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Topical keloid therapy is performed with triamcinolone acetonide (TA) intralesional injection. However, the recurrence rate is high with various side effects. Mesenchymal stem cells (MSCs) have high proliferative abilities and reduce the activity and proliferation of fibroblast cells in keloids. To overcome the costs and limitations, conditioned medium (CM) is used. This study aims to evaluate feasibility of intralesional injection of umbilical cord MSC (UC-MSC) and conditioned medium (UC-CM) compared to TA for keloid therapy. Twenty-four patients with keloids who met the inclusion criteria were included, randomized into three treatment groups and then got assessed for the sociodemographic data, keloid volume, histopathology (type 1:3 collagen ratio), interleukin-10 (IL-10) levels and Patient and Observer Scar Assessment Scale (POSAS) score during visits. Largest volume regression occurred in the UC-MSC group, followed by UC-CM and then the TA group (UC-MSC: 45.32% ± 2.61%; UC-CM: 43.61% ± 3.67%; TA: 28.34% ± 3.81%; p = 0.003). Similar pattern was also observed in increase in IL-10 levels, the decrease in POSAS scores and the reduction of type 1:3 collagen ratio. Hence, UC-MSC and UC-CM are promisingly more effective than TA for keloid therapy, showcasing their superiority in reducing keloid volume, symptoms and type 1:3 collagen ratio, as well as increasing the levels of IL-10., (© 2023 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: This study aims to compare the use of one-per-mil tumescent solution (a mixture of epinephrine and 0.2% lidocaine in a ratio of 1:1,000,000 in normal saline solution) and tourniquet to create clear operative fields and to evaluate the functional outcomes after post burn hand contracture surgery., Methods: The subjects of this randomized controlled trial were divided into one-permil tumescent technique and tourniquet group for a similar surgical procedure. Three independent assessors evaluated the clarity of the operative fields through recorded videos for the first 15 min and the first 10-minute of each hour of the surgery. Functional outcome was evaluated at least three months postoperatively using total active and passive motion (TAM and TPM) of each digit. Malondialdehyde (MDA) and tumor necrosis factor alpha (TNF-α) were tested during baseline (5 min before the procedures), ischemia phase, and reperfusion phase (a phase when the blood flow returned to the tissue)., Results: 35 subjects were included in this study: 17 in the tumescent group and 18 in the tourniquet group. We found a significant difference in the clarity of operative field between tumescent and tourniquet groups, 5 vs 35 bloodless operative fields, respectively (p < 0.05). TAM and TPM of each digit before surgery and 3 months postoperatively showed no significant difference between both groups (p > 0.05). Furthermore, we found no difference in MDA and TNF-α levels between both groups at their respective phases., Conclusions: The use of one-per-mil tumescent technique does not replace tourniquet use to create bloodless operative fields in burned hand contracture surgery. However, the postoperative functional results were similar in both groups showing that tumescent technique can be used as an alternative to tourniquet without compromising outcomes. The MDA and TNF-α examinations do not provide conclusive outcomes regarding ischemia and reperfusion injury., (Copyright © 2022 Elsevier Ltd and ISBI. All rights reserved.)

