A prospective randomised clinical pilot study to compare the effectiveness of Biobrane® synthetic wound dressing, with or without autologous cell suspension, to the local standard treatment regimen in paediatric scald injuries

Background

Scald is the most common cause of burn in children in Australia. The time taken by the burn wound to heal impacts on scar outcome. Commonly scald injuries are treated conservatively; in our unit the practice is that if healing does not occur within 10 days, surgery is used to aid healing with the aim of improving scar outcome. This randomised controlled pilot study compares early treatment regimens to facilitate tissue salvage and reduce the incidence of definitive surgery at 10 days following scald injury.

Methods

All paediatric patients with partial thickness scald injury were clinically assessed between July 1, 2009 and June 30, 2010. A burn of 2% TBSAB or more and deemed not to heal within 10 days, were considered for the trial. These patients were randomised to one of three treatment arms: the local standard treatment (Intrasite™, Acticoat™ and Duoderm^® dressings every 2–3 days) with surgery at 10 days, Biobrane^® only or Biobrane^® and autologous cell suspension using the ReCell^® kit. The primary outcome was surgery performed after 10 days; secondary outcomes were rates of healing, pain experienced, and scar outcomes.

Results

15% of scald presentations in the 12 month period met the eligibility criteria. 13 patients were recruited into the pilot study; early intervention was associated with a decreased time to healing with fewer dressing changes, less pain and better scar outcomes.

Conclusion

Investment of surgical resources in the acute stages within 4 days of injury saved on nursing time, dressing, analgesic and scar management costs.     

Fractional photo-thermolysis by laser Fraxel as an adjuvant for facial surgical rejuvenation

The fractional resurfacing (Fraxel laser) is a new procedure for facial and extrafacial rejuvenation. His claim is obtain a great efficacy on wrinkles, close to those of the CO(2) and erbium lasers, but without their risks and long lasting down time. We use a scanner, able to create multiple (around 2000 to 3000/cm(2)) 70-150 microns diameter microthermal zones surrounded by islands of viable tissue. The reepithelialization is complete in a day, but there is a collagen denaturization in the dermis, between 300-750 microns like after a traditional resurfacing. At each session, around 25% of the dermis are treated. 4 treatments are performed with a 1 to 2 weeks interval. We report our comprehensive results since we began in December 2004. At the time of the abstract, 600 sessions were performed (150 Patients). A visible reduction of wrinkles is observed anytime, with improvement of the texture of the skin, and in the same time, a dramatic improvement of the pigmented lesions. About tolerance, no severe side effects or dyschromia were noticed. We observed two case of limited erosion, (one of the first patients) due to a practical problem (bulk heating). The average erythema duration is 2 days. On the face, a 2-4 days edema occurs in many of the patients. Fraxel laser treatment is not designed as a substitute for surgical skin tightening such as facelift. Therefore, the fractional resurfacing is safe and effective for a visible reduction of wrinkles and appears as a very interesting treatment in association with face lift to rejuvenate the face.     

Dermal preservation using the Versajet hydrosurgery system for debridement of paediatric burns

Loss of dermis is one of the principal factors that contributes to poor scar outcome after severe burn. Dermal loss may be due to the primary injury, surgical management or as a result of infection. Strategies for dermal preservation are therefore important to improve scar quality. We report our early experience using the Versajet hydrosurgery system, to preserve dermal tissues, both directly during surgical debridement and indirectly by reducing infection and optimising the use of biological dressings. In deep partial thickness burns softer necrotic dermis can be removed with the Versajet sparing the underlying tougher viable dermis. In superficial burns the Versajet cleans and removes loose epidermal elements providing an optimal wound surface for the application of biological dressings, even a number of days after injury. Versajet is most useful when the tissue to be removed is softer than that to be left behind.     

Moist occlusive dressing (Aquacel(®) Ag) versus moist open dressing (MEBO(®)) in the management of partial-thickness facial burns: a comparative study in Ain Shams University

Introduction

The face is the central point of the physical features; it transmits expressions and emotions, communicates feelings and allows for individual identity. Facial burns are very common and are devastating to the affected patient and results into numerous physical, emotional and psychosocial sequels. Partial thickness facial burns are very common especially among children. This study compares the effect of standard moist open technique management and a moist closed technique for partial thickness burns of the face.

