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Background: In the multifactorial etiology of orofacial clefts (OFCs), environmental factors play an important role. To trace the influence of these factors, the timing of the cell biological mechanisms that occur during embryological development of the primary and secondary palates must be taken into account. That is, the fusion process of the facial and palatal processes, respectively, followed by their differentiation into bone and musculature, which take place during the first trimester of pregnancy. During this period, harmful seasonal influences such as viral infections and vitamin deficiencies could induce OFC in the embryo. Aims: The aim of this study is to find out whether a seasonal conception period with an increased risk of OFC development exists, particularly gender related. Methods: This was a retrospective cross-sectional study on children with OFC born in the Netherlands from 2006 to 2016. Total conception rates of live births in the Netherlands were used as a control group. χ2 tests were performed to analyze monthly and seasonal differences. Males and females, positive and negative family history and subphenotype groups based on fusion and/or differentiation (F- and/or D-) defects, and their timing in embryogenesis were analyzed separately. Results: In total, 1653 children with OFC, 1041 males and 612 females, were analyzed. Only males with FD-defects showed a significant seasonal variation with an increase in conceptions during spring, most often in May. Conclusions: Males with FD-defects showed a significant seasonal variation with an increase in conceptions during spring. No other seasonal trends could be demonstrated.

Background: A recently published validated classification system divides all orofacial cleft (OFC) subphenotypes into groups based on underlying developmental mechanisms, that is, fusion and differentiation, and their timing, that is, early and late periods, in embryogenesis of the primary and secondary palates. Aims: The aim of our study was to define gender differences in prevalence for all subphenotypes in newborns with OFC in the Netherlands. Methods: This was a retrospective cross-sectional study on children with OFC born from 2006 to 2016. Clefts were classified in early (E-), late (L-), and early/late (EL-) embryonic periods, in primary (P-), secondary (S-), and primary/secondary (PS-) palates, and further divided into fusion (F-), differentiation (D-), and fusion/differentiation (FD-) defects, respectively. Results: A total of 2089 OFC children were analyzed (1311 males and 778 females). Orofacial cleft subphenotypes in females occurred significantly more frequent in the L-period compared to males (66% vs 55%, P = .000), whereas clefts in males occurred significantly more in the EL-periods (40% vs 27%, P = .000). Females had significantly more S-palatal clefts (42% vs 23%, P = .000), while males had significantly more PS-palatal clefts (44% vs 30%, P = .000). Furthermore, the clefts in females were significantly more frequent the result of an F-defect (60% vs 52%, P = .000). Conclusions: Orofacial cleft in females mainly occur in the L-period are mostly S-palatal clefts, and are usually the result of an F-defect. Orofacial cleft in males more commonly occur in the EL-periods, are therefore more often combined PS-palatal clefts, and are more frequent D- and FD-defects.

Objective To examine quality of life in internationally adopted children with cleft lip and/or palate (CL/P) versus non-adopted children with CL/P. Design Cross sectional study. Setting Multidisciplinary cleft team of a secondary and tertiary hospital in the Netherlands. Methods Parents of children under the age of 8 treated by the multidisciplinary cleft team of our institutions were asked to fill out a questionnaire containing demographic and clinical data and a validated parent proxy measure of cleft-specific quality of life instrument for children aged 0–8: the CleftChild-8. Adopted children were matched to non-adopted children using propensity score matching based on sex, age, type of cleft, if palatal surgery was completed and the level of education of the parent. CleftChild-8 scores were then compared between the matched samples of adopted and non-adopted children with CL/P. Main Outcome Measure(s) Differences in (sub)domain scores of the CleftChild-8. Results Most median CleftChild-8 scores of the adopted children (n = 29) were slightly lower compared to the 29 matched non-adopted children. A significant difference was seen for the domain score ‘satisfaction with (operative) treatment’ and 3 of the 13 subdomain scores: ‘post-operative results’, ‘acceptance by siblings’ and ‘acceptance by family/friends’. Conclusions By parent report, adopted children with CL/P experienced some areas of lower quality of life when compared to non-adopted children. Members of cleft teams should be aware of the problems associated with adoption and offer additional guidance and counseling to adopted children and their parents.

