Publications by authors named "Valentin Haug"

40 Publications

Software-based Detection of Acute Rejection Changes in Face Transplant.

J Reconstr Microsurg 2021 Sep 1. Epub 2021 Sep 1.

Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School; Boston, Massachusetts.

Background:  An objective, non-invasive method for redness detection during acute allograft rejection in face transplantation (FT) is lacking.

Methods:  A retrospective cohort study was performed with 688 images of 7 patients with face transplant (range, 1 to 108 months post-transplant). Healthy controls were matched to donor age, sex, and had no prior facial procedures. Rejection state was confirmed via tissue biopsy. An image-analysis software developed alongside VicarVision (Amsterdam, Netherlands) was used to produce R, a measure of differences between detectable color and absolute red. R is inversely proportional to redness, where lower R values correspond to increased redness. Linear mixed models were used to study fixed effect of rejection state on R values. Estimated marginal means of fitted models were calculated for pairwise comparisons.

Results:  Of 688 images, 175, 170, 202, and 141 images were attributable to Banff Grade 0,1,2, and 3, respectively. Estimated change in R value of facial allografts decreased with increasing Banff Grade ( = 0.0001). The mean R value of clinical rejection (Banff Grade ⅔) (16.67, 95% Confidence Interval [CI] 14.79-18.58) was lower ( = 0.005) than non-rejection (Banff Grade 0/1) (19.38, 95%CI 17.43-21.33). Both clinical and non-rejection mean R values were lower ( = 0.0001) than healthy controls (24.12, 95%CI 20.96-27.28).

Conclusion:  This proof-of-concept study demonstrates that software-based analysis can detect and monitor acute rejection changes in FT. Future studies should expand on this tool's potential application in telehealth and as a screening tool for allograft rejection.
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http://dx.doi.org/10.1055/s-0041-1733995DOI Listing
September 2021

The status quo of early burn wound excision: Insights from the German burn registry.

Burns 2021 Sep 10;47(6):1259-1264. Epub 2021 Jul 10.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany. Electronic address:

Background: There is a common, well-known and established recommendation to excise burn wounds within 24-72 h in order to mitigate the systemic inflammatory and immunomodulatory response, shorten length of hospitalization through early grafting and optimize patient survival. Despite this apparent consensus, surprisingly few systematic studies have evaluated the actual adherence to this practice and its implications on patient outcomes. In this registry study, we sought to objectify the current status of early burn wound excision, its influencing factors and impact on patient outcomes for all German burn centers.

Methods: The German burn registry ('Deutsches Verbrennungsregister') was queried for 3 consecutive years for all patients, who received at least one surgical intervention. Patients were stratified based on whether the first surgical procedure was performed early (EE, within 72 h) or late (LE, after 72 h) post-burn. Descriptive statistics and univariate regressions were performed to quantify fraction of EE vs. LE and to evaluate factors which might favor one over the other (i.e. age, inhalation injury, burn severity by total body surface area (TBSA), scald vs. other burns, obesity, time of admission). Key patient outcomes were analyzed for each group (i.e. mortality, length of hospitalization, number of surgeries) and multifactorial regression analyses were carried out to model the impact of EE on mortality. Statistical significance was accepted at p < 0.05.

Results: After initial screening, 1494 complete records were included for final analysis and were stratified into EE and LE. Only 670 (44%) underwent EE within 72 h. Increasing TBSA burned (i.e. [TBSA > 30%]: 53.8% EE, [TBSA < 30%]: 43.5% EE, p < 0.01) and admission on a weekday between Sunday and Wednesday were associated with higher probability of EE (51.5% EE) versus Thursday to Sunday (37.3%, p < 0.001). Age, inhalation injury, cause of burn, and obesity had no effect on EE vs. LE. Patients with EE had significantly shorter median lengths of hospitalization (EE: 18 d, LE: 21 d, p < 0.01). The median number of operations was comparable for both groups. Gross mortality appeared higher in the EE group, but turned out to be comparable to LE after correction for age, TBSA and sex in multifactorial regression analysis.

Conclusion: Despite apparent consensus among burn physicians, early excision of burn wounds is performed in less than 50% of cases in German burn centers. The relationship of EE to TBSA burned is expected and clinically sound, while a dependence on admission weekday raises administrative and infrastructural questions, especially when patients who receive EE have significantly shorter hospital stays. More analyses from other burn repositories are needed to compare and benchmark the international status quo of early burn wound excision.
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http://dx.doi.org/10.1016/j.burns.2021.06.010DOI Listing
September 2021

The impact of closed incisional negative pressure therapy on anterior lateral thigh flap donor site healing and scarring: A retrospective case-control study.

J Plast Reconstr Aesthet Surg 2021 Jun 13. Epub 2021 Jun 13.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany. Electronic address:

Background: The objective of this study was to investigate whether closed incisional negative pressure therapy (cINPT) is suitable to improve anterior lateral thigh (ALT) flap donor site healing and scarring.

