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Frostbite causes tissue damage through five major mechanisms, out of which two are amenable to treatment. The first-line treatment is rapid rewarming therapy using water at 40°C to 42°C, which addresses the formation of ice crystals in the intra and extra cellular compartments. The second mechanism is progressive tissue ischemia after rewarming and is only accessible to a second-line therapy represented by thrombolysis. This study aimed to determine the efficacy of thrombolysis. This is a single-center retrospective cohort study, where it was aimed to evaluate two groups of patients. A total of 18 patients were included in this study. Mean times between injury to thrombolytic therapy and admission to thrombolytic therapy was 26.04 hours (SD 13.6) and 9.65 hours (SD 9.89), respectively. All patients suffered injuries ranging from second-degree deep to third degree. The rate of patients having complete, partial, and no angiographic responses were 55.6%, 11.1%, and 33.3%, respectively. The main outcome of interest showed that 11 (61.1%) patients in total had amputations at different levels. Results showed that in the intervention group, five (55.6%) of the patients had amputations compared with six (66.7%) from the control group (P = .6) at comparable levels of amputation. The literature supports that the use of intra-arterial tissue plasminogen activator might be beneficial for severe cases of frostbites; however, it lacks of studies of major significance and results are often controversial. Our study has not shown statistically significant results on amputation levels and cannot support the hypothesis of efficacy of thrombolytic therapy.

Background Skin coverage remains a significant hurdle in large-sized burns. Recent advances have allowed to grow Bilaminar Cultured Skin Autografts (BCSGs) from patients’ own donor sites. The aim of this study was to report long-term outcomes in patients with large-sized burns having received BCSGs. Methods Nine patients received BCSGs from January 2010 to May 2015. Except one patient who died during hospitalization, all patients were contacted. Four agreed to partake in the study. Patients were tested with the Vancouver Scar Scale (VSS), QuickDASH questionnaire and Burn Specific Health Scale (BSHS). Incisional biopsies of BCSGs were compared with patients’ autografts. Results From nine patients, mean age was 40 years and mean TBSA was 70.3%. For the four patients included, score averaged was 2.25 on the VSS, 29.5 on QuickDASH, 36/36 for psychosocial items and 63/84 for functional abilities on the BSHS. Compared with autografts, BCSGs demonstrated better pliability VSS and functionality. Biopsies showed no evidence of malignancy or atypical changes, but areas of hyperpigmentation. Conclusion This is the first report investigating the long-term outcome of a newly developed BCSG. BCSGs demonstrated comparable results with patients’ autografts, functional outcomes on self-reported questionnaires and excellent psychological states. Precaution given the extensive unexpected hyperpigmentation must be taken and a randomized controlled study is underway.

Free flap reconstruction in acute burns has high failure rates, relating mainly to a systemic inflammatory state. The “vulnerable phase” can last for 6 weeks after burn and can cause thrombosis of the flap microcirculation with patent arterial and venous anastomoses. Revision surgery alone may be unsuccessful, but thrombolysis can lead to flap salvage. We describe a case of successful flap salvage with thrombolysis after unsuccessful revision surgery by permeable arterial and venous anastomoses in a patient in the acute burn phase suffering from microcirculatory thrombosis. Thrombolysis in these cases has not been described to date, but it could contribute to salvaging flaps by radiological intervention alone. A 23-year-old man was admitted with a 38% TBSA burn, including loss of all eyelid skin. The right eye was reconstructed in a satisfactory manner, but the left eye required urgent corneal coverage on day 32 with a dorsalis pedis fasciocutaneous free flap. The flap was hypo-perfused postoperatively, but anastomoses were found to be permeable on exploration. Angiography performed postoperatively after revision confirmed anastomotic patency, but failed to demonstrate small vessel beds within the flap. Thus, r-tPa was given at the anastomosis site and immediately the flap recovered completely. However, a total of 10 packed red blood cell transfusions were needed over the next 9 days. Thrombolysis in the context of free flap microvascular compromise may improve the overall success rates, especially in acute-phase burn patients where this etiology may be found, due to a vulnerable inflammatory period.