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

Background: The female breast comes in many different shapes and sizes. The literature remains inconclusive on the ideal breast size. This study aims to investigate and compare breast size preferences among three cohorts (patients, plastic surgeons, and laypeople) to provide a better understanding of Western European ideals. Methods: Patients, plastic surgeons, and laypeople were interviewed using a survey containing three-dimensional simulations of nine females, each depicted using five simulations with increasing breast size (1 = natural breast without breast implants, 2 = moderate, 3 = moderate plus, 4 = high, and 5 = ultra-high). Linear regression models were performed to define statistically significant associations between preferred breast size and predictor variables. Results: In total, 28 patients, 45 plastic surgeons, and 100 laypeople (50 males and 50 females) participated in this study. On average, patients (3.5 ± 0.7) preferred larger breast sizes compared to surgeons (3.0 ± 0.7) and laypeople (3.1 ± 0.8). The difference between patients and surgeons was statistically significant. Overall, males preferred larger breast sizes than women. Patients of older age and with a higher BMI preferred larger breast sizes, while higher educational level was significantly associated with smaller breast size preference. Female plastic surgeons would undergo breast augmentation, while male plastic surgeons and female lay participants seem more skeptical. Conclusions: Significant preferential differences exist between patients and surgeons. It is important for professionals to be aware of societal ideals and preferential differences to adequately consult patients and achieve more satisfactory results.

BACKGROUND AND OBJECTIVES Recent studies show that whole specimen intraoperative frozen section analysis (WIFSA) is a reliable method for margin analysis in basal cell carcinoma (BCC) and has low recurrence rates after five-years follow-up. There are no studies with longer follow-up. Our aim is to present long-term recurrence rates after WIFSA. MATERIALS AND METHODS All patients with a facial BCC receiving excision with WIFSA between 1992 and 2007 were evaluated. Recurrence rates were examined for primary BCC (pBCC), recurrent BCCs (rBCC), and the different histological subtypes. The accuracy of WIFSA was assessed by comparing with formalin-fixed paraffin-embedded section analysis. RESULTS A total of 1140 patients with 1265 BCCs underwent excision with WIFSA, with a median and maximum follow-up of 10 and 25.3 years, respectively. Of all tumors, 90.0% were primary. Excisions were radical after an average of 1.4 excision rounds;5, 10, and 15-year recurrence rates for pBCCs are 3.3%, 5.1%, and 7.3%, respectively. An aggressive growth pattern and rBCCs are associated with more recurrences. The accuracy of WIFSA is 98.4%. CONCLUSIONS WIFSA provides a highly accurate analysis and has a low recurrence rate for primary BCCs. The increasing recurrence rates over time imply 5 years of follow-up may be insufficient.

Periocular skin tumors are difficult to treat because of the friability of the tissue and close relationship to adjacent, functional structures. After excision, direct reconstruction with alike tissue is desirable to prevent shrinkage and deformation. We analyzed whether a quick intraoperative pathology method using whole specimen bread loaf frozen section analysis delivers a sufficiently reliable result concerning completeness of the excision in periocular basal cell carcinoma (BCC). This is a cohort study by case note review of 132 patients undergoing excision of periocular BCC between 1996 and 2012 at the Medical Centre Leeuwarden. Whole specimen intraoperative frozen section analysis (WIFSA) was performed and compared with final paraffin-embedded tissue sections. Sensitivity and specificity of WIFSA and 5-year recurrence rate were calculated. One hundred thirty-nine periocular BCCs were excised. Paraffin sections of primary excision showed clear margins in 90 cases and tumor-positive margins in 49 cases. In 87 of 90 excisions with clear margins, WIFSA showed clear margins as well (specificity 97%). In 48 of the 49 excisions with tumor-positive margins, WIFSA showed incomplete excision as well (sensitivity 98%). Recurrence rate was 3.6% (5/139), with average follow-up of 79 months. This study indicates that WIFSA is an effective method for histological examination of the margins of surgically removed periocular BCCs, with high specificity and sensitivity. Recurrence rates are low. Level of Evidence: Level II, diagnostic study.

