for anesthesia depends on the type of surgery. Surgical procedures are described for diagnostic biopsies, nail avulsion in general, onychogryposis, paronychia treatment, hematomas and bone fracture due to trauma, removal of subungual foreign bodies, ingrowing nails, pincer nails, warts, ungual fibrokeratomas, digital myxoid pseudocyst, subungual exostoses, and various tumors. If performed correctly with adequate skills, nail surgery will lead to functionally and aesthetically satisfying results in the majority of instances., (© 2013 Elsevier Inc. All rights reserved.)

Background: The free jejunal flap is a widely spread method of pharyngo-oesophageal reconstruction and can also be used in patients presenting with aspiration tendency following treatment for head and neck cancers or caustic injury of the upper aero-digestive tract to create a separate food pathway, the free jejunal diversionary conduit., Methods: Sixteen patients, 13 males and 3 females, aged between 32 and 66 years, undergoing pharyngo-oesophageal reconstruction with a free jejunal flap between October 2005 and July 2011, were included in this study. An extra length of jejunum was used in 10 patients for widening of the upper portion of a prefabricated free jejunal flap, in three patients who developed a leak at the jejuno-oesophageal junction during the follow-up for creation of a seromuscular flap that was used to seal off the leak and in three patients with aspiration tendency for simultaneous creation of a free jejunal diversionary conduit and a separate pharyngo-cutaneous fistula., Results: All flaps survived completely. No complication was observed at the pharyngo-jejunal junction during the follow-up in patients reconstructed with the prefabricated free jejunal flap. No recurrence of the leak was observed in patients treated with a seromuscular flap during the follow-up period. Patients with a free jejunal diversionary conduit did not experience episodes of aspiration and no obstruction of the pharyngo-cutaneous fistula was noted in the postoperative period., Conclusions: We want to encourage the use of an extra length of jejunum in pharyngo-oesophageal reconstruction with a free jejunal flap because it helps to manage postoperative complications, such as leakage and stricture, and it does not increase the morbidity related to the reconstruction. Furthermore, we believe that the creation of a separate pharyngo-cutaneous fistula represents another step forward in the improvement of pharyngo-oesophageal reconstruction with a free jejunal diversionary conduit., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Tissue expansion has been widely used to provide additional soft tissue for clinical reconstruction. Rapid expansion requires a much shorter clinical period than conventional expansion; however, less natural skin growth occurs resulting in a larger stretch-back ratio and insufficient extra soft tissue for clinical use. In this study, hyperbaric oxygen therapy (HBOT) was used in the inflation phase of rapid expansion to increase natural skin growth., Methods: Twelve rabbits were divided into two groups. Each group received rapid expander inflation every day. One group received HBOT and the other did not. Blood flow in the expanded skin of each rabbit was assayed in the 10-day inflation phase. After the inflation phase, a rectangular expanded flap of each rabbit was harvested. The instant stretch-back ratio, tension, weight and histological characteristics of the flaps were evaluated., Results: (1) After the second inflation day, the mean blood flow of the HBOT group became significantly higher than that of the control with each day (P < 0.05). At the last day, the blood flow of the HBOT group increased to 131 ± 17 pu, while the control group decreased to 35 ± 5 pu. (2) The mean instant stretch-back ratio of the HBOT group under no-tension conditions was 29 ± 4%, which was significantly less than that of the control group, 46 ± 3% (P < 0.01). (3) The mean flap tension of the HBOT group was 15.3000 ± 1.47648 g and 12.9833 ± 0.73598 g in the transverse and longitudinal axis, respectively, both significantly smaller than that of the control group (33.9167 ± 4.78390 g and 26.5000 ± 2.45031 g, respectively) (P < 0.01). (4) Mean per unit flap weight of the HBOT group was 0.221 ± 0.005 g cm(-2), significantly heavier (P < 0.01) than that of the control group (0.143 ± 0.010 g cm(-2)). (5) Histologically, the epidermal layer and thickness of the expanded skin of the HBOT group were much thicker than those of the control group, and more vessels were visible in the subcutaneous tissue., Conclusions: The use of HBOT in the inflation phase of rapid expansion can effectively promote blood flow in the expanded skin, increase its natural skin growth and reduce the instant stretch-back ratio and tension of expanded skin., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The wound healing attributes of five acellular dermal skin substitutes were compared, in a two-step procedure, in a porcine model. Ten pigs were included in this experimental and randomized study. During the first step, dermal substitutes (Integra(®), ProDerm(®), Renoskin(®), Matriderm(®) 2mm and Hyalomatrix(®) PA) were implanted into full-thickness skin wounds and the epidermis was reconstructed during a second step procedure at day 21 using autologous split-thickness skin graft or cultured epithelial autograft. Seven pigs were followed-up for 2 months and 3 pigs for 6 months. Dermal substitute incorporation, epidermal graft takes, wound contraction and Vancouver scale were assessed, and histological study of the wounds was performed. Results showed significant differences between groups in dermis incorporation and in early wound contraction, but there was no difference in wound contraction and in Vancouver scale after 2 and 6 months of healing. We conclude there was no long-term difference of scar qualities in our study between the different artificial dermis. More, there was no difference between artificial dermis and the control group. This study makes us ask questions about the benefit of artificial dermis used in a two-step procedure., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Background: Wound morbidity commonly accompanies transposition of the femoral vein when used for hemodialysis access, mainly because of the length of the skin incision. A short incision may reduce wound complications but may compromise the arteriovenous (AV) function because of the shorter length of femoral vein available for puncture. This report presents our experience with a modification of the original technique, in which a smaller skin incision and fistula elevation were used., Methods: The clinical course of 25 AV fistulas in the thigh using the femoral vein was retrospectively analyzed. The original technique to create femoral AV access was used in 12 patients and the modified technique in 13. The procedures were performed between 2005 and 2007, and patients were monitored until January 31, 2011., Results: Three fistulas failed in each group. Five patients in the original group had wound complications. No wound complications occurred in the modified group. The fistula was first used at an average of 10.45 weeks and 6.14 weeks, respectively. Patency was similar in both groups., Conclusions: It is possible to obtain a functional AV fistula in the thigh using the femoral vessels and limiting the extent of the incision. Long-term patency is reasonable, despite the use of a short femoral segment for puncture., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)