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Postoperative complications such as surgical site infections, dehiscence, seromas, and hematomas prolong wound care and impose significant cost increases to patients and healthcare providers. Clinicians aiming to reduce the incidence of these complications should be aware of risk factors associated with surgical type, procedures used, patient characteristics, and postoperative care. Today, improved guidelines and general practices for managing surgical incisions have reduced the incidence of complications to historic lows. In addition to these standard care options, advanced wound care approaches have been extensively studied and exist as options for clinicians to provide adjunctive postoperative support and facilitate wound healing. These systems include advanced wound dressings and closed-incision negative-pressure therapy. Advanced wound care is not appropriate in all settings, and healthcare providers must assess each case for specific needs to be addressed by the available incision management plans. Emerging therapies that are intended to improve the continuum of postoperative care should continue to be evaluated in controlled clinical trials to determine their effectiveness under different circumstances and to support the creation of more robust guidelines for their use.

Purpose: Synthetic non-absorbable meshes are routinely used in hernia surgery for clean cases but are avoided in the case of clean-contaminated or contaminated hernia or dirty cases to minimize the risk of infection. The present study was conducted to evaluate the outcome of polypropylene mesh in the settings of bowel resection performed for strangulated hernias of the abdominal wall., Methods: This prospective observational study was conducted in the Department of Surgery of a teaching hospital in central India between 1st March 2015 and 31st Aug 2017. Adult patients > 18 years age, with abdominal wall hernias, presenting with strangulation, and requiring resection and anastomosis for gangrenous bowel were included in the study. Outcomes noted were wound infection, morbidity and mortality, need for the removal of the mesh, and recurrence of the hernia., Results: 30 (22 men and 8 women) patients with strangulated hernias underwent emergency surgery with resection of gangrenous bowel and anastomosis. The 30 cases included 21 inguinal, seven incisional, one femoral and one umbilical hernia. 12 of the 30 cases having gross contamination of the operative wound due to perforated gangrenous bowel were classified as 'dirty'; while the remaining 18 cases with non-perforated gangrenous herniating bowel were classified as 'contaminated'. Wound infection occurred in 8/30 patients (26.67%); but these healed with antibiotics and dressing. Mesh removal was not required in any patient during entire study period. Two recurrences (6.7%; one inguinal and one incisional hernia) were observed. There was no mortality., Conclusion: The use of polypropylene mesh for contaminated and dirty strangulated hernias is effective and safe, with acceptable morbidity and good short-term results.

Background: Loco-regional treatment failure after radiotherapy with or without chemotherapy and/or prior surgery represents a significant portion of head and neck cancer patients. Due to a wide array of biological interactions, these patients have a significantly increased risk of complications related to wound healing., Methods: Review of the current literature was performed for wound healing pathophysiology, head and neck salvage surgery, and wound therapy., Results: The biology of altered wound healing in the face of previous surgery and chemoradiotherapy is well described in the literature. This is reflected in multiple clinical studies demonstrating increased rates of wound healing complications in salvage surgery, most commonly in the context of previous irradiation. Despite these disadvantages, multiple studies have described strategies to optimize healing outcomes. The literature supports preoperative optimization of known wound healing factors, adjunctive wound care modalities, and microvascular free tissue transfer for salvage surgery defects and wounds., Conclusion: Previously treated head and neck patients requiring salvage surgery have had a variety of disadvantages related to wound healing. Recognition and treatment of these factors can help to reverse adverse tissue conditions. A well-informed approach to salvage surgery with utilization of free vascularized or pedicled tissue transfer as well as optimizing wound healing factors is essential to obtaining favorable outcomes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aim: Wound dehiscence is a serious postoperative complication associated both with high morbidity and mortality. It has a significant rate of occurrence in breast reconstruction surgeries with a deep internal epigastric perforator (DIEP) and with a profunda artery perforator (PAP) flap. Risk factors for wound dehiscence include smoking, diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The aim of this pilot study was to assess whether postoperative treatment with closed incision negative pressure therapy (ciNPT) decreases the incidence of donor site wound dehiscence in breast reconstruction patients., Method: Women undergoing a breast reconstruction with a DIEP or PAP flap were enrolled in a pilot randomized controlled trial and assigned treatment with either ciNPT or adhesive strips. The primary outcome was wound dehiscence upon follow-up after four weeks. Secondary outcomes that were evaluated included wound infection, pain, and allergy. There was no loss to follow-up., Results: This pilot study included 51 women (n = 25 ciNPT, n = 26 adhesive strips). The two groups did not differ significantly in patients demographics or comorbidities. Wound dehiscence occurred in 11 patients (n = 2 ciNPT, n = 9 adhesive strips). This difference was statistically significant: p = 0.038. There were no statistically significant differences in secondary outcomes between the two groups., Conclusion: In this pilot study, postoperative treatment with ciNPT decreased the incidence of donor site wound dehiscence in breast reconstruction patients. Further research is ongoing by the same hospital. This trial was registered in the Netherlands Trial Register (NTR) under ID no. NTR5808., (Copyright © 2018 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Avoidance of early wound complications is critical to the success of total joint arthroplasty. The magnitude of postoperative complications can be as simple as quickly resolving wound drainage, to persistent wound drainage and full-thickness soft tissue necrosis. Persistent postoperative drainage and wound complications can lead to a devastating deep periprosthetic infection. Attention to several steps in the clinical and perioperative pathway should be addressed to avoid this complication including addressing modifiable patient risk factors, implementing meticulous surgical technique, and following an algorithmic approach in response to persistent wound drainage., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To identify changes in body image in patients with surgical wound dehiscence., Design and Setting: This cross-sectional, descriptive, analytical study was conducted in a university hospital and nursing care center in Brazil., Patients and Intervention: Sixty-one adult surgical patients of both genders from different inpatient wards or receiving outpatient care were selected. Forty-one participants had surgical wound dehiscence, and 20 had achieved complete wound healing (controls)., Main Outcome Measure: The Body Dysmorphic Disorder Examination (BDDE), Body Investment Scale (BIS), and a questionnaire assessing clinical and sociodemographic characteristics of patients were used for data collection., Main Results: Surgical wound dehiscence defects were 0.5 to 30 cm in length, located on the arms, legs, and chest. They were significantly associated with being white (P = .048), number of children (P = .024), and presence of comorbid conditions (P = .01). Overall, men reported higher BIS scores (positive feelings about the body) than women (P = .035). Patients with wound dehiscence had higher BDDE scores (negative body image) than controls (P = .013). The BDDE scores were associated with presence of surgical wound dehiscence (P = .013), number of children (P = .009), and wound length (P = .02). There were significant correlations between BIS scores in men with wound dehiscence (P = .042), number of children (P < .001), and BDDE scores (P < .001) and between BDDE scores and number of children (P = .031), wound length (P = .028), and BIS scores (P < .001)., Conclusion: Surgical wound dehiscence had a negative impact on body image.