Background: Transferring critically ill patients with COVID-19 is a challenging task; therefore, well-trained medical team is needed. This study aimed to determine the role of in situ simulation training during pandemic by using high-fidelity manikin to improve interprofessional communication, skills and teamwork in transferring critically ill patients with COVID-19., Methods: This single-blinded randomised control trial included 40 subjects allocated into standard low-fidelity simulator (LFS) and high-fidelity simulator (HFS) groups. Subjects, who were not members of multiprofessional team taking care of patients with COVID-19, in each group were assigned into small groups and joined an online interactive lecture session, two sessions of in-situ simulation and a debriefing session with strict health protocols. The first simulation aimed to teach participants the skills and steps needed. The second simulation aimed to assess transfer skills, communication and teamwork performance, that participants had learnt using a validated, comprehensive assessment tool. Data were analysed using unpaired t test or Mann-Whitney test., Results: The HFS group showed significantly better overall transfer and communication skills than LFS group (89.70±4.65 vs 77.19±3.6, <0.05 and 100 vs 88.34 (63.33-100), p=0.022, respectively). The HFS group also demonstrated significantly better teamwork performance than the standard LFS group (90 (80-900) vs 80 (70-90), p=0.028)., Conclusion: In situ simulation training using HFS significantly showed better performance than the standard training using LFS in regards to overall transfer and communication skills as well as teamwork performance. The training using HFS may provide a valuable adjunct to improve interprofessional skills, communication and teamwork performance in transferring critically ill patients with COVID-19.Trial registration numberNCT05113823., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Keloids are pathological wound healing responses to dermal injuries. These scars may lead to considerable morbidity, but treatments remain challenging for physicians. Interleukin 10 (IL-10), a potent anti-inflammatory cytokine, plays a prominent role in fetal scarless regenerative healing; therefore, it may become a more targeted and effective therapy for keloids. This review aimed to obtain an overview of the background of keloid and IL-10 functions as its promising forthcoming treatment., Materials and Methods: Studies were sought from Pubmed, ScienceDirect, PLOS, and Clinical Key. Keywords are interleukin 10, keloid, and wound healing as Medical Subject Headings terms., Results and Discussion: Keloids and fetal scarless healing represent 2 opposing ends of the tissue repair spectrum. Promising multiple animal models have demonstrated successful regenerative healing promotion through IL-10 overexpression by its ability to minimize inflammatory wound microenvironment, downregulate transforming growth factor β/SMAD signaling pathway, increase extracellular matrix breakdown, and regulate extracellular matrix. These results have led to the development of clinical trials investigating human recombinant IL-10., Conclusions: Interleukin 10 has the potential to become a more targeted and promising therapy of keloids owing to its pleiotropic effects., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Adipose-derived stem cells (ASCs) have recently gained researchers' interest as a solution to various diseases and conditions, including hypertrophic scar. This literature review aims to elucidate ASCs as a potential solution to alleviate hypertrophic scar in human subjects., Methods: Literature search was done in databases which includes PubMed, MEDLINE, and ProQuest using terms 'adipose derived stem cells', 'adipose cells', 'fat graft', 'fat grafting', 'autologous fat graft', 'fat injection', 'lipofilling', 'scar management', 'scar treatment', 'burn scar', and 'wound management'. The included articles which were published during year 2000-November 2020 must describe the use of ASCs or fat grafting or lipofilling as an attempt to alleviate hypertrophic scar., Remarks: Clinically, ASCs improve hypertrophic scars in terms of scar color, elasticity, texture, thickness, and size. Histologically, ASCs promotes healthy tissue regeneration, reduction in fibroblasts, and reorganisation of collagen, resembling those of normal skin. In terms of molecular aspects, ASCs alleviates hypertrophic scars through direct differentiation and paracrine mechanisms., Conclusion: Adipose-derived stem cells, emerge to be a potential solution for alleviating hypertrophic scar, as demonstrated in various studies. However, there has been no studies conducted in human subjects to investigate the effect of ASCs on hypertrophic scar., (© 2021 Wiley Periodicals LLC.)