Background: The use of intraoperative fluoroscopy has become mandatory in osseous hand surgery. Due to its overall practicality, the mini C-arm has gained popularity among hand surgeons over the standard C-arm. This study compares image quality and radiation exposure for patient and staff between the mini C-arm and the standard C-arm, both with flat panel technology. Methods: An observer-based subjective image quality study was performed using a contrast detail (CD) phantom. Five independent observers were asked to determine the smallest circles discernable to them. The results were plotted in a graph, forming a CD curve. From each curve, an image quality figure (IQF) was derived. A lower IQF equates to a better image quality. The patients’ entrance skin dose was measured, and to obtain more information about the staff exposure dose, a perspex hand phantom was used. The scatter radiation was measured at various distances and angles relative to a central point on the detector. Results: The IQF was significantly lower for the mini C-arm resulting in a better image quality. The patients’ entrance dose was 10 times higher for the mini C-arm as compared with the standard C-arm, and the scatter radiation threefold. Conclusions: Due to its improved image quality and overall practicality, the mini C-arm is recommended for hand surgical procedures. To ensure that the surgeons’ radiation exposure is not exceeding the safety limits, monitoring radiation exposure using mini C-arms with flat panel technology during surgery should be done in a future clinical study.

Background Various techniques are used to correct prominent ears. The authors describe their experience with four different otoplasty techniques in 565 patients with congenital deformities of the ears (1060 ears) that were performed in their hospital during an 11-year period (2002 to 2012). Methods The authors divided the techniques into two groups: group I, cartilage-sparing techniques (i.e., IA, Mustarde; and IB, Furnas); and group II, cartilage-cutting techniques (i.e., IIA, Chongchet; and IIB, concha shell reduction). The authors compared early and late and minor and major complications, recurrence rates, and revision surgery. Furthermore, aesthetic outcome was scored by three different groups (consultant plastic surgeons, plastic surgery residents, and laymen) on a visual analogue scale using a blinded random selection of preoperative and postoperative photographs. Results The percentage of complications without the need for reoperation was 20 percent and 21 percent in the cartilage-sparing and cartilage-cutting groups, respectively (p = 0.44). In 6 percent of all cases, a reoperation of the otoplasty was required (7 percent and 6 percent in the cartilage-sparing and cartilage-cutting groups, respectively). Aesthetic postoperative results showed that the cartilage-cutting group scored significantly lower on postoperative shape (p = 0.04), result (p = 0.03), and satisfaction (p = 0.04) compared with the cartilage-sparing group. Conclusions The study shows that patients who have undergone operations with cartilage-sparing or cartilage-cutting techniques have a similar rate of complications and need for reoperation. However, the cartilage-sparing techniques have a better aesthetic outcome, as judged by the different groups. Clinical question/level of evidence Therapeutic, III.

Background Basal cell carcinomas (BCCs) excised leaving positive tumour margins, are at a higher risk of recurrence. Accordingly, complete tumour removal with preservation of healthy tissue, aiming for low recurrence rates, is the main goal in treating BCCs. Objective The present study aimed to identify the reliability of the Whole Specimen Intraoperative Frozen Section Analysis (WIFSA) technique by comparing intraoperative WIFSA and postoperative Formalin-Fixed Paraffin-Embedded section analysis (FFPE) results in 1082 basal cell carcinomas and by assessing the recurrence rates during a follow-up period up to 10 years. Methods A single-centre retrospective cohort of all patients with BCC of the face receiving surgical excision with the WIFSA method between January 2007 and December 2013 was evaluated. We compared the intraoperative frozen section results with postoperative FFPE in order to assess accuracy of the WIFSA. Recurrence rates were assessed among all BCCs with a tumour-free margin at final excision that had a minimum follow-up of 6 months. Results A total of 996 patients with 1082 BCCs were treated with the WIFSA. Overall agreement of WIFSA with conventional postoperative FFPE was 98·8%, sensitivity and specificity being 99·0% and 98·7% respectively. We excluded 23 BCCs that still had positive tumour margins at the end of the procedure and another 67 for the analysis of recurrence rate because follow-up was shorter than 6 months. A total of 992 BCCs with a tumour-free margin at final excision had a mean follow-up of 5·6 years (mean 67 ± 27·7 months (range 6–117 months)). The total recurrence rate was 2·1% (21 out of 992 BCCs). The recurrence rate among the primary tumours was 1·6% (13 out of 828 cases) and 4·9% among the recurring tumours (8 out of 164 cases). Conclusion This study indicates that, in patients with primary or recurring BCCs, WIFSA provides a high accuracy for intraoperative specimen analysis and has a low recurrence rate after a mean follow-up of 5·6 years. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Purpose The purpose of this study was to analyze the influence of patient and treatment characteristics on the occurrence of complications after hypospadias correction and the impact of complications on final clinical outcome. Materials and Methods The study cohort consisted of 205 hypospadias patients who had surgery in the Medical Centre Leeuwarden (1996–2011). Patient and treatment characteristics were hypospadias severity (preoperative meatal location and chordee), number of planned surgeries, reconstruction technique, operation year, and patient's age at the time of surgery. The final clinical outcome was measured with the Hypospadias Objective Scoring Evaluation (HOSE) (maximum score = 16) and compared between patients with and without complications. Results Sixty-four patients (31%) had complications, most of which were fistulas (n = 40). An increased complication risk was seen in patients with severe hypospadias (preoperative proximal meatus or chordee), multistage reconstruction, reconstruction techniques other than Mathieu, and surgeries performed before 2005. Uncomplicated treatment resulted only in a marginally higher HOSE (15.7) compared with complicated treatment (15.4). Fistulas and multiple complications reduced clinical outcome more (15.3 and 14.9, respectively), while urinary tract infections, wound dehiscence, or prepuce related complications did not (16.0, 16.0, and 15.8, respectively). Conclusion The complication risk after hypospadias correction is influenced by hypospadias severity and type and year of reconstruction. Certain, but not all complications diminish final clinical outcome.