Airway complications after lung transplantation are well described and can lead to significant morbidity and mortality. Treatment options for anastomotic dehiscence include expectant management, placement of endobronchial stents, or surgical repair. The use of fibrin sealant instilled by bronchoscopy to seal a dehiscence has not been well described. Our patient is a 57-year-old man who underwent orthotropic bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. He was found to have a partial bronchial anastomosis dehiscence and was subsequently treated with endobronchial fibrin sealant glue instillation. This case illustrates the successful use of endobronchial fibrin sealant for bronchial anastomosis dehiscence., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Negative pressure wound therapy (NPWT) has been described for closure of complex neonatal abdominal wounds, but advanced techniques for stoma or fistula control, skin protection, and the use of high pressure therapy not as well established., Cases: We identified neonatal patients at our institution who received NPWT for a complex abdominal wound, defined as a wound associated with a stoma or fistula with partial or complete dehiscence of the abdominal fascia or skin. We then reviewed techniques for decreasing wound contamination and protecting the newborn's skin. One patient had an especially complex wound; she was born at ∼23 weeks' gestational age (birth weight 580 g). She developed necrotizing enterocolitis and strictures, requiring multiple surgeries to relieve obstruction, ultimately resulting in an end ileostomy with mucous fistula. She suffered from wound dehiscence and retraction of her surgically created stoma, resulting in a complex abdominal wound with significant damage to the surrounding skin. We used advanced NPWT techniques to heal her wound, including topical skin protectants, placement of an adhesive dressing over the skin prior to placement of negative pressure dressing, placement of a negative pressure sponge directly on the wound bed and stoma, diversion of enteric contents away from the wound using a Malecot catheter, and an increase in the negative pressure applied., Conclusion: Complex neonatal abdominal wounds can be treated effectively using NPWT. The techniques we describe divert enteric contents away from the wound bed while maintaining negative pressure and protecting the surrounding skin. In addition, we used negative pressure up to -125 mm Hg and found it was well tolerated by our patients.

Anastomotic airway complications, including the dehiscence of the bronchial anastomosis, are a severe cause of morbidity after lung transplantation. We present a case of dehiscence treated by placing an uncovered metal stent into the main bronchus. We usually use this procedure for bronchial stenosis, but in this case, the stent favored the growth of granulation tissue and so the closure of the dehiscence. This procedure was minimally invasive and may be an alternative to an open repair, without precluding open repair in case of failure., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Raoultella ornithinolytica is a rare opportunistic aerobic gram-negative bacillus that naturally exists in soil, water and plants. The pathogen has been described in association with diabetic foot infections, biliary infections, bacteraemia and native and prosthetic joint infections. Fat necrosis and wound infection following breast reduction surgery or other plastic surgeries caused by this pathogen have not been previously described. We present a case of bilateral fat necrosis, wound infection and dehiscence in a 24-year-old woman with no significant past medical problems. She initially had an uneventful early postoperative course but 3 weeks after surgery noticed pain and discharge from both nipple/areola area of both breasts which later developed into full-thickness fat necrosis and complete destruction of the nipple areolar complex. R. ornithinolytica , Escherichia coli and Enterococcus faecalis were identified from wound exudate cultures. She was treated with surgical debridement and 2 weeks of appropriate antibiotics with a favourable outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

There is a dearth of data on management of anastomotic airway dehiscence following lung transplantation. Herein we report a case of successful conservative management of an anastomotic airway dehiscence after cadaveric donor lung transplantation. A 41-year-old woman with primary ciliary dyskinesia underwent cadaveric bilateral lung transplantation without cardiopulmonary bypass. On the postoperative day 25, left pneumothorax developed and bronchoscopy demonstrated a localized anastomotic dehiscence at the left main bronchus. The dehiscence was managed with 2 weeks of pleural drainage and was completely covered with regenerated bronchial epithelium at 4 months after transplantation. There is no finding suggestive of significant stenosis at 4 years of follow-up. Our case suggested asymptomatic and localized anastomotic dehiscence does not always require endobronchial stent placement or re-operation. Multiple factors that may contribute to the successful conservative management were discussed in this article.