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: "upper extremity," "arm," "forearm," "wrist," "hand," "finger" AND "negative-pressure wound therapy," "VAC therapy," "vacuum assisted closure." A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Midfacial distraction for facial stenosis is minimizing the communication between cranial fossa and nasal fossa caused by the Le Fort III osteotomy during frontofacial advancement procedures. There are different types of distractors, such as internal and external devices. The aim of our study is to present a series of 22 consecutive distraction cases operated without any Le Fort osteotomy with external distraction frames. We completely avoid the gap between the skull and nose, thus avoiding related complications. Between 1997 and 2012, we operated on 22 patients presenting syndromes associating midfacial retrusion, maxillomandibular class III malocclusion and upper airway obstruction. We perform a fronto-orbital advancement. We do not perform any maxillary osteotomy. A vertical cut in the lateral orbital wall is done towards the inferior orbital fissure and another cut on the zygomatic arch. We realise the fixation of the frame posteriorly with a folded K-wire and anteriorly with a transmaxillary pin. Aiming overcorrection, we distract on average 1 mm a day for a mean period of 26 days and with a horizontal distraction vector. No deaths or life-threatening complications were reported. All midfacial retrusions were corrected without relapse. The advancement ranged between 6 and 20 mm. Several complications were notified: one sphenopetrous dislocation, one ethmoidonasal dislocation, two device disassemblages and two cases of maxillary sinusitis. Some of these complications caused an incomplete distraction result. Compared to other techniques, this method is safe, simple and efficient. By sparing major osteotomies, it avoids severe complications.

Resume Depuis plusieurs dizaines d’annees les taux d’echec de la microchirurgie restent relativement constants. A l’aide de deux cas cliniques nous presentons une nouvelle possibilite de sauver des lambeaux microchirurgicaux par des interventions d’angioradiologie. Le premier cas montre les effets benefiques potentiels de la thrombolyse in situ, notre deuxieme cas decrit la premiere utilisation de stent au sein d’une anastomose microchirurgicale. Dans les deux cas, le lambeau aurait ete voue a l’echec immediat, car les tentatives de reprise s’etaient revelees infructueuses. Ainsi, avant de deposer un lambeau microchirurgical en apparence non fonctionnelle, la simple angiographie pourrait nous orienter vers cette nouvelle possibilite pouvant ainsi reduire a long terme le taux d’echec global de la microchirurgie.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Skin graft is the most common and simple procedure to cover superficial defect. Skin of variable thickness and size is completely detached from its origin (donor site) to cover a defect (recipient site). This simple procedure is the result of a long and eventful technical and theoretical evolvement. The aim of this article is to re-trace the history of skin grafting, from its discovery until today.

Human lymphokines can elicit several effects associated with inflammation, e.g. leucocyte migration inhibition and fibrinolysis. These effects can be assessed in vitro by the leucocyte migration agarose technique (LMAT) and the leucocyte migration fibrinolysis technique (LMFT). The present study shows that preincubation of normal leucocytes with aprotinin, tranexamic acid and phenyl-methyl-sulfonylfluoride (PMSF) reduces or abolishes their migration inhibition response to leucocyte migration inhibition factor. The compounds exert this effect at non-toxic concentrations, which do not otherwise interfere with migration or fibrinolysis, and are non-toxic as estimated by PHA stimulation of lymphocytes. The LMFT is more sensitive to the modifying effect than the LMAT. The effect of aprotinin and tranexamic acid is reversible, the effect of PMSF is irreversible.

The in vitro effects of heparin, dipyridamole (DIPY) and lysine-acetylsalicylate (LASA) on human peripheral blood leucocyte migration and upon production/release and effect of leucocyte migration inhibitory activity (LMIA) from lymphocytes stimulated with concanavalin-A (con-A) have been studied. The final concentration of each drug was of the same order of magnitude as during clinical treatment. The leucocyte migration under agarose was significantly increased by DIPY at a concentration of 100 mug/ml. The release/production of LMIA was inhibited by DIPY at 1 mug/ml and by LASA at 0.3 mug/ml. Heparin had no influence on LMIA release, even at 10 IU/ml. The LMIA of supernatants from con-A-stimulated lymphocyte cultures was inhibited by DIPY at a concentration of 10 mug/ml, by LASA at 3 mug/ml and by heparin at 10 IU/ml. The findings suggest that DIPY and LASA could have a dual role as modifiers of inflammation: 1) the well known role as antiaggregants tending to limit and impede thrombosis, and 2) as antagonists to the lymphocyte-mediated (type IV) immune reaction through a depressive action on lymphokine production/release and activity.