A 57-year-old woman presented herself in the plastic surgery department's outpatient clinic at our hospital. She had been experiencing a tingling sensation of the first three digits of the left hand. Our first differential diagnosis was a classic carpal tunnel syndrome. Physical examination showed a minor prominence, which provoked the same tingling sensation when given tactile pressure. Diagnostic MRI showed that the prominence seemed like a peripheral nerve tumour of the median nerve. Primary excision was performed, after which the symptoms disappeared without lasting effects. Pathologic investigation confirmed the diagnosis of schwannoma of the median nerve.

Purpose During mini C-arm fluoroscopy , both the patient and surgical team are exposed to scatter radiation. The objective of this study was to quantify body, thyroid, and hand radiation exposure to surgeon and assistant during intraoperative use of flat panel mini C-arm fluoroscopy in hand and wrist surgical procedures. Methods Over 5 months, the surgeon’s and assistant’s radiation exposure was recorded during all osseous hand and wrist surgical procedures. Whole-body and thyroid radiation exposure were measured with 2 types of dosimeters: a photon thermoluminescence detector and a RaySafe i2 real-time dosimeter. Ring dosimeters were used to quantify hand radiation exposure. Results Mini C-arm fluoroscopy was used in 94 surgical procedures. Total fluoroscopy time was 1,996 seconds and varied between surgical procedures (range, 1-152 seconds; median, 11 seconds). No thermoluminescence detector photon dosimeter exceeded the threshold limit of 0.1 mSv. The RaySafe i2 real-time dosimeters recorded a cumulated dose of 0.029 mSv for the body and 0.012 mSv for the thyroid position of the surgeon. The assistant received a cumulated dose of 0.011 mSv for the body and 0.011 mSv for the thyroid position. The ring dosimeters showed a cumulated dosage of 1.28 mSv for the surgeon and 0.20 mSv for the assistant. Conclusions Our results show that the surgeon’s and assistant’s body, thyroid, and hands were exposed to acceptable levels of scatter radiation during intraoperative use of the flat panel mini C-arm. The surgeon received the highest radiation exposure: 2.9% of the yearly radiation limits for the body, 0.05% for the thyroid position, and 2.56% for the hands. The assistant was exposed to less scatter radiation: 1.1% for the body, 0.04% for the thyroid, and 0.4% for the hands. Clinical relevance This study quantified radiation levels to which surgeon and assistant are exposed during mini C-arm fluoroscopy in hand and wrist surgical procedures.