Management of sternal wound dehiscence in newborns after cardiac operations can be a slow and lengthy process, during which the risk of progression to deep sternal wound infection and mediastinitis remains a concern. We report the case of a neonate born with single-ventricle physiology who underwent a Damus-Kaye-Stansel procedure as first-stage palliation toward creating Fontan circulation. The postoperative period was characterized by sterile wound dehiscence of the subcutaneous layers. We used a CorMatrix extracellular matrix patch as an adjunct to repair the wound defect. After 7 weeks, the wound had healed with excellent results. To our knowledge, this is the first report of extracellular matrix patch implantation for sternal wound reconstruction in a neonate.

Purpose: Negative pressure wound therapy with instillation (NPWTi) has been proved to be a safe and effective treatment option for abdominal wall wound dehiscence with mesh exposure. Our aim in this study is to examine whether it is also cost-effective., Methods: We performed a retrospective cohort study with 45 patients treated for postoperative abdominal wall wound dehiscence and exposed mesh: 34 were treated with conventional wound therapy (CWT) and 11 with NPWTi. We carried out a cost analysis for each treatment group using the Diagnosis-related group (DRG) system and a second evaluation using the calculated costs "per hospital stay". The differences between NPWTi and CWT were calculated with both evaluation systems. Comparative analysis was performed using the Mann-Whitney U test., Results: Mean costs using the DRG estimation were 29,613.71€ for the CWT group and 15,093.37€ for the NPWTi group, and according to the calculated expenses "per hospital stay", 17,322.88€ for the CWT group and 15,284.22€ for the NPWTi group. NPWTi showed a reduction in the total expense of treatment, related to a reduction in episodes of hospitalization and number of surgeries required to achieve wound closure. However, differences were not statistically significant in our sample., Conclusions: NPWTi proves to be an efficient treatment option for abdominal wall wound dehiscence with mesh exposure, compared to CWT. More trials aimed to optimize treatment protocols will lead to an additional increase in NPWTi efficiency. In addition, to generalize our results, further studies with larger samples would be necessary.

Introduction: The management of chronic, nonhealing wounds in patients with multiple comorbidities continues to be a challenge for health care practitioners. Chronic wounds typically do not progress through the normal phases of wound healing and generally remain stagnant during the inflammatory phase, resulting in an increase in proteolytic enzymes with degradation of the extracellular matrix. Bacterial biofilm has been documented to be one of the main factors delaying wound healing, resulting in the prolongation of the inflammatory phase., Objective: In order to control biofilm formation, sequester proteolytic enzymes, and provide a biocompatible scaffold to support healing, the investigators utilize a purified collagen matrix containing polyhexamethylene biguanide (PCMP) in a case series of 9 wounds on 8 patients with multiple comorbidities who did not respond to previous conventional or adjuvant therapy., Materials and Methods: Wound etiologies included 3 pressure ulcers, 1 diabetic foot ulcer, 1 venous leg ulcer, 2 postsurgical wound dehiscences, 1 ulcer secondary to calciphylaxis, and 1 traumatic wound secondary to hematoma. The average wound size at the first PCMP application was 34.0 cm2, and the wounds were present for an average of 9.2 weeks prior to the first PCMP application., Results: Patients received an average of 5.8 PCMP applications. Of the 6 wounds that healed, average time to closure from the first PCMP application was 10 weeks. The remaining 3 wounds demonstrated improved wound appearance with 100% granulation tissue and an average area reduction during PCMP treatment of 61.4%., Conclusions: This case series demonstrated that PCMP along with good wound care supported both wound closure and improvements in wound bed condition and area reduction on recalcitrant, nonhealing wounds of various etiologies.

The aim of this study was to compare the amount of radiographic horizontal buccal bone thickness (BBT) at implant dehiscence defects grafted with the sandwich bone augmentation (SBA) and modified sandwich bone augmentation (MSBA) techniques. Compared to the SBA technique, the MSBA approach involved an additional outer layer of deproteinized bovine bone mineral (DBBM) to maintain the space for bone regeneration for longer periods. A total of 19 patients, each with a buccal implant dehiscence defect, were recruited. The control group was treated with SBA technique (n = 10), while the test group was treated with MSBA technique. Cone beam computed tomography (CBCT) scans, taken at three time points (before and immediately after implant surgery, and 6 months post-treatment) were used to assess the BBT at the implant platform (-1.8 mm), the rough-smooth junction (0 mm), and 2, 4, 6, 8, and 10 mm apical to the rough-smooth junction. At 6 months postsurgery, the mean BBT in control and test groups was 1.69 ± 0.38 mm and 2.55 ± 0.21 mm, respectively. Mean BBT was significantly greater in the test group at 2, 4, 6, and 8 mm apical to the rough-smooth junction. There was no statistical difference in the mean BBT at the implant platform, the rough-smooth junction, and 10 mm apical to the rough-smooth junction between the two groups (P > .05). Within the limitations of this study, it was concluded that the additional layer of DBBM enhanced BBT along the implant, except at the smooth collar.