Methods: We identified 271 ALT free flaps of widths between 7 and 9 cm and primary donor site closure performed between January 2012 to December 2019. Patients were divided into cases of cINPT versus controls without cINPT as part of this retrospective case-control review. We compared the incidences of postoperative donor site complications (wound dehiscence, infection, seroma, hematoma) and the degree of scarring severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS).

Results: A total of 106 ALT donor sites received cINPT (39%), whereas the remaining 165 donor sites received conventional dressings (61%). The distribution of gender, age, body mass index, comorbidities, and mean flap sizes were comparable between both groups. The occurrence of surgical wound dehiscence was significantly lower in the cINPT group (2.8%), when compared to controls (9.0%) (p = 0.04). Furthermore, the mean length of postoperative hospital stay was significantly shorter in the cINPT group (19 ± 8 days versus 21 ± 11 days; p = 0.03). CINPT was associated with a more favorable donor site scar quality when assessed by VSS (p = 0.03) and POSAS (p = 0.002).

Conclusion: The use of cINPT was associated with significantly less ALT donor site complications and superior scar quality accelerating patients' postoperative recovery.
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http://dx.doi.org/10.1016/j.bjps.2021.05.049DOI Listing
June 2021

Lights, camera, scalpel: a lookback at 100 years of plastic surgery on the silver screen.

Eur J Plast Surg 2021 Jul 8:1-11. Epub 2021 Jul 8.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, 45 Francis St, Boston, MA 02115 USA.

Background: The presentation of medical topics in the cinema can greatly influence the public's understanding and perception of a medical field, with regard to the doctors and surgeons, medical diagnosis, and treatment and outcome expectations. This study aims to evaluate the representation of plastic surgery in commercial films that include a character with a link to plastic surgery, either as a patient or surgeon.

Methods: The international film databases Internet Movie Database (IMDb), The American Film Institute (AFI), and British Film Institute (BFI) were searched from 1919 to 2019 to identify feature-length films with a link to plastic surgery. Movies were visualized and analyzed to identify themes, and the portrayal of plastic surgery was rated negative or positive, and realistic or unrealistic.

Results: A total of 223 films were identified from 1919 to 2019, produced across 19 countries. Various genres were identified including drama (41), comedy (25), and crime (23). A total of 172 patient characters and 57 surgeon characters were identified as major roles, and a further 102 surgeons as minor roles. Disparities were noted in presentation of surgeons, both in terms of race and gender, with the vast majority of surgeons being white and male. In total only 11 female surgeons were portrayed and only one black surgeon. Thirteen themes emerged: face transplantation, crime, future society, surgeon mental status, body dysmorphic disorder, vanity, anti-aging, race, reconstructive surgery, deformity, scarring, burns, and gender transitioning. The majority of films (146/223) provide an unrealistic view of plastic surgery, painted under a negative light (80/146). Only 20 films provide a positive realistic image (24/77).

Conclusions: There exists a complicated relationship between plastic surgery and its representation on film. Surgical and aesthetic interventions are portrayed unrealistically, with surgeons and patients presented negatively, perpetuating stigma, particularly with regard to cosmetic surgery. Cinema is also characterized by lack of representation of female and non-white surgeons. Recruitment of surgeons as technical advisors would help present a more realistic, representative view, without necessarily sacrificing creativity.Level of evidence: Not ratable.
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http://dx.doi.org/10.1007/s00238-021-01834-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263318PMC
July 2021

Long-term sequelae of critical illness in sepsis, trauma and burns: a systematic review and meta-analysis.

J Trauma Acute Care Surg 2021 Jul 9. Epub 2021 Jul 9.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Division of Molecular and Translational Cardiology, Department of Internal Medicine III University Hospital Heidelberg, Germany.

Background: Sepsis, major trauma and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aim of this study is to assess the current state of long-term outcome research, and to identify key outcome parameters between the three forms of critical illness.

Methods: This systematic review (SR) and meta-analysis (MA) were conducted according to the PRISMA guidelines. PubMed was searched from January 1st, 1975 to December 31st, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life (HRQoL), and organspecific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma.

Results: In total 125 articles could be included in the SR and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared to sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall HRQoL, as assessed by ShortForm-36, and European Quality-of-Life Index, the three different etiologies were comparable to one another.

Conclusion: The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians as well as to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts.

Level Of Evidence: III.
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http://dx.doi.org/10.1097/TA.0000000000003349DOI Listing
July 2021

Donor and Recipient Matching in Facial Vascularized Composite Allotransplantation: A Closer Look at the Donor Pool.

Plast Reconstr Surg 2021 Jul;148(1):194-202

From the Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; and the Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg.