Resume La reconstruction des pertes de substance des membres inferieurs a un objectif morphologique, trophique et mecanique. Le but de notre etude est de demontrer la fiabilite du lambeau libre osteomusculaire de latissimus dorsi associe au bord lateral de la scapula dans cette indication. Une etude anatomique a ete realisee sur 12 cadavres. L'artere angulaire s'est revelee constante avec des varietes d'origine qui sont decrites. Trois patients presentant une perte de substance complexe de jambe ont beneficie d'une reconstruction par ce lambeau libre. L'application clinique s'est revelee realisable.

Introduction During the 1970s, frontofacial advancement revolutionized the treatment of severe facial stenosis. Unfortunately, this method was associated with significant morbidity due to the Le Fort III osteotomy, which creates a major communication between the frontocranial dead space and the nasal fossae. Midfacial distraction improves the complication rate by diminishing the size of this gap. The aim of our study was to present an original technique that uses external distraction frames and eliminates the need for Le Fort osteotomies. This innovative technique eliminates the gap between the skull and nose, thus avoiding related complications. Patients and methods Between 1997 and 2008, we operated on 17 patients presenting midfacial retrusion and maxillomandibular class III malocclusion. We performed classic fronto-orbital advancement. The only facial osteotomies are vertical cuts of both the lateral orbital wall and the zygomatic arch. The distraction device is then anchored posteriorly with a K-wire and anteriorly with a transfacial pin through the maxilla. Finally, the distraction is performed horizontally until a class II overcorrection is obtained. Results No life-threatening complications or mortalities occurred. In all cases, the midfacial retrusion was corrected without relapse. All patients with complications fully recovered. It was observed that most complications were a result of either an overly rapid activation (>1 mm/d). Discussion Midface distraction using the external transfacial pin is a simple and safe procedure that allows an efficient correction of major facial retrusion. The external transfacial pin acts directly onto the maxilla and allows distraction without Le Fort osteotomy. By eliminating major osteotomies, it reduces the number of severe complications encountered in craniofacial surgery.

Supernatants from Con-A stimulated human lymphocytes containing leucocyte migration inhibitory activity were measured for thrombocyte aggregation activity and for influence on thrombocyte rich plasma clot retraction and whole blood clot retraction. The lymphocyte released activity of the supernatants produced thrombocyte aggregation and an acceleration of clot retraction. The activity resisted heating at 56 degrees C for 30 min and was inactivated at 80 degrees C for 30 min. The active substance seems to have a molecular weight above 10,000 daltons. The findings suggest that thrombotic processes associated with cell-mediated (type IV) immune inflammation could be due, at least partially, to lymphokine effects on thrombocytes.

Human lymphocytes stimulated with concanavalin-A produce a coagulant activity which decreases the clotting time as expressed through the recalcification time of citrated plasma, the partial thromboplastin time, the thrombin clotting time of citrated plasma and the thrombin clotting time of fibrinogen solutions. The culture supernatants of human lymphocytes stimulated with concanavalin-A also have a direct coagulant effect on human fibrinogen solution. They decrease the lag period of recalcification time of citrated plasma but do not modify the duration of polymerization as measured with a spectrophotometric method.

Lymphocytes from 14 patients treated with a combination of acetylsalicylic acid (ASA) and dipyridamole (DIPY) showed a decreased ability to produce leucocyte migration inhibitory activity (LMIA) when stimulated with concanavalin-A (ConA). The combined treatment also produced a decrease of leucocyte response to a standard LMIA-containing culture supernatant. Treatment with only one of the two drugs did not cause detectable alteration of the lymphocyte response to Con-A or the leucocyte response to LMIA. In vitro, both DIPY and ASA were independently effective in decreasing the LMIA production of Con-A-stimulated lymphocytes and the leucocyte response to a standard LMIA-containing culture supernatant.