Background: To date, various surgical techniques were developed for gynecomastia and pseudogynecomastia surgery, providing surgeons vast range of options. These variations of techniques, however, may have different efficacy and results depending on the severity of patients' conditions., Objectives: This review aims to delineate comprehensively the variations of surgical approaches to gynecomastia and pseudogynecomastia in relation to surgical and patients' outcomes., Methods: Database search (October 28, 2020) from PubMed, Scopus, Science Direct, and Cochrane Library was performed to identify relevant studies using the keywords ("gynecomastia" OR "pseudogynecomastia") AND ("surgery" AND "mastectomy" OR "liposuction") within January 2011-November 2020, published in English. Inclusion criteria were approached according to patients, intervention, comparator, outcomes, and study design (PICOS). Data from the included studies were extracted based on study and subjects' characteristics, type of intervention, and outcome measures., Results: Out of all relevant studies revealed, 53 studies met inclusion criteria with 5345 subjects included. Most subjects, from 44 studies, were classified as Simon's Grade II (68.49%) with idiopathic cause (94.51%). Most cases were approached using the minimally invasive techniques (37.50%) and were highly satisfied. Among intervention groups, complication rates vary from 12.12-22.30%, with the minimally invasive approach having the lowest rate. Hematoma and bruise were the most reported complications. However, the risk of bias was relatively high due to missing data., Conclusions: Different surgical approaches for gynecomastia treatment have been described and were consistent with good outcomes. To achieve a low rate of complications, the minimally invasive techniques can be considered, since most patients seem to be satisfied., Competing Interests: Declaration of Competing Interest The authors report no conflict of interest., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Most hand flaps are local intrinsic flaps because hand perforators are small and fragile. The purpose of this review was to gather anatomical data on cutaneous perforators of the hand and their implications on intrinsic hand flaps., Methods: An electronic search was performed through PubMed, Scopus, ScienceDirect, ProQuest, and CINAHL in April 2021. The search terms included "hand," "palm," "manus," "cutaneous artery," "angiosome," and "perforasome." Studies were filtered according to the PRISMA flow chart, and critically appraised using the Quality Appraisal for Cadaveric Studies (QUAC) and Appraisal Tool for Cross-sectional Studies (AXIS)., Results: A total of 33 studies were included, of which 20 were pure anatomical studies, 10 combined anatomical and clinical studies, and three imaging-based clinical studies. A total of 643 hands and 406 fingers were included. The dorsal aspect of the hand, the dorsal digits, hypothenar, midpalm, thenar, and dorsal wrist consistently have adequate, closely distributed perforators of small diameters and short pedicle lengths. A series of clinical studies proved the success of elevating local perforator flaps on each of these areas., Conclusions: The hand contained densely interlinked cutaneous perforators of varying sizes and pedicle lengths. Although some areas of the hand are still unexplored, knowledge on cutaneous perforators of the hand allows the creation of a variety of possibilities for intrinsic hand flap designs., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: This study aims to analyse the quality of studies and revisit the liposuction assisted gynecomastia surgery performed through minimal incision., Methods: A systematic review, based on the literature in the PubMed, Scopus, Science Direct, and Cochrane, to the treatment of Simon's grade I and II gynecomastia was conducted using keywords "gynecomastia" AND "liposuction." Study appraisal was performed using MINORS to assess the methodological quality of the paper., Results: There were 18 out of 415 studies eligible to review. A total of 244 out of 1628 patients with the average age of 23.13 years. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved quality of life in terms of satisfaction after surgery. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Complication rates were inconsistent throughout the studies, ranging from 0.06 to 26.67%. Reoperation rate of liposuction-assisted surgery is between 0.6 and 25%. There are only two studies of a total 25 patients that are considered as good in quality. The two studies, which discuss laser-assisted liposuction technique, show minor complication of seroma in two patients. While one study shows high patient's satisfaction rate; both studies indicate high surgeon's satisfaction rate., Conclusion: Small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in quality of life. However, only 2 studies reported good quality methods of non-randomized case series urging for a better quality of studies in the future., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. 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 ., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