Background: Identifying a donor for facial vascularized composite allotransplant recipients can be a lengthy, emotionally challenging process. Little is known about the relative distribution of key donor characteristics among potential donors. Data on actual wait times of patients are limited, making it difficult to estimate wait times for future recipients.

Methods: The authors retrospectively reviewed charts of nine facial vascularized composite allotransplant patients and provide data on transplant wait times and patient characteristics. In addition, they analyzed the United Network for Organ Sharing database of dead organ donors. After excluding donors with high-risk characteristics (e.g., active cancer or risk factors for blood-borne disease transmission), the authors calculated the distribution of relevant donor-recipient matching criteria (i.e., ethnicity, body mass index, age, ABO blood group, cytomegalovirus, Epstein-Barr virus, hepatitis C virus) among 65,201 potential donors.

Results: The median wait time for a transplant was 4 months (range, 1 day to 17 months). The large majority of United Network for Organ Sharing-recorded deaths from disease were white (63 percent) and male (58 percent). Female donors of black, Hispanic, or Asian descent are underrepresented, with 7, 5, and 1 percent of all recorded deaths from disease, respectively. Potential donors show cytomegalovirus and Epstein-Barr virus seropositivity of 65 and 95 percent, respectively. The number of annual hepatitis C-positive donors increased over time.

Conclusions: Actual facial vascularized composite allotransplant wait times vary considerably. Although most patients experience acceptable wait times, some with underrepresented characteristics exceed acceptable levels. Cytomegalovirus-seropositive donors present a large portion of the donor pool, and exclusion for seronegative patients may increase wait time. Hepatitis C-seropositive donors may constitute a donor pool for underrepresented patient groups in the future.
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http://dx.doi.org/10.1097/PRS.0000000000008094DOI Listing
July 2021

The modified 5-item frailty index is a predictor of perioperative risk in head and neck microvascular reconstruction: An analysis of 3795 cases.

Am J Otolaryngol 2021 Jun 18;42(6):103121. Epub 2021 Jun 18.

Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA. Electronic address:

Background: The modified frailty index 5 (mFI-5)-a scale based on the five variables diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and functional dependency-has been shown to be a valid predictor of surgical outcomes. In this study we sought to evaluate the ability of the mFI-5 to predict the postoperative outcomes of head and neck microvascular reconstruction.

Methods: Review of the 2015-2019 American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) database identified 5323 cases of microvascular reconstruction, of which 3795 were head and neck cases that provided parameters necessary to calculate the mFI-5. The groups were compared in terms of demographics and comorbidities. Post-operative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and non-home discharge.

Results: Increases in the mFI were associated with longer hospitalization periods (10.5 ± 7.5 days in mFI 0 vs 14.9 ± 15.4 in mFI ≥ 3; p < 0.0001) higher rates of mortality (1% in mFI 0 vs 3.1% in mFI ≥ 3; p = 0.02), reoperation (15.4% in mFI 0 vs 17.2% in mFI ≥ 3; p = 0.002) and unplanned readmission (7.6% in mFI 0 vs 18.8% in mFI ≥ 3; p = 0.001). Rates of any complications (p < 0.0001), as well as surgical (p < 0.002) and medical (p < 0.0001) complications specifically were higher with greater mFI scores. Higher mFI scores also predicted decreased home discharge (p < 0.0001). Differences remained significant on multivariate analysis and subgroup analysis by age.

Conclusion: The mFI-5 is a significant predictor of risk in microvascular head and neck reconstruction. Subgroup analysis by age highlights that the tool can help identify younger patients who are frail and hence at risk. Through appropriate pre-operative identification of frail patients surgeons can prospectively modify their operative and discharge planning as well as post-operative support.
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http://dx.doi.org/10.1016/j.amjoto.2021.103121DOI Listing
June 2021

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

Microsurgery 2021 Jun 24. Epub 2021 Jun 24.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.

Introduction: We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety.

Methods: 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated.

Results: Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04).

Conclusions: Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.
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http://dx.doi.org/10.1002/micr.30775DOI Listing
June 2021

Adherence to Personal Protective Equipment Guidelines During the COVID-19 Pandemic Among Health-Care Personnel: A Louisiana Case Study.

Disaster Med Public Health Prep 2021 Jun 8:1-4. Epub 2021 Jun 8.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Objective: The aim of this study was to determine the extent that appropriate personal protective equipment (PPE), per Centers for Disease Control and Prevention (CDC) guidance, was used during the coronavirus diseases 2019 (COVID-19) pandemic by health-care personnel (HCP) in Louisiana in 5 clinical settings.

Methods: An online questionnaire was distributed to the LA Nursery registry. Appropriate use of PPE in each of the 5 clinical scenarios was defined by the authors based on CDC guidelines. The scenarios ranged from communal hospital space to carrying out aerosol generating procedures (AGPs). A total of 1760 HCP participated between June and July 2020.