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Introduction: Necrosis, wound breakdown, and infection represent major complications associated with radical vulvectomy. We aimed to analyze the feasibility of hyperbaric oxygen (HBO₂) therapy as an adjunctive treatment for such complications., Methods: We performed a retrospective analysis of the medical records, clinical charts, and operative records of vulvar cancer patients who underwent hyperbaric oxygen therapy after extensive surgical resection in our institute between 2012 and 2016, with a comparison of the clinical outcomes of patients with similar surgical procedures andsevere wound complications who did not undergo HBO₂., Results: A total of 16 patients were included in the study. In the subgroup treated with HBO₂, seven patients were identified. Two patients had primary surgery, while five had recurrent surgery (of these, two had previously undergone radiation therapy). Six patients received reconstructive flaps (five myocutaneous and onefasciocutaneous), while one patient had primary suture. Dehiscence, ischemia and necrosis were estimated to cover 30%-80% of the surgical surface area. Surgical debridement was performed in six patients. Daily 90-minute sessions in the hyperbaric chamber were performed at a pressure of 2.2 atmospheres absolute, with partial oxygen pressure of 1672 mbar. Infection control and satisfactory healing were achieved using 10-61 sessions. All patients in the subgroup who did not receive HBO₂ required surgical debridement due to partial or near-total flap necrosis, with two reconstructive interventions required., Conclusions: Hyperbaric oxygen therapy was an efficient adjuvant for wound healing and infection control in managing wound complications after extensive vulvar resections., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post-bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=-0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post-bariatric abdominoplasty. An adequate post-treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self-assessment and poor overall quality of life, regardless of the received treatment., (© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Objective: The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures., Methods: Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months., Results: The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living., Conclusion: The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To compare clinical performance of a new resorbable non-cross-linked collagen membrane, creos xenoprotect (CXP), with a reference membrane (BG) for guided bone regeneration at dehisced implant sites., Materials and Methods: This randomized controlled clinical trial enrolled patients with expected dehiscence defects following implant placement to restore single teeth in the maxillary and mandibular esthetic zone and premolar area. Implants were placed using a two-stage surgical protocol with delayed loading. Bone augmentation material placed at the implant surface was immobilized with CXP or BG membrane. Soft tissue health was followed during the healing period, and the defect size was measured at reentry and 6 months after implant placement., Results: Of the 49 included patients, 24 were treated with CXP and 25 with BG. Patient characteristics did not differ between the two arms. In the CXP arm, the defect height at implant insertion was (mean ± SD) 5.1 ± 2.1 mm (n = 24) and reduced at reentry by 81% to 1.0 ± 1.3 mm (n = 23). In the BG arm, the defect height at implant insertion was 4.9 ± 1.9 mm (n = 25) and reduced at reentry by 62% to 1.7 ± 2.1 mm (n = 24). Assuming a margin of non-inferiority of 1 mm, CXP was non-inferior to BG. Membrane exposure rate was highest at week 3 in both arms, reaching 16.7% for BG and 8.7% for CXP., Conclusions: The new resorbable non-cross-linked collagen membrane facilitates bone gain to support implant placement in expected dehiscence defects. The observed trend toward higher mean bone gain and lower exposure rate with CXP compared to BG should be further investigated., (© 2016 The Authors. Clinical Oral Implants Research Published by John Wiley & Sons Ltd.)