Background: Complications after silicone implantation, with silicone extravasation being the most severe, remain a safety issue in breast implantation surgery. The purpose of our study was to determine the incidence of medium- and long-term postoperative complaints and complications and indications for explantation in patients with a silicone breast implant.Methods: This is a retrospective cohort study consisting of patients who received silicone breast implants of the fourth or fifth generation between 2003 and 2015. Long-term outcomes (> 3 months after initial placement) were derived from medical records. The association with indication of breast surgery, method of placement, and type of reconstruction was determined.Results: In total, 448 patients (n=738 silicone breast implants) met the inclusion criteria with a median follow-up of 330 days. Overall, 18% of the implants resulted in postoperative complaints, with discomfort or pain being the most common complaint (12%), significantly more frequent in reconstructive cases and significantly associated with subglandular placement in cosmetically augmented breasts. Physical examination revealed in 14% one or more postoperative complications, with capsular contracture being the most common complication. A total of 12% of the implants were eventually explanted within a median time of 568 days. Predominant reasons were cosmetic dissatisfaction, capsular contracture, and pain (in 37%, 21%, and 15%, respectively). Macroscopic leakage was demonstrated in 3% of the explanted prostheses.Conclusions: Explantation of breast implants occurred in 12%, within a median time of 1.6 years, wherein macroscopic leakage was rarely seen. Cosmetic dissatisfaction, capsular contracture, and pain were the most common indications. (C) 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Recent studies show that whole specimen intraoperative frozen section analysis (WIFSA) is a reliable method for margin analysis in basal cell carcinoma (BCC) and has low recurrence rates after five-years follow-up. There are no studies with longer follow-up. Our aim is to present long-term recurrence rates after WIFSA.All patients with a facial BCC receiving excision with WIFSA between 1992 and 2007 were evaluated. Recurrence rates were examined for primary BCC (pBCC), recurrent BCCs (rBCC), and the different histological subtypes. The accuracy of WIFSA was assessed by comparing with formalin-fixed paraffin-embedded section analysis.A total of 1140 patients with 1265 BCCs underwent excision with WIFSA, with a median and maximum follow-up of 10 and 25.3 years, respectively. Of all tumors, 90.0% were primary. Excisions were radical after an average of 1.4 excision rounds;5, 10, and 15-year recurrence rates for pBCCs are 3.3%, 5.1%, and 7.3%, respectively. An aggressive growth pattern and rBCCs are associated with more recurrences. The accuracy of WIFSA is 98.4%.WIFSA provides a highly accurate analysis and has a low recurrence rate for primary BCCs. The increasing recurrence rates over time imply 5 years of follow-up may be insufficient.

Background and Objectives We excised cutaneous squamous cell carcinoma (cSCC) of the face while using intra-operative frozen section analysis of the margins in an optimized bread-loafing fashion (WIFSA). Methods Medical records were reviewed of 160 cSCCs of the face that were treated by surgical excision with WIFSA between April 2007 and January 2013. The accuracy of WIFSA was verified by comparing results with postoperative formalin-fixed paraffin-embedded (FFPE) sections. Also, recurrence and metastasis during follow-up were studied and duration of treatment and complications were analyzed. Results The 160 cSCCs affected 152 patients. In 131 cSCCs (mean follow-up: 41.0 months, SD: ±26.3, range: 3.0-110.7) occurred 6 (4.6%) recurrences and 2 (1.5%) metastases. Of the WIFSA results, 98.8% corresponded with postoperative FFPE sections. Mean duration of treatment was 77 min (SD: ±25, range: 34-159) and complication rate was 8.1%. Conclusions Surgical excision with WIFSA is an excellent treatment modality for cSCC of the face because of its accurate method for assessment of complete tumor removal, low recurrence and metastasis rate, short average duration of treatment, and low complication rate.