Results: The average adherence in LA was lowest for the scenario of carrying out AGPs at 39.5% compliance and highest for the scenario of patient contact when COVID-19 not suspected at 82.8% compliance. Adherence among parishes varied widely. Commentary to suggest a shortage of PPE supply and the practice of re-using PPE was strong.

Conclusions: Use of appropriate PPE varied by setting. It was higher in scenarios where only face masks (or respirators) were the standard (ie, community hospital or when COVID-19 not suspected) and lower in scenarios where additional PPE (eg, gloves, eye protection, and isolation gown) was required.
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http://dx.doi.org/10.1017/dmp.2021.176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314049PMC
June 2021

Full facial retransplantation in a female patient-Technical, immunologic, and clinical considerations.

Am J Transplant 2021 May 25. Epub 2021 May 25.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.
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http://dx.doi.org/10.1111/ajt.16696DOI Listing
May 2021

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study.

Microsurgery 2021 May 29;41(4):309-318. Epub 2021 Mar 29.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects.

Methods: Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis.

Results: Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size.

Conclusion: To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.
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http://dx.doi.org/10.1002/micr.30730DOI Listing
May 2021

Dynamic Maxillary Sinus Changes of Facial Vascularized Composite Allotransplants.

Plast Reconstr Surg 2021 03;147(3):722-727

From the Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; and the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg.

Summary: Skin is one of the target tissues of rejection in face transplants and, because of its easy accessibility, has become the gold standard in the diagnosis of rejection. The allograft contains deeper tissues where rejection can occur, but samples cannot be obtained because of difficult access. Deep tissue changes were monitored on computed tomographic scans of the midface in six face transplant recipients with the help of image segmentation. The maxillary sinus was identified as a dynamic anatomical compartment. Observed changes in volume of the aeration relative to the opacification (aeration coefficient) of the maxillary sinus were quantified with the help of image segmentation. Changes in the aeration coefficient as a surrogate of mucosal swelling were quantified and related to time, treatment, and skin rejection grade. Lower aeration coefficients were found only in patients with transplanted maxillary sinus mucosa. Pathologic changes were not observed in face transplant recipients with a native maxillary sinus. The data show that the aeration coefficient was significantly lower at the time of biopsy-proven allograft rejection. Neither mechanical, nor infectious, nor medication side effects sufficiently explain the findings presented herein. The authors' findings are important to consider for clinical management of face transplant patients who receive parts of the sinonasal tract. The authors identify a potential radiologic biomarker of deep tissue allograft rejection. In the future, the proposed methodology might prove useful in monitoring deeper dynamic tissue changes in vascularized composite allografts and might help in designing patient-specific, individualized treatment strategies.
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http://dx.doi.org/10.1097/PRS.0000000000007673DOI Listing
March 2021

Dynamic Maxillary Sinus Changes of Facial Vascularized Composite Allotransplants.

Plast Reconstr Surg 2021 03;147(3):722-727

From the Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; and the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg.

Summary: Skin is one of the target tissues of rejection in face transplants and, because of its easy accessibility, has become the gold standard in the diagnosis of rejection. The allograft contains deeper tissues where rejection can occur, but samples cannot be obtained because of difficult access. Deep tissue changes were monitored on computed tomographic scans of the midface in six face transplant recipients with the help of image segmentation. The maxillary sinus was identified as a dynamic anatomical compartment. Observed changes in volume of the aeration relative to the opacification (aeration coefficient) of the maxillary sinus were quantified with the help of image segmentation. Changes in the aeration coefficient as a surrogate of mucosal swelling were quantified and related to time, treatment, and skin rejection grade. Lower aeration coefficients were found only in patients with transplanted maxillary sinus mucosa. Pathologic changes were not observed in face transplant recipients with a native maxillary sinus. The data show that the aeration coefficient was significantly lower at the time of biopsy-proven allograft rejection. Neither mechanical, nor infectious, nor medication side effects sufficiently explain the findings presented herein. The authors' findings are important to consider for clinical management of face transplant patients who receive parts of the sinonasal tract. The authors identify a potential radiologic biomarker of deep tissue allograft rejection. In the future, the proposed methodology might prove useful in monitoring deeper dynamic tissue changes in vascularized composite allografts and might help in designing patient-specific, individualized treatment strategies.
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http://dx.doi.org/10.1097/PRS.0000000000007673DOI Listing
March 2021

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients.

J Plast Reconstr Aesthet Surg 2021 05 2;74(5):1031-1040. Epub 2020 Nov 2.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA. Electronic address:

Background: Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.

Methods: By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

Results: We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).

Conclusion: Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.
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http://dx.doi.org/10.1016/j.bjps.2020.10.045DOI Listing
May 2021

Adherence to Personal Protective Equipment Guidelines During the COVID-19 Pandemic Among Health Care Personnel in the United States.