Patients and methods

Patients with partial-thickness facial burns admitted in the burn unit, Ain Shams University, Cairo, Egypt in the period from April 2009 to December 2009 were included in this study. They were divided into two groups to receive either open treatment with MEBO^® (n = 20) or coverage with Aquacel^® Ag (n = 20). Demographics (age, gender, ethnicity, TBSA, burn areas), length of hospital stay (LOS), rate of infections, time to total healing, frequency of dressing changes, pain, cost benefit and patient discomfort were compared between the two groups. The long-term outcome (incidence of hypertrophic scarring) was assessed for up to 6 months follow-up period.

Results

There were no significant differences in demographics between the two groups. In the group treated with the Aquacel^® Ag, the mean time for re-epithelialization was 10.5 days, while it was 12.4 days in the MEBO^® group (p < 0.05). Frequency of changes, pain and patient discomfort were less with Aquacel^® Ag. Cost was of no significant difference between the two groups. Scar quality improved in the Aquacel^® Ag treatment group. Three and 6 months follow-up was done and long-term outcomes were recorded in both groups.

Conclusion

Moist occlusive dressing (Aquacel^® Ag) significantly improves the management and healing rate of partial thickness facial burns with better long-term outcome compared to moist open dressing (MEBO^®).     

Characterisation of the cell suspension harvested from the dermal epidermal junction using a ReCell® kit

Background

The use of non-cultured autologous cells to promote wound healing and in reconstructive procedures is increasing. One common method for preparing these cells is the use of the ReCell^® device. However, despite its current clinical use, no characterisation of the cell suspension produced using a ReCell^® device has been published.

Objective

To characterise the ReCell suspension that is applied to wounds for cell type, viability, yield, stability and proliferative potential.

Methods

The ReCell^® device was used to harvest cells from a 2 cm² piece of split-thickness skin isolated using a dermatome. The resulting cell suspension was analysed for cell yield, cell type, viability over time, proliferative potential and reproducibility.

Results

Average viable cell yield was 1.7 × 10⁶/cm² of tissue, with 75.5% of the total cell isolate viable. Total viable cell number was not significantly reduced after 4 h storage at 22 °C or 4 °C, and was stable for 24 h at 4 °C. Proliferative potential was assessed using a colony forming assay, with 0.3% of viable cells isolated forming keratinocyte colonies. Predominantly the suspension contained keratinocytes (64.3 ± 28.8%) and fibroblasts (30.3 ± 14.0%), with a small population of melanocytes also identified (3.5 ± 0.5%). Finally, the supernatant contained low total protein (0.92 mg/ml) and the supernatant had no significant effects on cell viability or growth when applied ex vivo.

Conclusions

These results suggest the ReCell^® device provides a method for the preparation of a cell suspension with high viability and proliferative potential, containing viable melanocytes and no apparent toxic cell debris. Further work on the sustained viability of these cells in vivo, and in particular after application to the wound, will be important to better understand the potential of the ReCell^® device in the clinic.     

Surgical management of GIST in the era of Gleevec

The diagnostic and treatment options for patients with GIST have evolved rapidly with the discovery of uncontrolled KIT tyrosine kinase and Gleevec that selectively inhibits Kit. Gleevec has already revolutionized the treatment of patients with metastatic disease and is also currently being tested as an adjuvant therapy after the resection of primary GIST. But the majority of responses are limited to partial responses and secondary resistances are emerging. These observations suggest that initial surgical resection remains a vital component of the treatment for patients with primary resectable cKIT+ GISTs and raises the question of secondary surgery after Gleevec. The objective of secondary surgery is to obtain a complete remission when the response to Gleevec is maximum. Surgery should be discussed between 6 and 12 months treatment when no additional improvement is observed on 2 consecutive CT scan. Three subgroups may benefit from secondary surgery: primary unresectable tumors amenable to surgery with Gleevec even in case of complete response, huge necrotic masses before expected complication, local re-progressions. Gleevec should also be discussed when a functionnal benefit can be expected by a tumor size decrease. Surgery is being evaluated in the other responding patients. The majority of responses being limited to partial responses, best indications of surgery are when complete resection may be expected (< 10%).     