Item does not contain fulltext Background: Hypospadias is a congenital malformation in which surgical correction is indicated in most cases. Postoperative patient satisfaction is important because of its influence on the child's psychological development. Objective: To evaluate patient satisfaction with surgical outcome after hypospadias correction, comparison with physician satisfaction, and the influence of patient and treatment characteristics on satisfaction. Design, setting, and participants: Seventy-four patients who had hypospadias surgery between 1996 and 2010 in Medical Centre Leeuwarden participated in the study. Measurements: Patient/parent and physician satisfaction scores were measured using a standardised hypospadias satisfaction questionnaire (maximum score 32), and clinical outcome using the Hypospadias Objective Scoring Evaluation (HOSE; maximum score 16). Patient and treatment characteristics recorded were: preoperative meatal location, preoperative chordee, number of planned surgeries, reconstructive type and timing, patient age during the study, complications, and repeat operations. Results and limitations: Patients (mean age 10.5 yr) had a lower overall satisfaction score (27.1) than the physicians (30.6). Patients were least satisfied with overall genital appearance (3.1), penile length (3.3), and scars (3.3), whereas physician satisfaction was lowest for scars (3.5). The mean HOSE was 15.4 (standard deviation 0.9). Patients with acceptable HOSE (85%) had higher patient and physician satisfaction compared to patients with unacceptable HOSE. Patient satisfaction was lower among patients with a preoperative proximal meatal location or chordee, and with correction techniques other than the Mathieu approach. Physician satisfaction decreased with increasing patient age and was lower for patients with preoperative chordee, postoperative complications, or repeat operations. Conclusions: Overall patient and physician satisfaction and clinical outcome scores were relatively high. Patient satisfaction was lower and based on different factors compared to physician satisfaction. Patient satisfaction seems more influenced by aesthetic appearance, but both patients and physicians appear to incorporate clinical characteristics and outcome in their opinion on satisfaction. Patient summary: Different factors seem to influence patient and physician satisfaction with hypospadias correction, and there is only low correlation between the two. Therefore, patient satisfaction should be evaluated properly instead of making assumptions based on physician satisfaction or clinical outcome only. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Background: Vacuum-assisted closure wound therapy (vacuum therapy) has been used in our department since 1997 as a tool to bridge the period between debridement and definite surgical closure in full-thickness wounds. We performed a prospective randomised clinical trial to compare the efficacy of vacuum therapy to conventional moist gauze therapy in this stage of wound treatment. Methods: Treatment efficacy was assessed by semi-quantitative scoring of the wound conditions (signs of rubor, calor, exudate and fibrinous slough) and by wound surface area measurements. Tissue biopsies were performed to quantify the bacterial load. Besides this, the duration until 'ready for surgical therapy' and complications encountered during therapy and postoperatively were recorded. Results: Fifty-four patients were included (vacuum n = 29, conventional n = 25). With vacuum therapy, healthier wound conditions were observed. Furthermore, a tendency towards a shorter duration of therapy was found, which was most prominent in late-treated wounds. In addition, the wound surface area reduced significantly faster with vacuum therapy. Surprisingly, these results were obtained without a decrease in the number of bacteria colonising the wound. Complications were minor, except for one case of septicaemia and one case of increased tissue necrosis, which compelled us to stop vacuum therapy. For the treatment of full-thickness wounds, vacuum therapy has proven to be a valid wound healing modality.

To date, there is a lack of consensus concerning the application of local anaesthetics with epinephrine in fingers, due to the alleged risk of ischaemic complications.We present the case of a 70-year old woman, with a medical history of diabetes mellitus and an ischemic cerebral infarct, who underwent operative trigger finger release under local anaesthetics with 1% lidocaine-epinephrine (1:100,000) solution. A few hours later, she developed persisting numbness and ischemic symptoms of the digits. Initial antithrombotic treatment with nadroparin did not resolve the issue, but vasodilatory treatment with nifedipine improved symptoms. Nevertheless, digital necrosis developed in the affected fingers several weeks later. Post-operatively, severe atherosclerosis was diagnosed in the affected hand.The use of local anaesthesia in conjunction with epinephrine for surgery on digits does offer advantages, but caution is warranted for patients with risk factors predisposing for local circulatory insufficiency. Timely vasodilatory treatment with phentolamine is the preferred option for patients who develop acute ischaemia following local anaesthesia with epinephrine.