Purpose: In maxillofacial surgery, hyperbaric oxygen treatment is used almost exclusively as adjunctive therapy for osteoradionecrosis of the mandible in irradiated patients. It also is used to prevent the occurrence of osteoradionecrosis in the irradiated patient when dental surgery is indicated. Theoretically, hyperbaric oxygen therapy should benefit the nonirradiated patient in maxillofacial surgery (eg, patients with persistent intraoral wound dehiscences after bone grafting)., Materials and Methods: Six nonirradiated patients underwent hyperbaric oxygen therapy because of compromised wound healing after intraoral bone grafting of the maxilla as a preimplant procedure. All patients were treated 7 to 26 times with hyperbaric oxygen therapy at 2.5 ATA., Results: All patients healed uneventfully. In retrospect, almost all patients had a history of chronic maxillary sinusitis or trauma to the operated area., Conclusion: Hyperbaric oxygen therapy seems to be an effective adjunctive therapy in the treatment of nonirradiated patients with compromised intraoral maxillary bone graft healing. Chronic maxillary sinus problems or a history of trauma could predispose to wound dehiscence after bone grafting., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Compromised wound healing in cranio-maxillo-facial surgery is a threat to the patient's rehabilitation. Therapy of chronic and/or infected wounds is time- and cost-consuming, burdensome and occasionally futile. Cold atmospheric plasma is a new approach that promises to overcome these limitations. The aim of this proof-of-concept study was to evaluate the clinical outcome of cold plasma irradiation in patients with impaired wound healing who are refractory to conservative wound therapy and/or revision surgery., Materials and Methods: We enrolled six patients (mean age: 63.5 years; SD 8.8 years; 1 female and 5 males) who experienced various cranio-maxillo-facial surgical procedures and suffered from wound healing disturbances. In addition to established wound care, all wounds were irradiated with cold atmospheric plasma. The primary outcome variable was the attainment of complete wound closure., Results: In all patients, complete remission in terms of wound closure was observed within a mean time of 15.5 weeks (range: 4-38 weeks). No undesirable side effects were observed, and no inflammation or infection occurred after cold plasma initiation., Conclusion: The use of cold atmospheric plasma might offer a reliable, conservative treatment option in complicated wound healing disturbances in cranio-maxillo-facial surgery., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To study the outcomes of large diameter soft bandage contact lens (BCL) in managing early trabeculectomy bleb leak., Materials and Methods: Of 972 eyes that underwent fornix-based trabeculectomy between 2011 and 2015, 19 eyes with bleb leak with at least 1 year follow-up were eligible. Bleb leak was conservatively managed using large diameter BCL (≥15.5 mm in diameter). Success was defined as complete, if bleb leak resolved and the intraocular pressure (IOP) was ≥5 and ≤18 mm Hg with no additional antiglaucoma medication and failure if surgical intervention was needed., Results: Mean age (±SD) of subjects was 43.5±11.9 years. Mitomycin C was used in 15/19 eyes. Median time (interquartile range) from trabeculectomy to bleb leak was 9 days (interquartile range: 8 to 19 d). Bleb leak was treated with 15.5 mm BCL in 16 eyes and 17 mm lens in 3 eyes. Bleb leak resolved with BCL in 17 [89.5%; 95% confidence interval (95% CI), 68.6-97] and 2 eyes (10.5%; 95% CI, 2-31) required bleb resuturing. Mean duration of BCL wear for bleb leak resolution was 23.7±8.9 days. Mean IOP increased from 5.8±2.7 to 12.5±3.1 mm Hg after resolution of bleb leak (P<0.05). At 16 months, complete success probability of trabeculectomy was 89.4% (95% CI, 75.6%-100%)., Conclusions: Large diameter BCL was effective in the management of early bleb leak with good intermediate term success for IOP control. We suggest a trial of soft contact lens of appropriate diameter to manage early bleb leaks, before planning any invasive intervention.

Objective: A clinical audit was performed to evaluate whether Acapsil micropore particle technology (MPPT) powder could improve the management of acute wounds to heal by secondary intention., Method: Wounds, which could be characterised as sloughy, wet and probably infected, normally managed by debridement followed by negative pressure wound therapy (NPWT), were included in the evaluation. The MPPT powder was applied topically to the wound surface either once daily or on alternate days, with each wound receiving a total of two to five applications. Most patients had NPWT after the MPPT powder treatment had finished to assist healing., Results: The study included nine patients with dehisced surgical wounds and one with a category IV pressure ulcer (PU). The wounds were generally covered in slough, exudate and showing signs of local infection. The topical MPPT powder rapidly desloughed the wounds, controlled exudate levels, promoted granulation and was well tolerated. All wounds proceeded towards closure., Conclusion: Comparison of the present data with MPPT powder to standard treatment suggests that the speed of healing using MPPT was improved. Further examination is required to determine if this reduces dressing changes, nursing time, and financial cost.

Objectives: To assess the clinical outcomes of simultaneous guided bone regeneration using native (CM) and cross-linked (VN) collagen membranes at 8 years., Materials and Methods: A total of n = 19 patients (19 implants) were available for the analysis. Each subject had received a simultaneous grafting of dehiscence-type defects using a natural bone mineral (NBM) and a random allocation to either CM and VN membranes (submerged healing of 4 months). Clinical parameters (e.g., bleeding on probing - BOP, probing pocket depth - PD, mucosal recession - MR, clinical attachment level - CAL) were recorded at 8 years after prosthesis installation., Results: At 8 years, CM and VN groups revealed comparable median BOP, PD, MR and CAL values at both vestibular and oral aspects. From 4 to 8 years (n = 14 patients), median CAL at the vestibular aspect improved in both groups; however, these changes were significantly higher at CM-treated sites (CM: 0.7 mm vs. VN: 0.5 mm)., Conclusion: The clinical long-term outcomes at 8 years were comparable in both VN and CM groups., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We offer the first report of hyperbaric oxygen (HBO₂) therapy to treat early surgical wound breakdown after oronasal fistula and cleft palate repair in the pediatric population. We present four patients' experiences after undergoing HBO₂ therapy. HBO₂ was initiated as soon as an oronasal fistula was identified. Three of the children underwent 10 HBO₂ treatments with the fourth undergoing 11 treatments. There were no adverse effects during treatment; none of the patients required decompressive myringotomy. Follow-up shows portions of the repair have been salvaged by initiating HBO₂ at the first sign of fistula formation. In our case series, the fistulas all decreased in size over the course of treatment and demonstrated granulation tissue at the wound edges. Given the positive outcomes from our preliminary results, our results suggest concurrent usage of HBO₂ therapy for wound breakdown after cleft palate repair is an effective treatment option., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