Suprathel, a new skin substitute, in the management of donor sites of split-thickness skin grafts: results of a clinical study

OBJECTIVE: A prospective, randomized, two center clinical study was conducted to evaluate the impact on wound healing of Suprathel in donor sites of split-thickness skin grafts. Suprathel represents an absorbable, synthetic wound dressing with properties of natural epithelium. METHODS: 22 burn patients who were treated with split-thickness skin grafts, and with a mean age of 39.6 years were included in the study. Donor sites of skin grafts were randomly selected; partly treated with Jelonet and partly treated with Suprathel. First gauze change was carried out the fifth day postoperatively followed by regular wound inspection until complete re-epithelization. The study focused on patient pain score, healing time, analysis of wound bed, ease of care, and treatment costs. RESULTS: There was no significant difference between the two materials tested regarding healing time and re-epithelization. There was a significantly lower pain score for patients treated with Suprathel (p=0.0002). Suprathel became transparent when applied and allowed close monitoring of wound healing. In contrast to Jelonet, Suprathel showed excellent plasticity with better attachment and adherence to wound surfaces. Throughout the healing process it detached from wounds without damaging the new epithelial surface. In addition, wound areas treated with Suprathel required less frequent dressing changes. It also demonstrated excellent ease of care. This, altogether with the significant pain reduction, presented a positive feedback by patients and healthcare professionals who both rated Suprathel as their treatment preference. Though Jelonet is more cost effective as dressing material, the study revealed an overall reduction in total treatment costs achieved with Suprathel. CONCLUSION: Suprathel represents a solid, reliable epidermal skin substitute with impact on wound healing, patient comfort and ease of care. The material effectiveness contributes to the reduction of overall treatment costs.     

Basement of matrix therapy in regenerative medicine by RGTA(®): From fundamental to plastic surgery

Cells present continuous renewal, permitting permanent regeneration which is called tissue homeostasis. The signaling protein, known as growth factors, cytokines, interleukins and chemokines, but also the extracellular matrix play a key role in the cellular communication. All processes are deregulated after tissue injury, inducing scars. By reconstituting the extracellular matrix, it is possible to avoid the development of scar and to favorize the regeneration of the injured tissue. Glycosaminoglycans, and particularly heparan sulfates, by participating to the extracellular matrix structure, are implicated in cellular communication. This article describes how, by creating heparan sulfate mimetic or Regenerating Agent (RGTA), a French academic team has demonstrated that mammals have the ability to regenerate, by restoring the proper cellular micro-environment. After a first clinical development in two severe and chronic pathologies (corneal and skin ulcers), we show now the potential of these agents in plastic and reconstructive surgery, to regulate fibrosis and to enhance speed and quality of tissue healing.     

Macrolane®: A severe case of calf cellulitis after modeling injection

In recent years, the market for resorbable injectables has been steadily expanding. The European Community's seal of approval (CE) is a sufficient guaranty to get them distributed. These injectables do not require official approval because they are considered to be "implantable medical devices" and not medicines. Macrolane(?)is a hyaluronic acid in gel form (NASHA [non-animal stabilized hyaluronic acid]) and has been on the French market since 2007. It can be injected into all areas except the face. It is highly cross-linked which, while slowing its absorption into the body, can also leave long-lasting residues. We report the first case of cellulitis after injection into the calf by a practitioner in his office.     

Botulinum toxin and the Face Recurve concept: decreasing resting tone and muscular regeneration

This study corroborates that the resting tone is indeed increasing with age. And that like in the Face Recurve concept, the deep fat is expelled superficially because of mimic muscle shortening. Botulinum toxin is therefore described for a new indication: resting tone decrease in order to slow down muscle shortening and consequently structural aging. Injections can be performed very early in the ageing process, when it is only visible in contraction, before the appearance at rest of wrinkle. Precision of the injection is related to the recent determination of motor end plate location in every mimic muscle. Finally, a new possibility for botulinum toxin injection is the blockage of muscular regeneration in order to stabilize the section of the age marker fascicles performed in the Face Recurve concept. This new indication is also useful in reconstructive surgery for treatment of the marginal mandibular lip deformity in patients with chronic unilateral facial palsies.     

