Systematic review of the venous thromboembolism risk assessment models used in aesthetic plastic surgery

BACKGROUND: A reliable venous thromboembolism (VTE) risk assessment model (RAM) can assist surgeons in identifying patients who would benefit from VTE prophylaxis. This systematic review was aimed at summarising the current available evidence on VTE RAMs used in aesthetic plastic surgery. METHODS: A comprehensive search was performed in the PubMed, EMBASE and Cochrane databases to include primary studies describing VTE RAMs in aesthetic plastic surgery from 1946 to February 2019. The objective was to compare the different VTE RAMs described for aesthetic plastic surgery to recommend a reliable model to stratify patients. RESULTS: Of the 557 articles identified in the PubMed, EMBASE and Cochrane databases, six articles were included in the final review. Five different RAMs were used in the included studies: Caprini 2005 RAM, Caprini 2010 RAM, Davison-Caprini 2004 RAM, the American Society of Anaesthesiologist's (ASA) physical status grading system and a tool developed by Wes et al. The difference in risk weightage amongst the tools along with the VTE incidences for different categories was compared. The Caprini 2005 RAM was the most widely reported tool and validated in plastic surgery patients. CONCLUSION: Amongst the five different tools currently used, the Caprini 2005 RAM was the most widely reported. This tool was validated in plastic surgery patients and reported to be a sensitive and reliable tool for VTE risk stratification; therefore, current data support its use until further higher quality evidence becomes available. Because of the heterogeneity of the data and low quality of the current evidence, a definitive recommendation cannot be made on the best VTE RAM for patients undergoing aesthetic plastic surgery. This paper highlights the need for randomised controlled trials evaluating the various RAMs which are essential to support future recommendations and guidelines

Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial

BACKGROUND: Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing. METHODS/DESIGN: EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events. DISCUSSION: This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care. TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT02535481 . Registered on 11 August 2015

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

Introduction: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. // Methods and analysis: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. // Ethics and dissemination: Ethical approval was obtained from the London—City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks

Upregulation of epidermal gap junctional proteins in patients with venous disease

Background Leg ulceration is a feared complication of venous insufficiency. It is not known whether varicose veins predispose skin to poor wound healing. The expression pattern of gap junctional protein connexin, a known marker of poor wound healing, was investigated across various stages of venous disease. Methods Patients undergoing intervention for varicose veins were assessed according to the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification of varicose veins. Paired 4‐mm punch biopsies were taken from above the ankle (pathological) and above the knee (control). Tissues were stained with haematoxylin and eosin, and for connexin 43, connexin 30 and connexin 26. Results Forty‐eight paired biopsies were taken (12 each for CEAP class C0, C2, C4 and C6). The pathological skin showed progressive epithelial hyperthickening, an increase in the number and depth of rete ridges, increased inflammation and loss of dermal architecture with disease progression from C4 onwards. The overall absolute connexin expression and mean connexin expression per cell in the pathological skin similarly increased across the CEAP classes from as early as C2. Increasing levels of connexin in control skin were also noted, indicating progression of the disease proximally. Connexin 43 expression showed the strongest positive correlation between pathological and control skin. Conclusion Connexins were overexpressed in patients with simple varicose veins, with a stepwise increased expression through venous eczema to ulceration. Connexin 43 is a potential biomarker for venous disease. This finding suggests that varicose veins predispose skin to poor wound healing.Accepted versio

A prospective, multicentre study on the use of epidermal grafts to optimise outpatient wound management

Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care

Uses of Smartphone Thermal Imaging in Perforator Flaps as a Versatile Intraoperative Tool: The Microsurgeon's Third Eye

Introduction: In this study, we evaluate the versatility of smartphone thermal imaging technology as a valuable intraoperative modality in different stages of perforator flap surgery aiming to minimize the complications and achieve the best postoperative outcome. Patients and methods: Thermography was performed in 20 perforator flaps in 20 patients at different surgical stages in three different ways to identify the most dominant perforator: first, by measuring the surface temperature of the skin; second, by using the dynamic infrared thermography technique; and third, by assessing the perfusion pattern when the flap was supplied by each perforator separately. Thermography was used to help in discarding the least perfused area of the flap. After microvascular anastomosis, the flap reheating pattern was evaluated. Results: Seventeen free and three pedicled perforator flaps were included. Intraoperatively, each of the selected perforators had a corresponding hotspot. The perforator with the hottest hotpot, best rewarming, and provision of best flap perfusion on thermography was found clinically dominant. After microvascular anastomosis in free flaps, rapid rewarming was recorded in 15 cases. In two deep inferior epigastric perforator flaps, no rapid rewarming was observed. The pedicle was kinked in one case and there was a venous insufficiency in another case that required a cephalic turndown. All flaps showed good perfusion on thermography after inset. Conclusion: Smartphone thermography has proven to be a valuable, cheap, rapidly employed, and objective tool not only for the design of perforator flaps, but also for the decision making intraoperatively to achieve the best surgical outcome

Extracellular matrix and cellular senescence in venous leg ulcers

High prevalence of non-healing chronic wounds contributes to a huge healthcare burden across the world. Early treatment interventions for non-healing wounds are vital. It was previously shown that accumulation of 15% or more of senescent cells in a chronic wound edge is an indicator that the wound is unlikely to heal. However, determining the presence of senescent cells would require invasive procedures such as tissue biopsies to be taken. In this study, we found a strong correlation between decreased collagen area and presence of senescent cells in human chronic wounds i.e. venous leg ulcer (VLU), diabetic foot ulcer (DFU) and pressure ulcer (PRU). We also report that the lowest collagen levels were found in VLU patients less than 60 years of age, with a persistent wound of > 24 months. Elevated levels of senescent cells were also found in VLU of males. Second harmonic imaging of collagen at the edge of chronic wounds with a handheld multiphoton device could be used to predict the number of senescent cells, indicating if the wound is on a healing trajectory or not. Our data support the use of collagen imaging in cutaneous wound assessment for a faster and non-invasive method to predict cellular senescence and determining wound trajectory of healing.Agency for Science, Technology and Research (A*STAR)National Research Foundation (NRF)Published versionThis research is supported by the Agency for Science, Technology and Research (A*STAR) under its Industry alignment fund—Pre-Positioning Programme (IAF-PP) with grant numbers H17/01/a0/0C9 as part of the Wound Care Innovation for the Tropics (WCIT) programme, sub awards H18/01/a0/019 and H1701a0004. The Skin Research Institute of Singapore, Phase 2: SRIS@Novena. AMP is funded by Singapore’s Agency for Science, Technology & Research (A*STAR) through core funds and under the HBMS IAF-PP Project (H1701a0004) and through the National Research Foundation Singapore under its Shared Infrastructure Support grant for SingaScope—a Singapore-wide microscopy infrastructure network (NRF2017_SISFP10)”