Necrotizing enterocolitis (NEC) is the most common surgical emergency in neonatal intensive care units, and patients who require surgery have high mortality and morbidity rates. The utility of negative pressure in the management of adults with complicated abdominal wounds has been documented, but there are few reports describing the use of negative pressure wound therapy (NPWT) in children or following neonatal surgery. The case of a 6 day old, 5-weeks premature neonate with NEC is presented. An exploratory midline laparotomy was performed on day 3 of life owing to rectal bleeding and abdominal distension that did not respond to gastric decompression, bowel rest, and intravenous antibiotics. Ten (10) cm of necrosis in the distal ileum were noted and resected; in addition, an ileostomy was performed, and a Penrose drain was left in the surgical site. On postoperative day 5, the laparotomy dehisced. Continuous NPWT (50 mm Hg) was initiated and changed owing to patient tolerance to intermittent therapy (5 minutes on, 30 seconds off) at 80 mm Hg. By postoperative day 11, granulation tissue formation was complete. No surgical procedures were required for the complete closure of the abdominal wall, and no adverse reactions were noted. The baby was discharged from the hospital on postop day 15. In this patient, the use of negative pressure was found to be safe and facilitated management of a complicated abdominal wound in the presence of a stoma and the formation of healthy granulation tissue. Additional research is needed to help clinicians provide optimal, evidence-based care for dehisced wounds in this vulnerable population.

Objective: To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT)., Design: A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology., Participants and Setting: A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes., Results: Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options., Conclusions: To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option., Trial Registration Number: ISRCTN05754020; results., Competing Interests: CK and KMKI run perineal repair workshops both nationally and internationally and have developed an episiotomy and second-degree tear training model with Limbs and Things, UK. They receive a small royalty fee that contributes towards women's health research funds., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To establish the feasibility of conducting a definitive randomised controlled trial (RCT) comparing the effectiveness of resuturing versus expectant management for dehisced perineal wounds., Design: A multicentre pilot and feasibility RCT., Setting: Ten UK maternity units from July 2011 to July 2013., Population: Eligible women with a dehisced perineal wound within 2 weeks of childbirth., Methods: The interventions were resuturing or expectancy. Randomisation was via web or telephone, stratified by participating centre. Blinding was not possible due to the nature of the interventions. Analysis was by intention-to-treat., Outcome: The primary outcome measure was wound healing at 6-8 weeks., Results: The study revealed a number of feasibility issues, particularly strong patient and clinician preference for treatment options at recruiting centres and the timing of the primary outcome measure. Thirty-four women were randomised (17 in each arm). Data from 33 women were analysed on an intention-to-treat analysis to obtain preliminary estimates of effect size. There was a difference in wound healing at 2 weeks favouring resuturing (OR 20.00, 95% CI 2.04 to 196.37, p=0.004). However, by 6-8 weeks all but one wound in both groups had healed., Conclusions: PREVIEW revealed a number of feasibility issues, which impacted on recruitment rate. These will have to be taken into account in the design of any future definitive study. In this feasibility study, resuturing was associated with quicker wound healing and women reported higher satisfaction rates with the outcome at 3 months., Trial Registration Number: ISRCTN05754020., Competing Interests: CK and KMKI run perineal repair workshops nationally and internationally and have developed an episiotomy and second-degree tear training model with Limbs & Things, UK. They receive a small royalty fee that contributes towards women's health research funds., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Surgery is widely used to treat vulvar cancer. However, postoperative complications after a vulvectomy can occur in 26-85 % of the cases. Here, the authors describe a complete radical vulvectomy with bilateral inguinal lymph node dissection performed in two patients. Both patients developed infection and wound breakdown postoperatively. Due to failure of local care, negative pressure wound therapy (NPWT) was started to reduce bacterial rates and tension on wound edges. Accelerated tissue healing was observed in both cases, as well as an improvement in the patients' quality of life.

Background: The management of chronic (nonhealing) wounds with epibole is challenging and costly, especially when the problem is not promptly identified or the patient is intolerant to conventional treatments., Case Description: We describe the use of a polymeric membrane dressing (PMD) in 3 patients with chronic (nonhealing) wounds and epibole who were unable to be treated with traditional interventions such as silver nitrate or sharp debridement. Patient 1 was a 51 year-old male with a right foot stasis ulcer with 60% fibrin/slough to the wound bed, patient 2 was a 58-year-old female with a stage 4 pressure injury of the left hip with undermining, and patient 3 was a 62-year-old female with a dehisced abdominal surgical wound., Conclusion: The use of PMD, when applied using a specific technique, proved to be effective for resolving epibole in 3 patients with nonhealing wounds of differing etiologies. Based on these experiences, we postulate that topical therapy using a PMD may provide an effective alternative means for resolving epibole and promoting wound healing in patients unable to undergo surgical excision or chemical cauterization.