Vacuum-assisted closure has become a new technique in the challenging management of contaminated, acute, and chronic wounds. Although promising clinical results have been described, scientific proof to substantiate the mechanism of action of this therapy is scarce. In the present study, we examined whether the positive effect on wound healing found in vacuum-assisted closure-treated wounds could be explained by an effect on the bacterial load. Fifty-four patients who needed open wound management before surgical closure were included in this study. Wounds were randomized to either vacuum-assisted closure therapy (n= 29) or treatment by conventional moist gauze therapy (n= 25). Healing was characterized by development of a clean granulating wound bed ("ready for surgical therapy") and reduction of wound surface area. To quantify bacterial load, biopsies were collected. No significant difference was found in time needed to reach "ready for surgical therapy" comparing both therapies. Wound surface area reduction was significantly larger in vacuum-assisted closure-treated wounds: 3.8 +/- 0.5 percent/day (mean +/- SEM) compared to conventional-treated wounds (1.7 +/- 0.6 percent/day; p < 0.05). The total quantitative bacterial load was generally stable in both therapies. However, nonfermentative gram negative bacilli showed a significant decrease in vacuum-assisted closure-treated wounds (p < 0.05), whereas Staphylococcus aureus showed a significant increase in vacuum-assisted closure-treated wounds (p < 0.05). In conclusion, this study shows a positive effect of vacuum-assisted closure therapy on wound healing, expressed as a significant reduction of wound surface area. However, this could not be explained by a significant quantitative reduction of the bacterial load.

Background . This study assessed the feasibility of applying a temporary luminal arteriotomy seal during end-to-side coronary artery bypass grafting on the beating heart. Methods . In 18 consecutive pigs, the left internal mammary artery was grafted to the left anterior descending coronary artery, and the arteriotomy was temporarily sealed luminally by a 200-μm-thick polyurethane seal. Endothelial denudation, medial necrosis, and intimal hyperplasia were measured quantitatively and compared with conventionally sutured anastomoses (n = 4 pigs). Results . Insertion and retrieval of the seal required 28 ± 12 and 11 ± 6 seconds, respectively. Including the arteriotomy, coronary artery occlusion was limited to about 80 seconds. The seal provided a bloodless arteriotomy in all anastomoses with unimpeded coronary artery blood flow. Endothelial denudation was limited to two thirds of the circumference of the coronary artery. No medial necrosis was found. Intimal hyperplasia at the suture line was small, although more pronounced when compared with conventionally sutured anastomoses. Conclusions . In off-pump, beating-heart coronary artery bypass grafting, the temporary luminal arteriotomy seal provided a bloodless arteriotomy with negligible obstruction to coronary artery blood flow, and with a minimum of arterial wall damage. It is conceivable that this seal may expand the indications for coronary surgical procedures without cardiopulmonary bypass.

Summary: A 15-year-old girl presented to the pediatrician with complaints of excessive fat distribution on the right side and breast asymmetry. At age 2, she had undergone a left-sided nephrectomy because of a stage III Wilms tumor using a transverse cut supraumbilical approach, followed by systemic chemotherapy and local radiotherapy. In the case of trunk asymmetry, it is questionable which side is deviant. The asymmetry may be an expression of isolated hemihyperthrophy, syndromal hemihypertrophy related to the Wilms tumor, or an expression of left-sided hemiatrophy as a late consequence of radiotherapy, chemotherapy, or surgery. Late clinical manifestations of childhood cancer treatment are difficult to distinguish from other independent diseases but must be considered as explanations for new onset of symptoms in adolescents.

The first wound an wound treatments were described five millennia ago. Since then, various principles of wound care have been passed on from generation to generation. In contrast to large numbers of general technological inventions over the last 100 years, progress beyond ancient wound care practices is a recent phenomenon. It is essential to know the historical aspects of wound treatment (both successes and failures) in order to continue this progress and provide future direction. A survey of the literature shows that concepts such as "laudable pus" persisted for hundreds of years and that lasting discoveries and meaningful progress did not occur until grand-scale manufacturing and marketing started. Landmarks such as understanding the principles of asepsis/antisepsis, fundamental cellular research findings, knowledge about antibiotics/antimicrobials, moist wound healing, and the chemical and physical processes of wound healing have provided the foundation to guide major developments in wound management, including available evidence-based guidelines. Although research regarding interaction of basic wound management principles remains limited, the combined efforts of global research and clinical groups predict a bright future for improved wound management.