Anaplastic thyroid carcinoma: aggressive radical resection and cervical reconstruction. A case report

STUDY AIM: Anaplastic carcinoma of the thyroid is a rare but highly malignant tumor. The goal of this study was to present the case of a patient who underwent a multimodal treatment and to analyze prognosis factors. PATIENT AND METHODS: We present the case of a patient treated in 1996 for an anaplasic thyroid carcinoma with cervical cutaneous invasion. The initial surgical procedure was a total thyroidectomy extended to the anterior cervical skin associated to bilateral neck dissection. The patient underwent a differed reconstruction with musculocutaneous latissimus dorsi flap. Management was then supplemented by radiotherapy and chemotherapy. RESULTS: This patient is free of tumor 9 years after this multimodal management. She does not present any functionary sequela and plastic results of the reconstruction is considered as very satisfactory. CONCLUSION: Anaplastic carcinoma is one of more aggressive neoplasm affecting humans. This case report suggests that multimodality therapy, including surgery, chemotherapy and radiotherapy may offer hope for long-term survival. A musculocutaneous latissimus dorsi flap is a reliable solution to cover this large cervical defect.     

Suprathel-an innovative, resorbable skin substitute for the treatment of burn victims

Autologous split skin grafts are the most reliable method for closing third degree burns. Under this scheme, donor sites as well as second degree burns under conservative treatment, however, would benefit from rapid wound closure. For this treatment, biological as well as synthetic materials are available. For the improvement of these materials, primary goals are pain reduction and easy handling in the absence of biological risk. From a synthetic copolymer mainly based on DL-lactic acid a new skin substitute was developed, marketed as Suprathel. Within the scope of a bicentric study Suprathel was compared versus paraffin gauze intraindividually applied on split skin donor sites. Wound pain was measured on the Visual Pain Analog Scale over a period of 10 days as the critical criterion. Accordingly Suprathel versus Omiderm were compared on second degree burns (degree 2a, partial thickness burns). In both study parts, Suprathel significantly reduced pain. Its easy handling was superior compared to other materials. The Suprathel membrane adhered rapidly to the wound thus protecting against infections and promoting wound healing. No allergic reactions were observed. The ability of the material to resorb ensured pain-free removal after complete healing of the wound.     

Growth hormone and epidermal growth factor together enhance amino acid transport systems B0,+ and A in remnant small intestine after massive enterectomy

BACKGROUND: Sodium-dependent brush-border nutrient transport is decreased 2 weeks after massive enterectomy. This down-regulation is ameliorated by a 1-week infusion of parenteral growth hormone (GH) and epidermal growth factor (EGF) started 1 week after resection. We hypothesize that glutamine (GLN) transport will be enhanced by earlier and longer growth factor infusion, with differential effects on the Na(+)-dependent GLN transport systems A, B(0,+), and B(0)/ASCT2. MATERIALS AND METHODS: New Zealand White rabbits underwent 70% small bowel resection then immediately received parenteral EGF, GH, both EGF and GH, or neither for 2 weeks. Na(+)-dependent 3H-GLN uptake by jejunal and ileal brush-border membrane vesicles was measured and the contribution of systems A, B(0,+), and B(0) was then determined by competitive inhibition. Data were analyzed using one-way analysis of variance. RESULTS: In nonresected animals, the relative contribution of the systems was similar in jejunum (A 9%, B(0,+) 20%, and B(0) 71%) and ileum (A 13%, B(0,+) 27%, and B(0) 60%). Na(+)-dependent GLN uptake was reduced by one half in resected untreated controls, primarily because of decreased B(0) activity. EGF or GH alone did not affect Na(+)-dependent GLN transport, but, as a combination, there was increased uptake in the residual ileum and jejunum by 144% and 150%, respectively, over resected controls (P < 0.05). This was twice that achieved by delayed and shorter-duration combination treatment. This augmentation was a result of a 6.1-8.2-fold increase in system A as well as a 3.8-3.9-fold enhancement of system B(0,+) activity in remnant ileum and jejunum (P < 0.01). CONCLUSIONS: Parenteral EGF and GH, given in combination for 2 weeks immediately after massive enterectomy, synergistically enhance GLN uptake by systems A and B(0,+).     