One-per-mil epinephrine solution (1:1,000,000) injected as a tumescent has been used in several hand and upper-limb surgery cases as a substitute for tourniquet. However, reviews of its effectiveness are still lacking. A comprehensive review was conducted based on PubMed, Scopus, Science Direct, Cochrane Library, and Semantic Scholar database search of relevant studies using the keyword "one-per-mil." Studies not using the exact one-per-mil tumescent solution formula were excluded. The review of clinical studies was conducted according to PRISMA guidelines. Epinephrine and the hydrostatic vasocompressive effect created bloodless operative fields, with 100% experimental flap survival after ischemic insult. The technique was effective in creating bloodless operative fields in 36.3% of varied hand and upper-limb surgery cases and in fully awake surgery. Current studies show that one-per-mil tumescent solution is safe and effective, enabling use of tourniquet to be avoided., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: This study aims to report how the practice of plastic surgeons and their attitude was during the first measure period of coronavirus disease 2019 (COVID-19) pandemic., Methods: A survey study was held among members of the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeons during week 5 after the first report of COVID-19. A 10 multiple-choice questions (MCQs) and 1 essay covered key questions on the area of surgery and operating room, clinics, internal meeting, and consultation. The only open-ended question relates to the last MCQ addresses a future "flipped" medical practice., Results: Response rate was 45.6% among 228 members, with 89.4% did no practice or limited their service to emergency and urgent cases only. Only 1.9% kept their official meeting as usual, while the majority modified it. The practice in the operating theatre and clinic were also altered to comply with the measures; with 21.2% from the total respondents only allowed patients with exposure to come for visit after taking 14 days of self-quarantine. Teleconsultation was practiced by 50% of the respondents, while 41.3% agreed and 10.6% disagreed upon the future "flipped" medical practice., Conclusion: In general plastic surgeons have made supportive actions during the pandemic. Surgery was performed with all precautions at the utmost as a reflection of high alert of viral infection. Teleconsultation has been embraced via existing social media. Agreement upon the future "flipped" medical practice is reasonable. All in all, the actions were considered as most relevant.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19., Competing Interests: NoteConflict of Interest The views expressed in this article are those of the authors and do not represent the official policy of the any country. None declared., (Society of Indian Hand & Microsurgeons. This article is published by Thieme.)

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly., (Copyright © 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: One-per-mil tumescent technique could provide local anesthesia in surgical procedures despite using low lidocaine concentration. Tumescence environment within the tissue may play a role in supporting local anesthesia effect. This study aims to delineate whether the tumescence environment, created by one-per-mil solution without a local anesthetic agent, had a local anesthesia effect., Methods: Four different compositions and volumes of tumescent solutions containing 1:1,000,000 epinephrine were injected into 50 Swiss Webster mice. The animals were divided into five groups: group A, a tumescent solution with 0.2% lidocaine; group B, a tumescent solution with 0.04% lidocaine; group C, a tumescent solution without lidocaine; group D, a doubled volume of tumescent solution without lidocaine; and group E, controls. Local anesthesia effects were tested by using the formalin test (n = 25) and tail immersion test (n = 25). Pain response behavior in the form of paw licking duration and tail withdrawal latency was observed. The analysis of variance and Kruskal-Wallis tests were used to test the statistical difference. Significance was set at P < 0.05., Results: The four interventional groups showed less pain response behavior and significantly longer tail withdrawal latency (P < 0.05) than the control group. However, the groups showed nonsignificantly shorter paw licking duration than the control (P > 0.05). Group A had the fastest onset of the local anesthesia effect., Conclusions: The tumescence environment was potentially able to provide a local anesthesia effect, although the solution did not contain a local anesthetic agent as proved by the tail immersion test., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS., Methods: Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2., Results: The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170-309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9-28.5)., Conclusions: Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.