Disaster Med Public Health Prep 2021 Jan 8:1-3. Epub 2021 Jan 8.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

Objectives: Protecting frontline health care workers with personal protective equipment (PPE) is critical during the coronavirus disease (COVID-19) pandemic. Through an online survey, we demonstrated variable adherence to the Centers for Disease Control and Prevention (CDC) PPE guidelines among health care personnel (HCP).

Methods: CDC guidelines for optimal and acceptable PPE usage in common situations faced by frontline health care workers were referenced to create a short online survey. The survey was distributed to national, statewide, and local professional organizations across the United States and to HCP, using a snowball sampling technique. Responses were collected between June 15 and July 17, 2020.

Results: Responses totaling 2245 were received from doctors, nurses, midwives, paramedics, and medical technicians in 44 states. Eight states with n > 20 (Arizona, California, Colorado, Louisiana, Oregon, South Carolina, Texas, and Washington) and a total of 436 responses are included in the quantitative analysis. Adherence to CDC guidelines was observed to be highest in the scenario of patient contact when COVID-19 was not suspected (86.47%) and lowest when carrying out aerosol generating procedures (AGPs) (42.47%).

Conclusions: Further research is urgently needed to identify the reasons underlying variability between professions and regions to pinpoint strategies for maximizing adherence and improving the safety of HCPs.
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http://dx.doi.org/10.1017/dmp.2021.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010287PMC
January 2021

Comparison of Acellular Solutions for Ex-situ Perfusion of Amputated Limbs.

Mil Med 2020 12;185(11-12):e2004-e2012

Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.

Introduction: Hypothermic ex-situ machine perfusion (MP) has been shown to be a promising alternative to static cold storage (SCS) for preservation of solid organs for transplantation and vascularized composite allotransplantation. Perfusion with blood-based perfusion solutions in austere environments is problematic due to their need for appropriate storage and short shelf life, making it impractical for military and emergency use. Acellular perfusion has been shown to be effective, but the ideal perfusate solution for MP of amputated limbs is yet to be determined. The purpose of this study is to evaluate the efficacy of alternative perfusate solutions, such as dextran-enriched Phoxilium, Steen, and Phoxilium in ex-vivo hypothermic MP of amputated limbs in a porcine model.

Materials And Methods: Amputated forelimbs from Yorkshire pigs (n = 8) were preserved either in SCS (n = 2) at 4°C for 12 hours or machine-perfused at 10°C for 12 hours with oxygenated perfusion solutions (n = 6) at a constant flow rate. The perfusates used include modified Steen-solution, Phoxilium (PHOX), or Phoxilium enriched with dextran-40 (PHODEX). The perfusate was exchanged after 1 and 6 hours of perfusion. Machine data were recorded continuously. Perfusate samples for clinical chemistry, blood gas analysis, and muscle biopsies were procured at specific timepoints and subsequently analyzed. In this semi in-vivo study, limb replantation has not been performed.

Results: After amputation, every limb was successfully transferred and connected to our perfusion device. The mean total ischemia time was 77.5 ± 5.24 minutes. The temperature of the perfusion solution was maintained at 10.18 ± 2.01°C, and perfusion pressure at 24.48 ± 10.72 mmHg. Limb weight increased by 3% in the SCS group, 36% in the PHODEX group, 25% in the Steen group, and 58% in the PHOX group after 12 hours. This increase was significant in the PHOX group compared with the SCS group. All perfusion groups showed a pressure increase of 10.99 mmHg over time due to edema. The levels of HIF-1a decreased over time in all groups except the Steen and the PHODEX group. The biomarkers of muscle injury in the perfusate samples, such as creatine kinase and lactate-dehydrogenase, showed a significant difference between groups, with highest values in the PHODEX group. No significant differences were found in the results of the blood gas analysis.

Conclusion: With the exception of significantly higher levels of creatine kinase and lactate dehydrogenase, MP with dextran-enriched Phoxilium provides similar results as that of the commercially available perfusates such as Steen, without the need for cold storage, and at circa 5% of the cost of the Steen solution. Further large-scale replantation studies are necessary to evaluate the efficacy of dextran-enriched Phoxilium as an alternate perfusate solution.
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http://dx.doi.org/10.1093/milmed/usaa160DOI Listing
December 2020

Pathologies of oral and sinonasal mucosa following facial vascularized composite allotransplantation.

J Plast Reconstr Aesthet Surg 2021 Jul 11;74(7):1562-1571. Epub 2020 Dec 11.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address:

Background: Cutaneous changes of facial vascularized composite allotransplants (fVCAs) are extensively described in the literature. Parts of the nose, nasal, and oral cavities are included in most fVCAs. Distinctively, the nose and mouth are lined by mucosa. Little is known about the histopathology and complications of the mucosa involved in fVCA patients.