Vacuum-assisted closure has become a new technique in the challenging management of contaminated, acute, and chronic wounds. Although promising clinical results have been described, scientific proof to substantiate the mechanism of action of this therapy is scarce. In the present study, we examined whether the positive effect on wound healing found in vacuum-assisted closure-treated wounds could be explained by an effect on the bacterial load. Fifty-four patients who needed open wound management before surgical closure were included in this study. Wounds were randomized to either vacuum-assisted closure therapy (n= 29) or treatment by conventional moist gauze therapy (n= 25). Healing was characterized by development of a clean granulating wound bed ("ready for surgical therapy") and reduction of wound surface area. To quantify bacterial load, biopsies were collected. No significant difference was found in time needed to reach "ready for surgical therapy" comparing both therapies. Wound surface area reduction was significantly larger in vacuum-assisted closure-treated wounds: 3.8 +/- 0.5 percent/day (mean +/- SEM) compared to conventional-treated wounds (1.7 +/- 0.6 percent/day; p0.05). The total quantitative bacterial load was generally stable in both therapies. However, nonfermentative gram negative bacilli showed a significant decrease in vacuum-assisted closure-treated wounds (p0.05), whereas Staphylococcus aureus showed a significant increase in vacuum-assisted closure-treated wounds (p0.05). In conclusion, this study shows a positive effect of vacuum-assisted closure therapy on wound healing, expressed as a significant reduction of wound surface area. However, this could not be explained by a significant quantitative reduction of the bacterial load.

Background . Recently, we described a temporary luminal arteriotomy seal that provided a bloodless arteriotomy without obstructing recipient artery blood flow during bypass grafting in nonarteriosclerotic porcine arteries. This postmortem study assessed the sealing properties in irregular arteriosclerotic human coronary arteries. Methods . Three hearts were obtained from donated corpses within 24 hours of death. The coronary arteries were pressure-perfused at 60 mm Hg with citrated porcine blood. At 15 anastomosis sites in four different coronary arteries, an end-to-side anastomosis was created using a 200-μm-thick polyurethane seal. Adequacy of sealing was determined at perfusion pressures of 60, 40, and 20 mm Hg. Results . After insertion, the arteriotomy was sealed instantaneously in 10 of 15 anastomoses. After repositioning, complete sealing with a bloodless operative field was obtained in all cases. Low intracoronary transmural pressure did not impede sealing. In 8 of 15 anastomoses, minor leakage without obscuring the arteriotomy edges was observed during anastomotic suturing. Histologic examination revealed no intimal tear or dissection caused by the anastomotic procedure. Conclusions . In postmortem-obtained arteriosclerotic human coronary arteries, the temporary luminal arteriotomy seal provided optimal visualization of the coronary anastomosis site in combination with persistent distal perfusion.

Objective: The nonpenetrating, arcuate-legged clip has proved its ability to provide a high-quality microvascular anastomosis. This study assessed the feasibility of constructing a coronary end-to-side anastomosis on the beating heart with a novel mechanical, sutureless anastomotic device that applies 12 circumferential clips simultaneously. Methods: In 14 consecutive pigs (70–90 kg), the left internal thoracic artery (diameter, 3 mm) was grafted to the left anterior descending coronary artery (diameter, 3 mm) by means of a one-shot anastomotic stapler prototype. Endothelial denudation, medial necrosis, and intimal hyperplasia were analyzed quantitatively and compared with those seen in conventionally sutured anastomoses (n = 4). Results: In 8 of 14 anastomoses, the one-shot anastomotic stapler successfully applied all 12 clips circumferentially across the everted arteriotomy edges. In the remaining, either 1 (n = 4) or 3 and 4 adjoining malaligned clips had to be replaced manually with a single-clip applicator. Coronary occlusion was limited to approximately 3 minutes. At follow-up, all anastomoses were patent angiographically. At 2 days, in 2 of 7 cases, a local coronary dissection was observed, and there was a considerable loss of endothelial cells and medial damage. At 28 days, however, minimal intimal hyperplasia was seen at the anastomotic lining, although more pronounced when compared with conventionally sutured anastomoses. Conclusions: The one-shot anastomotic stapler prototype enabled short-occlusive (3 minutes), sutureless end-to-side grafting on the beating porcine heart. In spite of early endothelial and medial damage and 2 local dissections, all anastomoses remained patent with minimal intimal hyperplasia at 4 weeks. (J Thorac Cardiovasc Surg 1999;117:117-25)