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BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Supplemental digital content is available in the text., BACKGROUND Clinical assessment of indeterminate burn wounds has been reported to yield poor accuracy, even when performed by burn experts. Indocyanine green (ICG) dye angiography has been found to be highly accurate in assessing burn depth, but there is still limited evidence of its use in indeterminate burn wounds. This study aims to compare the accuracy of ICG angiography to that of clinical assessment in assessing indeterminate burn wounds. METHODS This is a prospective, multicentered, triple-blinded, experimental study. Participants were stable patients, admitted to the hospital with burn wounds of indeterminate depth. The burn wounds were clinically assessed by an attending plastic surgeon. ICG angiography was performed and evaluated by another surgeon. Tissue biopsies were obtained and sent for histological study to be assessed as the gold standard. RESULTS In the 30 burn sites that were assessed, the accuracy of ICG angiography was 100.0%, compared with 50.0% for clinical assessment (p < 0.001). Clinical assessment yielded a sensitivity of 33.3% and specificity of 66.7%, while ICG angiography yielded both a sensitivity and specificity of 100.0%. Therefore, the number needed to treat for using ICG angiography in indeterminate burn wounds was two. CONCLUSION Indocyanine green angiography yields a significantly higher accuracy than clinical assessment in indeterminate burn wounds. This intervention can, thus, be a useful tool to aid clinical judgment. TRIAL REGISTRATION Thai Clinical Trials Registry, number TCTR20170821001. LEVEL OF EVIDENCE Diagnostic test, level I.

Performing interrupted intradermal suture during bi-layered skin closure is time consuming. The oblique intradermal suture is hypothesized to be a faster choice for intradermal closure while yielding similar wound cosmetic outcomes. This study aims to demonstrate the equivalence of wound outcomes between the interrupted oblique intradermal suture (OIS) and conventional interrupted intradermal suture (IS) methods. This prospective, multicenter, double-blind randomized equivalence trial included patients scheduled to undergo elective surgery with a linear incision wound. A split-wound model was used. One half of the wound was sutured using IS method and the other using OIS method. Wounds were evaluated at 1 week and 2 months after surgery. Of the 120 patients, OIS was found to be equivalent to IS for all clinical outcome parameters. OIS was associated with 50% reduction in suture time and the number of stitches required, and a 40% reduction in suture material used (p .001). Rates of wound dehiscence and infection were not different between methods. Wound outcomes using OIS were equivalent to those observed when using IS, except that OIS yielded reductions in suturing time, number of stitches and suturing material used. OIS is a cost and clinically effective wound closure method. Trial registration: ClinicalTrials.gov registration number NCT03001856 Meeting presentation: 7th Bozner Symposium of Plastic Surgery, Bozen, Italy, January 2017.

In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle.In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers.The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers.Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months' recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids.This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote.

Too much or too little information during patient education can increase patient anxiety. Needs-based patient education helps to determine the appropriate amount of information required to provide education based on patient needs. This study aimed to compare needs-based patient education with traditional patient education in reducing preoperative anxiety. This was a prospective, multicenter, single-blind, randomized controlled trial with a 1:1 allocation ratio. Patients undergoing day surgery were randomized into a study group (needs-based education) or a control group (traditional education). The primary outcome was patient anxiety. Secondary outcomes were patient satisfaction and time spent in patient education. Patients completed questionnaires to evaluate their anxiety and satisfaction before patient education, after patient education, and after surgery. In total, 450 patients were randomized and analyzed (study group n = 225, control group n = 225). Comparisons before education, after education, and after surgery showed that there was a significant decrease in patient anxiety and an increase in satisfaction in both groups (p

Most patient education involves passive learning. To improve patient education regarding surgery, an active learning workshop-based teaching method is proposed. The objective of this study was to assess level of patient surgical knowledge, achievement of workshop learning objectives, patient apprehension about future surgery, and participant workshop satisfaction after completing a surgical training workshop. A four-station workshop (surgical scrub, surgical suture, laparoscopic surgery, and robotic surgery) was developed to teach four important components of the surgical process. Healthy, surgery-naive adolescents were enrolled to attend this 1-h workshop-based training program. Training received by participants was technically and procedurally identical to training received by actual surgeons. Pre- and post-workshop questionnaires were used to assess learning outcomes. There were 1312 participants, with a mean age 15.9 ± 1.1 years and a gender breakdown of 303 males and 1009 females. For surgical knowledge, mean pre-workshop and post-workshop scores were 6.1 ± 1.5 and 7.5 ± 1.5 (out of 10 points), respectively (p