Background: This study aimed to find out the optimal time delay of epinephrine in one-per-mil tumescent solution containing 1:1,000,000 epinephrine and 0.2% lidocaine to achieve optimal visualization in hand surgery., Materials and Methods: Twelve healthy male subjects who volunteered to join this prospective, randomized, double blind study were selected with convenient sampling technique. The subject's hand and the solution, either the one-per-mil or normal saline solution, were randomly selected. Injections were given to the ring finger's pulp, whereas the oxygen saturation (SpO 2 ) of each finger was measured with Masimo's Radical-7 Pulse Oximeter at 5 min before injection and continuously up to 45 min after injection. The device showed the SpO 2 every 2 s. Any value of SpO 2 was noted if it stayed the same point for at least 30 s in a row without interruption. The time of the lowest SpO 2 was recorded and analyzed., Results: The average of SpO 2 after injection in the epinephrine group was 96.5 (95-97), P = 0.002, whereas the normal saline group was 97.5 ± 1.168, P = 0.003. Both were statistically significant compared with their respective baseline values. The average delta SpO 2 of the epinephrine group was 3.42 ± 0.996, whereas the normal saline group was 1.50 ± 1.567 (P = 0.001; CI 0.923-2.911). The time to achieve the lowest SpO 2 in the epinephrine group was obtained at the average time of 13.90 ± 5.38 min after injection., Conclusions: The optimal time delay of the epinephrine in the one-per-mil tumescent solution was 13.90 ± 5.38 min after injection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to assess the safety of one-per-mil tumescent injections into viable skin flaps that had survived an ischemic insult, in order to assess the potential suitability of one-per-mil tumescent injections in future secondary reconstructive procedures such as flap revision and refinements after replantation., Methods: Forty groin flaps harvested from 20 healthy Wistar rats weighing 220 to 270 g were subjected to acute ischemia by clamping the pedicle for 15 minutes. All flaps showing total survival on the 7th postoperative day were randomly divided into group A (one-per-mil tumescent infiltration; n=14), group B (normal saline infiltration; n=13), and group C (control, with no infiltration; n=13) before being re-elevated. Transcutaneous oxygen tension (TcPO2) was measured before and after infiltration, and changes in TcPO2 were statistically analyzed using analysis of variance, the paired t-test, and the independent t-test. The viability of flaps was also assessed using the Analyzing Digital Images software at 7 days after the second elevation., Results: Thirty-nine flaps survived to the final assessment, with the sole exception of a flap from group A that did not survive the first elevation. TcPO2 readings showed significant decreases (P<0.05) following both one-per-mil tumescent (99.9±5.7 mmHg vs. 37.2±6.3 mmHg) and normal saline (103±8.5 mmHg vs. 48.7±5.9 mmHg) infiltration. Moreover, all groin flaps survived with no signs of tissue necrosis., Conclusions: One-per-mil tumescent infiltration into groin flap tissue that had survived ischemia did not result in tissue necrosis, although the flaps experienced a significant decrease of cutaneous oxygenation.

Background: This study aimed to measure the least initial and maintenance forces of syringe and needle combinations to provide a reference for local anesthetic injection., Methods: An experimental study was conducted in our Physics Laboratory during September 2015. A series of syringes sized 1 mL, 3 mL, 5 mL, 10 mL and 20 mL were paired with the original needles, 27G, 27G spinal and 30G. Each combination was tested three times using a compression testing Instron 5940 Series to measure initial and maintenance forces. Statistical analysis was performed using One-way ANOVA., Results: The lowest initial force was shown by the combination of 1 mL syringe and 27G spinal needle. However, the 1 mL syringe showed no significant difference across the needles [ F (3, 8) = 3.545; P < 0.068]. The original and 27G needle showed mean difference 0.28 (95%CI: -0.19, 0.75; P = 0.420). The lowest maintenance force was measured in the combination of 1 mL syringe and its original 26G needle. On the contrary, both the highest initial and maintenance forces were shown by the combination of 10 mL syringe and 30G needle., Conclusion: The 1 mL syringe with original 26G needle shows the best combination., Competing Interests: Conflict of Interest: None.

Background: This study is aimed to set a benchmark of skin color and texture index based on digital photographs for living and nonliving skin., Materials and Methods: Photography was taken with standardized camera inside a Mini Mobile Medical Photo Studio (MiniMoPS) prototype. A pilot analysis was conducted by comparing color and surface texture of 16 living and cadaveric skins each. Baseline data of viable and nonviable skin were obtained and analyzed using ImageJ software for its color tone, components, and texture index. Results were expressed as total digital number (TDN)., Results: MiniMoPS prototype consists of a dusty white foldable acrylic box, blue Pantone 635C background, and two 8-Watt light bulbs on the ceiling. The whole box is covered with a thick white cotton fabric to eliminate the influence of environmental light. The prototype was tested for its light intensity with David Quiles Lightmeter in various environments setting. It showed a constant result for skin photographs. The best probable cutoff point for skin color is TDN 138.1 (sensitivity 81.3%; specificity 100%). Cadaveric skin shows a higher texture digital number than living skin ([155.4 ± 25.0] versus 120 [80-135]; P = 0.001)., Conclusions: In regards of color, TDN >138 is a cutoff point for nonliving skin. Texture index 120 is a benchmark for living skin, whereas nonliving skin indicates 155., (Copyright © 2018 Elsevier Inc. All rights reserved.)