Methods: The study constitutes a retrospective cohort study of nine fVCA patients. Medical records were reviewed for information about changes of oral and nasal mucous membranes. Types of mucosal lesions were recorded and analyzed. Uni- and multivariate generalized estimating equation (GEE) models were used to assess the odds of developing mucosal inflammation in the presence of clinico-pathologic variables.

Results: A total of 186 clinical encounters with examination of oral and nasal mucous membranes were included. Membranes were devoid of clinical pathology in 101 instances (53% of all clinical assessments). Ulcerations/erosions (27%), edema (18%), and erythema (14%) were the most common lesions. Oral lesions affected the lips (58%), buccal mucosa (38%), and palate (5%). Sinonasal processes predominantly affected nasal vestibules and septae. In univariate analysis, sirolimus, skin rejection, and skin Banff grade were associated with the presence of an acute inflammatory mucosal lesion (p<0.05). In multivariate analysis, skin Banff grade and sirolimus were independent predictors of mucosal inflammation.

Conclusion: Pathologies of fVCA mucous membranes are more common than previously reported. Mucosal assessment plays an important role in the pleomorphic allograft rejection process evaluation rather than diagnosis and treatment based on cutaneous pathology.  A closer look at the pathophysiology of fVCA mucosal rejection and inflammation is warranted.
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http://dx.doi.org/10.1016/j.bjps.2020.11.028DOI Listing
July 2021

Management of Acute and Traumatic Wounds With Negative-Pressure Wound Therapy With Instillation and Dwell Time.

Plast Reconstr Surg 2021 01;147(1S-1):43S-53S

From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School; Wirth Plastic Surgery; Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine; Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University; and Department of Orthopedic Oncology and Septic Orthopedic Surgery, Orthopedic University Hospital.

Background: A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds.

Methods: A systematic review was performed analyzing articles from major clinical databases. Only clinical studies ≥10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included.

Results: One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported.

Conclusion: NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.
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http://dx.doi.org/10.1097/PRS.0000000000007610DOI Listing
January 2021

The Rising Interest in Canthoplasty: An Analysis of Online Search Trends.

J Craniofac Surg 2020 Nov 23. Epub 2020 Nov 23.

Angiogenesis Laboratory, Ophthalmology Department, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Canthoplasty as a cosmetic procedure appears to be on the rise in the West. Online search query data offers a powerful tool for analyzing population trends, including changes in patient interest in surgical procedures. Cosmetic surgeons can utilize the internet to increase patient education and interest, as well as to provide information and address misinformation. In this study we sought to verify the increase in cosmetic canthoplasty, for the first time, through analysis of Internet search data, and to establish trends in the interest of Internet users for cosmetic canthoplasty. These trends were subsequently compared with trends in literature publication to establish whether there is a correlation between patient and surgeon interest in the procedure.
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http://dx.doi.org/10.1097/SCS.0000000000007272DOI Listing
November 2020

Local immunosuppression in vascularized composite allotransplantation (VCA): A systematic review.

J Plast Reconstr Aesthet Surg 2021 02 21;74(2):327-335. Epub 2020 Oct 21.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Electronic address:

Background: Local immunosuppression in vascularized composite allotransplantation (VCA) aims to minimize immunosuppressant-related toxic and malignant side effects. Promising allograft survival data have been published by multiple workgroups. In this systematic review, we examine preclinical animal studies that investigated local immunosuppression in VCA.

Material And Methods: We conducted a systematic review of manuscripts listed in the MEDLINE and PubMed database concerning preclinical VCA models. Papers included had to be available as full-text and written in English. Non-VCA studies, human trials, and studies using cell-based therapy strategies were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: Literature research retrieved 980 articles. Ten studies published between 2010 and 2019 met the inclusion and exclusion criteria. Seven out of ten articles demonstrated a significant prolongation of allograft survival by using local immunosuppression. Five articles employed tacrolimus (TAC) as the main immunosuppressive agent. Seven studies performed hind-limb VCA in a rat model.

Conclusion: The easily accessible location of skin containing VCAs makes it an ideal candidate for local immunosuppression. Published preclinical data are very promising in terms of improved allograft survival and reduced systemic toxicity.
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http://dx.doi.org/10.1016/j.bjps.2020.10.003DOI Listing
February 2021

Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature.

Transplantation 2021 08;105(8):1869-1880

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Background: Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared with conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA.

Methods: We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥3 years follow-up, were included.

Results: The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first-year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively.

Conclusions: Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression-related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.
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http://dx.doi.org/10.1097/TP.0000000000003513DOI Listing
August 2021

Novel application of autologous micrografts in a collagen-glycosaminoglycan scaffold for diabetic wound healing.

Biomed Mater 2020 Oct 22. Epub 2020 Oct 22.

Brigham and Women's Hospital, Boston, UNITED STATES.