Handouts have been a primary tool to help students learn and understand class content in lectures better. Some lecturers, however, do not provide handouts to students. Currently, little research has studied the disadvantages of lectures without handouts. We, therefore, aim to survey medical student opinions and behaviors in lectures with handouts comparing to lectures without.A cross-sectional study using questionnaires was conducted on first to fifth year medical students at the Faculty of Medicine, Chulalongkorn University.Study response rate was 89.5%. Less concentration in lectures without handouts was reported at 83.6%. Note-taking decreased 38.3% from 89.7% to 51.4% (p 0.001) with a statistically significant increase of class-skipping behavior. Absence of handouts also resulted in a rise in photocopying peer lecture notes but had no significance increase in either self-directed or peer learning. There was no association between student grade point average and handout attitudes.Handouts are essential in lectures for medical students. Taking them away could immensely reduce student capability to concentrate and understand dynamic lectures. Providing handouts does not spoon-feed students with information. Rather, handouts help offer qualitative improvements to lectures.

Introduction Tutoring in suturing was developed to compensate for a shortage of suturing cases. The objective of this study was to compare ideal suturing score (ISS; 9 points), suturing time (min:sec), and suture placement error (mm) between medical students completing the suturing tutoring program and medical students attending ordinary medical school training program. Methods Participants consisted of 2 groups of medical students who had never performed suturing. The study group had the role of suturing tutor to teach interested high school students. The control group consisted of volunteers from the ordinary medical school program. Skills measurement was performed by having students from both the groups perform 3 vertical mattress sutures on a model. The study group was tested at weeks 1, 9, and 10 to assess improvement. Both the groups were tested at week 10 to compare final learning outcome. Results There were 41 and 40 participants in the study group and the control group, respectively. ISS was significantly improved in the study group from week 1-week 10 (7.0 ± 1.3 vs. 8.2 ± 0.9, p=0.01). At week 10, the study group had a higher mean ISS than the control group (8.2 ± 0.9 vs. 7.8 ± 1.1, p=0.68). Mean suturing time and mean placement error were also lower in the study group at the end of suturing training (5:1 ± 1:0 vs. 5:2 ± 1:2, p=0.13; 7.4 ± 7.4 vs. 8.0 ± 10.8, p=0.44). Conclusion Tutoring trainees to suture can improve a student's ability to learn how to suture.

Objective After many years, heart transplantation is still the most accepted treatment for end-stage heart disease. A heart transplantation program was started at our hospital in December 1987 as the first intrathoracic organ transplantation in Southeast Asia. Herein, we have reviewed our 20 years of experience from 1987 to 2007. Methods We followed every individual within our 52-patient cohort for up to 20 years. Three eras were studied: 1987 to 1995, 1996 to 2002, and 2003 to 2007. End points were survival, rejection, infection event, and graft coronary artery disease (CAD). Results There were 52 patients (39 males and 12 females). The mean age was 41.7 years (range, 12–23 years). Perioperative mortality (within 1 month) was 13.4% (n = 7) due to graft failure (n = 2), rejection (n = 3), infection (n = 1), on pulmonary hypertension (n = 1). Medium-term mortality (1–12 months) was 30.7% (n = 16) due to rejection (n = 8), infection (n = 7), or CAD (n = 1). After 1 year causes of death were rejection (n = 4), infection (n = 4), renal failure (n = 2), or CAD (n = 1). Overall actuarial 1-, 5-, and 10-year survival rates for all recipients were 54.7%, 43.3%, and 32.5%, respectively. The first patient in this series is still alive. For the period 2003 to 2007, actuarial 1-year and 4-year survival rates for all recipients were both 77.8%. The rate of rejection was reduced to just one event during this period. All surviving patients were NYHA Functional class I and II; 86% went back to work, leading almost normal lives. Conclusion Improved survival in the current era may be attributed to better organ preservation, improved immunosuppression, and control of infection, as well as less graft CAD. Those who survive more than 1 year have a good quality of life.