Purpose: To report on a case of autoconjunctival graft compromise after pterygium surgery in a patient on long-term anti-vascular endothelial growth factor (anti-VEGF) therapy, due to the deleterious effects of anti-VEGF agents on ocular wound healing., Methods: A white female in her early eighties presented with large right nasal pterygium, first noted 5 years previously. She also had macular degeneration and had been receiving monthly injections of ranibizumab, which was later switched to aflibercept. She proceeded to have a right nasal pterygium excision with a conjunctival autograft, 9 days after her last dose of intravitreal aflibercept., Results: Surgery was uneventful; however, at the week 2 postoperative review, there was conjunctival graft dehiscence with melting of the graft and underlying sclera. The patient was administered hyperbaric oxygen treatments, topical antibiotics, steroids, and lubricating eye drops, and aflibercept injections ceased. The scleral melt slowly resolved and her aflibercept was restarted 3 months later., Conclusions: This case highlights the potential hazards of performing elective surgery in patients on VEGF inhibitors and the need for an appropriate interval between cessation/subsequent restart of anti-VEGF agents and surgery to be established.

Introduction: There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA., Methods: One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period., Results: After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups., Conclusion: Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.

Background: Defects of the abdominal wall pose a problem for general surgeons that negatively affects patient prognosis. In cases of abdominal wall wound dehiscence and exposed abdominal mesh, conservative treatment has not been proven effective to date. We aimed to study patient outcomes in cases of abdominal wall wound dehiscence with mesh exposure treated with vacuum-assisted closure system with intermittent instillation (VAC-instillation) as a temporary cover to achieve wound closure., Methods: A retrospective cohort study was performed to evaluate and compare the outcomes of 45 patients with postoperative abdominal wall wound dehiscence and exposed mesh: 34 were treated with conventional dressings and 11 with the VAC-instillation device. Clinical records were reviewed, and patient demographics, indication for abdominal surgery, and existing risk factors were noted. Patient outcome was evaluated in terms of number of reoperations, length of hospital stay, and total time of treatment., Results: Demographic features did not differ significantly between the two groups. Patients treated with conventional dressings required a significantly higher number of surgeries to achieve wound closure. We did not find statistical differences between the two groups regarding length of hospital stay, but the VAC-instillation group showed a significantly shorter total time of treatment. The incidence of complications was lower in the VAC-instillation group, though hernia recurrence rate was slightly higher in these patients., Conclusions: VAC-instillation is a valid option for the conservative treatment of critical patients with abdominal wall wound dehiscence and exposed infected mesh that allows recovery with fewer surgeries and complications and avoids the need of mesh removal., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Large congenital melanocytic nevi entail significant medical and cosmetic ramifications for patients and families. Reconstruction is a challenging endeavor, especially when the lesion is present on the limbs. The literature describes various methods by which a plastic surgeon can address reconstruction; yet, to date, there has been no series describing a method that provides consistent results with low complication rates. In this study, we describe our surgical technique for reconstruction of the upper extremity after excision of large circumferential CNM with a pre-expanded bi-pedicled flap, namely the "sleeve" flap., Methods: A systematic review of our database of pediatric patients treated for large and giant nevi was performed. Patients with large and giant circumferential upper extremity nevi were retrieved, and their charts reviewed for demographics, number of procedures performed, duration of follow-up, and complications., Results: Over a course of 12 years, eight patients with large or giant circumferential nevi of the upper extremity were treated at our institution with "sleeve" flap reconstruction. Mean follow-up time was 36 months. A single complication was seen. All reconstructions achieved satisfactory results, both functionally and cosmetically., Discussion: We describe our surgical approach for treating upper extremity large and giant circumferential nevi with pre-expanded bi-pedicled "sleeve" flaps. When properly planned and executed, this technique enables successful treatment of large and giant nevi of the arm and the forearm. Although arduous and complex, the process yields excellent aesthetic results with low complication rates. This technique is promising as the reconstructive option of choice for these difficult lesions., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with complex ventral hernias may benefit from preoperative optimization. This study evaluates the financial impact of preventable comorbidities (PCM) in elective open ventral hernia repair., Methods: In this single institution prospectively collected data from 2007-2011, hospital charges (included all hernia-related visits, interventions, or readmissions) and wound-related complications in patients with PCM-diabetes, tobacco use, and obesity-were compared to patients without such risks using standard statistical methods., Results: Within the study period, there were 118 patients with no PCM; of those, 33 had complications, and 85 did not. In the 131 patients with two or more PCM, 81 had complications; 89 of 251 patients had complications in the group with only 1 PCM; groups with PCM were significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female (57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm 2 (interquartile range, 50-283 cm 2 ). Body mass index was higher in PCM group with complications than in PCM without complications (40 versus 36 kg/m 2 , P < 0.05). For patients with complications, the average hospital charges were $80,660 in the PCM group compared to $55,444 in the no PCM group (P = 0.038). Hospital charges in those with PCM without complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P = 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P ≤ 0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P = 0.04), but there was no difference in hospital or overall total charges (P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P = 0.02) and total charges ($41,911 versus $65,453, P = 0.01) were increased for patients with 2+ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges (P > 0.05)., Conclusions: Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated., (Published by Elsevier Inc.)