Background: Therapeutic strategies that successfully combine two techniques-autologous micrografting and biodegradable scaffolds-offer great potential for improved wound repair and decreased scarring. In this study we evaluate the efficacy of a novel modification of a collagen-glycosaminoglycan scaffold with autologous micrografts using a murine dorsal wound model.

Methods: db/db mice underwent dorsal wound excision and were treated with a collagen-glycosaminoglycan scaffold (CGS), a modified collagen-glycosaminoglycan scaffold (CGS+MG) or simple occlusive dressing (Blank). The modified scaffold was created by harvesting full thickness micrografts and transplanting these into the collagen-glycosaminoglycan membrane. Parameters of wound healing, including cellular proliferation, collagen deposition, keratinocyte migration, and angiogenesis were assessed.

Results: The group treated with the micrograft-modified scaffold healed at a faster rate, showed greater cellular proliferation, collagen deposition, and keratinocyte migration with higher density and greater maturity of microvessels. The grafts remained viable within the scaffold with no evidence of rejection. Keratinocytes were shown to migrate from the wound border and from the micrograft edges towards the center of the wound, while cellular proliferation was present both at the wound border and wound bed.

Conclusion: We report successful treatment of diabetic wounds with a novel collagen-glycosaminoglycan scaffold modified with full-thickness automicrografts. Differences in cellular migration and proliferation offer maiden evidence on the mechanisms of wound healing. Clinically, the successful scaffold engraftment, micrograft viability and improved wound healing offer promising results for the development of a new therapeutic modality for wound repair.
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http://dx.doi.org/10.1088/1748-605X/abc3dcDOI Listing
October 2020

Partial Loss of Nasal Tissue in a Facial Vascularized Composite Allograft Patient.

Plast Reconstr Surg Glob Open 2020 Aug 14;8(8):e3038. Epub 2020 Aug 14.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

Supplemental Digital Content is available in the text.
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http://dx.doi.org/10.1097/GOX.0000000000003038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489603PMC
August 2020

The Treatment of Capsular Contracture Around Breast Implants Induced by Fractionated Irradiation: The Collagenase of the Bacterium Clostridium Histolyticum as a Novel Therapeutic Approach.

Aesthetic Plast Surg 2021 06 23;45(3):1273-1281. Epub 2020 Sep 23.

Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.

Background: Irradiation therapy limits the utilization of silicone implants for breast reconstruction due to a significant risk for capsular contracture. The injection of the collagenase of the bacterium Clostridium histolyticum (CCH) might trivialize this risk by providing a minimal-invasive treatment option by capsular contracture degradation. However, efficacy in degrading breast implant capsules induced by fractionated irradiation remains unclear.

Methods: Twenty-four rats in three groups received miniature silicone implants in a submuscular pocket. After 3D dose calculation and treatment field definition, rats of two groups underwent fractionated radiotherapy (6 × 8 Gy) using a linear accelerator. A third group served as control. On day 120, one irradiated group received injections of 0.3 mg/ml collagenase. Administration of plain solvent solution served as control in the two other groups. Outcome parameters included CT-imaging, histology, vessel wall analysis, immunohistochemistry, chemical collagen quantification and gene expression analysis.

Results: Fractioned irradiation leads to a significant increase in collagen deposition around silicone implants with higher capsule thickness and collagen density when comparing all groups. Additionally, significant alterations of collagen fiber deposition were evident. Vessel wall thickness was significantly increased after radiotherapy. The injection of collagenase led to a significant reduction of capsule thickness, collagen density and content. However, the collagenase application induced a significant overexpression of TGFβ1. No side effects were monitored.

Conclusions: The CCH proved to be a safe and effective approach to degrade capsule tissue induced by fractionated irradiation in an animal model. This may pave its way for clinical application in implant-based breast reconstruction patients.

Level Of Evidence: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-01970-1DOI Listing
June 2021

Low mortality oxidative stress murine chronic wound model.

BMJ Open Diabetes Res Care 2020 09;8(1)

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA

Introduction: Investigators have struggled to produce a reliable chronic wound model. Recent progress with antioxidant enzyme inhibitors shows promise, but mortality rates are high. We modified the dosage and administration of an antioxidant enzyme inhibitor regimen to reduce mortality while inducing a chronic wound environment.

Research Design And Methods: To chemically induce a chronic wound environment, we applied modified doses of catalase (3-amino-1,2,4-triazole; intraperitoneal 0.5 g/kg) and glutathione peroxidase (mercaptosuccinic acid; topical 300 mg/kg) inhibitors to the dorsal wounds of 11-week-old db/db mice. A cohort of these mice was treated with a collagen-glycosaminoglycan scaffold. Both groups were compared with Diabetic control mice.