Growth hormone and epidermal growth factor together enhance amino acid transport systems B(0,+) and A in remnant small intestine after massive enterectomy

BACKGROUND: Sodium-dependent brush border nutrient transport is decreased 2 weeks after massive enterectomy. This downregulation is ameliorated by a 1-week infusion of parenteral growth hormone (GH) and epidermal growth factor (EGF) started 1 week after resection. We hypothesized that glutamine (GLN) transport would be enhanced by earlier and longer growth factor infusion, with differential effects on the Na(+)-dependent GLN transport systems A, B(0,+), and B0/ASCT2. MATERIALS AND METHODS: New Zealand White rabbits underwent 70% small bowel resection then immediately received parenteral EGF, GH, both, or neither for 2 weeks. Na(+)-dependent 3H-GLN uptake by jejunal and ileal brush-border membrane vesicles was measured and the contribution of systems A, B(0,+), and B0 then determined by competitive inhibition. Data were analyzed using one-way analysis of variance. RESULTS: In nonresected animals, the relative contribution of the systems was similar in jejunum (A, 9%, B(0,+), 20%; and B0, 71%) and ileum (A, 13%; B(0,+), 27%; and B0, 60%). Na(+)-dependent GLN uptake was reduced by half in resected, untreated controls, primarily because of decreased B(0) activity. EGF or GH alone did not affect Na(+)-dependent GLN transport, but as a combination, increased uptake in the residual ileum and jejunum by 144% and 150%, respectively, over resected controls (P<0.05). This was twice that achieved by delayed and shorter-duration combination treatment. This augmentation was due to a 6.1- to 8.2-fold increase in system A as well as a 3.8- to 3.9-fold enhancement of system B(0,+) activity in remnant ileum and jejunum (P<0.01). CONCLUSIONS: Parenteral EGF and GH, given in combination for 2 weeks immediately after massive enterectomy, synergistically enhance GLN uptake by systems A and B(0,+).     

Use the hyaluronic acid according to the concept Face Recurve: vacuum technical and interpores technical

Two new applications of the Face Recurve concept to hyaluronic acid injections are: --the vacuum technique, for deep and for retro muscular injections, which is performed to avoid diffusion and increase precision; --the interpore technique for superficial injections, which is performed in the epidermis to macroscopically erase the interpore wrinkle and to decrease the pore diameter.     

Melatonin and vitamin D3 increase TGF-beta1 release and induce growth inhibition in breast cancer cell cultures

BACKGROUND: Evidence has accumulated that 1,25-dihydroxyvitamin D(3) [1,25-(OH)(2)D(3)] is involved in the regulation of the proliferation of breast tumor cells. For complete tumor suppression high hypercalcemic doses of 1,25-(OH)(2)D(3) are needed. The aim of this study was to assess the effect of combined treatment of 1,25-(OH)(2)D(3) at low doses and melatonin (MEL) on the proliferation of estrogen-responsive rat breast cancer cell line RM4. MATERIALS AND METHODS: RM4 cell proliferation was assessed by [3H]thymidine uptake. The presence of TGF-beta(1) in serum-free conditioned medium was determined by inhibition antibody binding assay. RESULTS: In 17-betaE cultured RM4 cells both MEL and 1,25-(OH)(2)D(3) alone and in combination significantly reduced [3H]thymidine incorporation in a dose-related fashion. MEL by itself was ineffective in inhibiting the FCS-cultured RM4 cells, while 1,25-(OH)(2)D(3) strongly inhibited [3H]thymidine incorporation. Meanwhile, MEL increased the sensitivity of the FCS-cultured RM4 cells to 1,25-(OH)(2)D(3) in the combined regimen, from 20- to 100-fold. MEL significantly enhanced the TGF-beta(1) secretion from RM4 cells and vitamin D(3) increased the TGF-beta(1) secretion in a dose-dependent manner, from 2- to 7-fold. Moreover, a further enhancement of the TGF-beta(1) release was obtained with the combined treatment, but only for low 1,25-(OH)(2)D(3) concentrations. The addition of monoclonal anti-TGF-beta(1) antibody to the medium of RM4 cells exposed to vitamin D(3) alone or in combination with MEL increased the [3H]thymidine uptake compared to the correspondent cells cultured without antibody. CONCLUSIONS: Our data point to a potential benefit of combination therapy with 1,25-(OH)(2)D(3) and MEL in the treatment of breast cancer and suggest that the growth inhibition could be related, at least in part, to the enhanced TGF-beta(1) secretion.     