Background: The extralevator abdominoperineal excision (ELAPE) procedure creates an extensive soft tissue defect of the pelvic floor. It has been suggested that primary reconstruction reduces the risk of wound infection and delayed wound healing in this high-risk area. Use of myocutaneous flaps or omentoplasty are associated with functional limitations and complications. We performed the perineal variant of the lotus petal flap, which was originally described for vulvar reconstruction. We aimed to verify if application of the lotus petal flap in pelvic floor reconstruction after ELAPE meets the goals of an ideal reconstruction., Methods: We performed a retrospective study of 28 patients who underwent the lotus petal flap procedure for pelvic floor reconstruction after ELAPE between January 2011 and March 2014., Results: Median age was 62.1 years and 78.6 % of patients were female. In most patients the tumor was preoperatively irradiated (89.3 %) and in 28.6 % of the reconstructions a biological mesh was applied. No total flap loss occurred. Six (21.4 %) patients had no complications, while 13 (46.4 %) patients had minor complications (Clavien-Dindo grade I-II). Reoperation (Clavien-Dindo grade IIIb) was performed in nine patients (32.1 %), three of whom required a second lotus petal flap reconstruction. Median time until wound healing was 14 weeks. No additional surgery was performed for aesthetic problems., Conclusions: Reconstruction of the pelvic floor after ELAPE using the fasciocutaneous lotus petal flap has limited major complications, but still with a high incidence of minor wound complications. This retrospective cohort study shows limited consequences on form and function.

Objectives: The primary objective was to assess osseointegration of implants with dehiscence defects grafted with a TiO 2 scaffold. The secondary objective was to assess the performance of the scaffold in terms of mechanical stability and bone fill., Material and Methods: Five minipigs had the mandibular premolars extracted. After healing, two dental implants (SLActive ® , Institut Straumann AG, Basel, Switzerland) with associated semi-cylindrical dehiscence defects (Ø = 6 mm, height = 10 mm) were installed in each quadrant. The defects were grafted with test scaffolds (n = 10) or control autologous bone blocks (n = 10). After 3 months submerged healing, the pigs were euthanized and the sites analysed by microcomputed tomography and histology., Results: Four minipigs were available for second stage surgery; (n = 9) experimental and (n = 7) control sites. The mean bone-to-implant contact on the defect side was 82% (±10%) and 79% (±11%) in the test and control groups respectively. The mean level of first bone-to-implant contact was more coronal on the defect side in the test group 3.2 mm (±0.4 mm) than in the control group 3.6 mm (±1.1 mm). The defect area occupied by bone within the extent of the scaffold varied, but averaged 37% (±14.6%) whereas the material itself occupied 7.4% (±3.5%)., Conclusions: Within the limitations of the study, the results suggest that the novel synthetic scaffold material perform similar to the autologous bone block control with respect to implant osseointegration. The mechanical properties of the scaffold appeared sufficient to withstand clinical load in the present experimental model., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Although skin necrosis following total knee arthroplasty or revision total knee arthroplasty is rare, it may cause severe complications. Skin changes begin with superficial infections and may result in removal of the prosthesis. Treatment of skin necrosis is an important factor, which determines the prognosis of the prosthesis. Several techniques have been defined for sufficient closure. In this article, we present the case of a patient who was treated for skin necrosis that developed after knee revision arthroplasty, using serial debridement, convergence sutures and an intermittent vacuum-assisted closure device (KCI Inc., San Antonio, TX)., (© 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Purpose of Review: Vaginal cuff dehiscence and evisceration are rare but potentially serious complications of hysterectomy. In this article, we review the incidence, risk factors, management, and preventive measures for dehiscence based on available literature., Recent Findings: Identifying risk factors for dehiscence is challenging because studies lack comparison groups and most studies are largely underpowered to draw concrete conclusions., Summary: High-quality data on cuff dehiscence after hysterectomy are limited. Potentially modifiable risks that optimize vaginal wound healing, minimize vaginal cuff strain, and minimize cuff infection should be optimized.

The potential impact of biofilm on healing in acute and chronic wounds is one of the most controversial current issues in wound care. A significant amount of laboratory-based research has been carried out on this topic, however, in 2013 the European Wound Management Association (EWMA) pointed out the lack of guidance for managing biofilms in clinical practice and solicited the need for guidelines and further clinical research. In response to this challenge, the Italian Nursing Wound Healing Society (AISLeC) initiated a project which aimed to achieve consensus among a multidisciplinary and multiprofessional international panel of experts to identify what could be considered part of 'good clinical practice' with respect to the recognition and management of biofilms in acute and chronic wounds. The group followed a systematic approach, developed by the GRADE working group, to define relevant questions and clinical recommendations raised in clinical practice. An independent librarian retrieved and screened approximately 2000 pertinent published papers to produce tables of levels of evidence. After a smaller focus group had a multistep structured discussion, and a formal voting process had been completed, ten therapeutic interventions were identified as being strongly recommendable for clinical practice, while another four recommendations were graded as being 'weak'. The panel subsequently formulated a preliminary statement (although with a weak grade of agreement): 'provided that other causes that prevent optimal wound healing have been ruled out, chronic wounds are chronically infected'. All members of the panel agreed that there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence. In the meantime it was agreed that expert-based guidelines were needed to be developed for the recognition and management of biofilms in wounds and for the best design of future clinical trials. This is a fundamental and urgent task for both laboratory-based scientists and clinicians.