Results: This study successfully induced a chronic wound in 11-week-old db/db mice, with no animal deaths. The antioxidant enzyme treated groups showed delayed wound contraction and significantly higher levels of inflammatory tissue, collagen deposition, cellular proliferation and leukocyte infiltration than the Diabetic control group. Angiogenesis was significantly higher in the antioxidant enzyme treated groups, but the vessels were immature and friable. Scaffold engraftment was poor but appeared to promote blood vessel maturation.

Conclusions: Overall, the two in vivo groups treated with the antioxidant enzyme inhibitors appeared to be arrested in the inflammatory stage of wound healing, while the Diabetic control group progressed to the maturation phase and ultimately remodeling. This model may be instrumental for the development of new wound therapeutics.
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http://dx.doi.org/10.1136/bmjdrc-2020-001221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478002PMC
September 2020

Adherence to Personal Protective Equipment Guidelines During the COVID-19 Pandemic: A Worldwide Survey Study.

Br J Surg 2020 Oct 24;107(11):e526-e528. Epub 2020 Aug 24.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.

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http://dx.doi.org/10.1002/bjs.12001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7460957PMC
October 2020

Evaluation of the Online-Presence of ABA-Verified Burn Centers.

J Burn Care Res 2020 09;41(5):1063-1068

Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston.

Currently, patients seek healthcare information online. An up-to-date online presence is vital for success among the competition amid hospitals. Hospital websites have become an important medium to communicate with patients, provide information about certain diseases/conditions, and advertise healthcare services. This study aims to evaluate burn centers websites verified by the American Burn Association (ABA). The online presence of the 73 ABA-verified burn centers was evaluated according to criteria previously published by Benedikt et al. This included general information on burns, first aid, treatment at the burn unit, research, and education. ABA-verified burn centers were then compared with 48 German-speaking burn centers evaluated by Benedikt et al. Online information about patient care including treatment options and techniques was more often present in ABA-verified burn centers. However, this information was still provided in only half of the websites. Furthermore, ABA-verified burn centers more often used multimedia-based elements and social media platforms. On the other hand, German-speaking burn centers more often provided translations, general information (eg, staff and ward) about the burn center, as well as research and education. This study demonstrates that although many burn centers have well-designed websites, relevant burn-related information on patient care, research, and education is often missing or sparse. Today, most patients look for healthcare information online. Also, applicants for residency or fellowship programs tend to get a first picture of their potential employer on websites or social media. Keeping websites and social media up-to-date and informative can improve recruitment of patients and employees.
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http://dx.doi.org/10.1093/jbcr/irz204DOI Listing
September 2020

Indications for and Outcomes of Endoscopic Sinus Surgery and Other Rhinologic Surgery After Facial Transplant.

JAMA Otolaryngol Head Neck Surg 2020 07;146(7):669-671

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.0774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290693PMC
July 2020

Radial collateral ligament repair of the thumb: long-term outcomes and predictive factors of postoperative deficits.

Arch Orthop Trauma Surg 2020 Sep 4;140(9):1293-1299. Epub 2020 Jun 4.

Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.

Background: The thumb's radial collateral ligament (RCL) plays an important role in stabilizing the first metacarpophalangeal joint (MCP-1). RCL injuries are rare and treatment recommendations are inconsistent in the current literature. The aim of this study was to report on long-term outcomes following surgical repair of thumb RCL tear and to identify prognostic risk factors for treatment failure.

Methods: Patients with RCL tear from 10/1998 to 10/2019 were included in the present retrospective single center cohort study. In follow-up visits, participants were assessed regarding pain, range of motion and strength as well as with disability of shoulder, arm and hands (DASH), and the Short-Form 36 (SF36) questionnaires. Finally, predictive factors of postoperative deficits were identified.

Results: 43 patients fulfilled inclusion criteria. Median age was 43.5 years (range 18-80 years). The most frequent mechanism of injury was a fall or impact. Bony avulsions were identified in 46.5% (20/43). Time from injury to surgery was 12 days (0-276 days). One Stener-like lesion was observed intraoperatively among our patients. After surgical repair, the MCP-1 joint was stable in every patient. Mean time to follow-up was 5.3 years (1 month to 17 years). Persistency of pain in the MCP-1 joint was reported by 11 patients. Postoperative averaged score was 3.75 on DASH and 44.96 on SF36, respectively. The average grip and pinch strength was 32.7 kg and 8.37 kg, respectively. Predictive factors of postoperative deficits were delay of surgery of > 3 weeks (OR 10.72, p 0.017) and palmar subluxation prior to surgery (OR 8.86, p 0.019).

Conclusion: Long-term follow-up has proven that surgical repair of RCL enables the patient to regain adequate stability and strength of the MCP-1 joint and minimizes disability. Predictive risk factors of pain persistency after surgery are surgical delay and palmar subluxation of the MCP-1 joint.
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http://dx.doi.org/10.1007/s00402-020-03509-0DOI Listing
September 2020
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