The Holland nail: a universal implant for fractures of the proximal femur and the femoral shaft

OBJECTIVE: To study the possibilities and outcomes for hip and femoral fractures treated with the universal Holland nail((R)). DESIGN: Retrospective study from November 1998 to December 2001. SETTING: Department of Traumatology, Erasmus Medical Centre, Rotterdam. SUBJECTS: 112 patients with 115 fractures of the proximal femur and/or the femoral shaft, due to traumatic causes or to metastatic disease. MAIN OUTCOME MEASURES: Implant possibilities of the Holland nail((R)) and observed complications. RESULTS: 110 patients presented for primary fracture treatment. Two patients were treated secondarily. In three patients, both femora were fractured. Nineteen patients suffered a pathological (impending) fracture. During operation we dealt with 27 minor difficulties. Postoperatively, in 80% of the cases full weight-bearing was allowed. Three patients developed wound infection. In follow-up, 14 patients were lost and two died. The remaining 77 patients (80 fractures) were available for follow-up with regard to fracture healing. Overall consolidation was achieved in 89% of the patients within 12 months. Two patients developed perforation of the femoral head, necessitating removal of the hip screws, and in two patients failure of the nail was seen. Overall, 19 patients needed a non-planned secondary intervention, of which 12 were deemed a minor procedure (e.g. 'dynamisation by distal screw removal'). CONCLUSION: The Holland nail((R)) is technically easy to use for any type of hip and femoral-shaft fracture.     

Immunoreactivity of p27<Superscript>(Kip1)</Superscript>, cyclin D3, and Ki67 in conventional renal cell carcinoma

The goal of the study was to evaluate expression of the cell-cycle regulatory proteins (p27^(Kip1) and cyclin D3) and proliferation marker Ki67 in normal human kidneys and renal cell carcinoma (RCC) tissues. Intensity of the markers’ expression was prospectively studied and compared between normal and RCC tissue samples. Association was analyzed with cancer clinical parameters. p27^(Kip1) was significantly upregulated in normal compared with in RCC samples. Immunoreactivity of the protein negatively correlated with tumor size and was associated with pathological stage and grade. Patients with symptomatic disease had significantly less marker expression than those with incidentally discovered tumors. Intensity of Ki67 staining positively correlated with primary tumor size and associated with disease stage and grade. Cyclin D3 immunoreactivity positively correlated with tumor size. Loss of p27^(Kip1) expression, pathological stage, grade, and tumor size were risk factors for disease recurrence (P = 0.0072, 0.0011, and 0.0467, and P < 0.0001, respectively) and patient death (P = 0.0021, 0.0106, 0.0151, and 0.0021, respectively). With Cox multivariate analysis loss of p27^(Kip1) expression (hazard ratio 9.3, P = 0.002) and tumor size (hazard ratio 5.9, P = 0.015) were the predictors of cancer-specific survival. In conclusion, intensity of the markers’ expression in RCC is associated with tumour clinical parameters (size, stage, grade, and disease presentation type). Loss of p27^(Kip1) expression is a risk factor for the disease recurrence and cancer-related patient death.     

Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature

For operative treatment of unstable trochanteric fractures two options exist: extramedullary or intramedullary stabilisation. A review of 18 international papers that compared two different treatment methods for trochanteric fractures, in prospective randomised clinical trials, is presented. In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. For these fractures one of the sliding hip screw systems provides a safe and simple alternative. For unstable fractures intramedullary implants are (biomechanically) superior. The review shows that clinical advantages of both treatment methods are suggested and advocated, but still remain to be demonstrated on evidence base.     

Comparison of Emla cream and topical lidocaine tape for pain relief of V-beam laser treatment

The authors compared the analgesic effects of two topical applications; Emla^® cream (Sato Pharmaceutical Co. Ltd., Tokyo, Japan) and 60% lidocaine tape (Penles^® tape; Maruho, Osaka, Japan). The authors examined 20 outpatients with capillary malformations. Emla^® cream or Penles^® tape was applied 1?h before laser irradiation using V-Beam. After V-Beam irradiation, pain intensity was measured using Pain Vision^® (NIPRO, Osaka, Japan), while subjective pain was converted into numerical values using the VAS system. In the assessment using Pain Vision^®, pain was significantly lower in patients who received Emla^® cream (Welch test), whereas no difference was observed in VAS ratings between the two applications (student’s t test). The objective system showed that Emla^® cream had a significantly greater analgesic effect. We plan to evaluate the analgesic effects of these topical anesthetics by applying them to other anatomical areas.