Reevaluation of the arterial blood supply of the auricle

The anatomical basis for auricular flaps used in multiple aesthetic and reconstructive procedures is currently based on a random distribution of the underlying arterial network. However, recent findings reveal a systematic pattern as opposed to the present concepts. Therefore, we designed this study to assess the arterial vascular pattern of the auricle in order to provide reliable data about the vascular map required for surgical interventions. Sixteen human auricles from eight body donors (five females/three males, 84.33 ± 9.0 years) were investigated using the unique 'Spalteholz' method. After arterial injection of silicone, a complete transparency of the tissue was achieved and the auricular arteries and branches were visible. Qualitative and quantitative evaluation of the arterial vascular pattern was performed. The superior and the inferior anterior auricular artery provided the vascular supply to the helical rim, forming an arcade, i.e. helical rim arcade. On the superior third of the helical rim another arcade was confirmed between the superior anterior auricular artery and the posterior auricular artery (PAA), i.e. the helical arcade. The perforators of the PAA were identified lying in a vertical line 1 cm posterior to the tragus, supplying the concha, inferior crus, triangular fossa, antihelix and the earlobe. The results of this study confirmed the constant presence of the helical rim arcade (Zilinsky-Cotofana), consistent perforating branches of the PAA, and the helical arcade (Erdman), and will help and guide physicians performing auricular surgeries toward fast and simple procedures with optimal patient satisfaction.

Silicone-based scar therapy: a review of the literature

Hypertrophic and keloid scars still are among the banes of plastic surgery. In the treatment arsenal at the disposal of the plastic surgeon, topical silicone therapy usually is considered the first line of treatment or as an adjuvant to other treatment methods. Yet, knowledge concerning its mechanisms of action, clinical efficacy, and possible adverse effects is rather obscure and sometimes conflicting. This review briefly summarizes the existing literature regarding the silicone elastomer's mechanism of action on scars, the clinical trials regarding its efficacy, a description of some controversial points and contradicting evidence, and possible adverse effects of this treatment method. Topical silicone therapy probably will continue to be the preferred first-line treatment for hypertrophic scars due to its availability, price, ease of application, lack of serious adverse effects, and relative efficacy. Hopefully, future randomized clinical trials will help to clarify its exact clinical efficacy and appropriate treatment protocols to optimize treatment results.

A new modality in the treatment of actinic cheilitis using the Er:YAG laser

BACKGROUND

Cheilitis is a precancerous skin lesion most often affecting the lower lip. We describe a technique in which this disorder can be treated using Er:YAG laser vaporization. The Er:YAG laser wavelength at 2940 nm lies in a very strong water absorption peak; tissue interaction results mainly in vaporization with minimal heat conduction to adjacent tissue.

OBJECTIVE

To evaluate the efficacy and outcome of a new modality in the treatment of actinic cheilitis with the Er:YAG laser.

METHODS

Between 2002 and 2005, 12 patients with actinic cheilitis were treated at our institute with the Er:YAG laser. All patients were cured with no recurrence to date, and none suffered postoperative complications.

RESULTS

Patients were men and women aged between 37 and 71 years. The healing duration varied from 7 to 30 days (mean 22.33+/-6.91 days) and the follow-up ranged from 8 months to 3 years (mean 23.16+/-9.48 months). No recurrences were detected in our study.

CONCLUSION

Using the Er:YAG laser provides accurate tissue ablation, giving a very satisfactory cosmetic result, with a short healing period, no lip deformity and no sensation loss.

Treatment of postdermabrasion facial hypertrophic and keloid scars with intralesional 5-Fluorouracil injections

Hypertrophic and keloid scarring is a known complication of dermabrasion facial resurfacing, although only a very small fraction of patients experience it. Treatment with intralesional corticosteroid injections and flashed pumped vascular dye laser is recommended in the literature. The treatment of keloid and hypertrophic scars using intralesional 5-fluorouracil (5-FU) injections has been well described, but there is no literature regarding use of the same treatment for postdermabrasion hypertrophic and keloid scars. In this case report, we describe a 67-year-old woman with persistent postdermabrasion facial hypertrophic and keloid scars that were treated at our scar clinic using intralesional 5-FU injections.

Evading a surgical pitfall: mastopexy--augmentation made simple

Many women have a dwindled ptotic breast. The surgical solution for these two concurring problems has two separate procedures: augmentation and mastopexy. Combining these two procedure into one surgery is considered unpredictable and avoided by many physicians. This study presents a revised mastopexy-augmentation technique found to be safer and more simple, enabling these two procedures to be performed together. A retrospective review of 60 patients who underwent surgery by a single surgeon is presented. The presented method has yielded a relatively low reoperation rate of 10% and a high satisfaction rate.

A comparison between CO2laser surgery with and without lateral fold vaporization for ingrowing toenails

BACKGROUND

An ingrowing toenail is an excessive lateral nail growth into the nail fold. It acts as a foreign body and exerts a local pressure sore-like effect, which may result in inflammation and granulation. Several treatment modalities exist, including chemical ablation and different surgical procedures. Here we describe and compare a simple and effective method of partial matricectomy using the CO2 laser (group A) versus a similar method with the addition of lateral nail fold vaporization (group B).

OBJECTIVE

Outcome evaluation of a modified laser treatment modality for ingrowing toenails and determination of the role of lateral fold vaporization in reducing the recurrence of symptoms.

METHODS

Forty patients (mean age 32.45 years) were treated with CO2 laser ablation of toenails between 1999 and 2005 by four physicians. One physician implemented a method that includes lateral nail fold vaporization and resection of the nail segment with its nail bed from 1999 to 2005. Three physicians implemented a similar technique but without lateral fold vaporization between 1999 and 2003, and added lateral fold vaporization to the performed procedure starting in 2004.

RESULTS

The recurrence rate was 37.5% in group A and 6.2% in group B. The overall average disease-free follow-up period was 42.2 months.

CONCLUSION

The use of CO2 laser in the treatment of ingrowing toenails offers an effective modality. We demonstrate the importance of lateral fold vaporization with the CO2 laser both in improving efficacy and in decreasing recurrence rates over a long follow-up period.

Third generation cellular multimedia teleconsultations in plastic surgery

We conducted a study to test whether new third generation (3G) mobile phones could be integrated into service as a working tool between plastic surgeons. During an eight-month period, 58 multimedia consultations were performed involving 57 patients. The majority of the consultations were for trauma or wounds. All consultations comprised a digital photograph taken with the integrated camera and sent via the Multimedia Messaging Service (MMS). In 86% of the cases the residents reported that multimedia information contributed to their ability to independently handle similar cases in future. Satisfaction scores were high among all participants. We believe that a multimedia consultation in a hospital setting adds information to an ordinary telephone call, thus decreasing medico-legal risks. We recommend it for routine use.

Increased serum NKG2D-ligands and downregulation of NKG2D in peripheral blood NK cells of patients with major burns

Immune suppression following major thermal injury directly impacts the recovery potential. Limited data from past reports indicate that natural killer cells might be suppressed due to a putative soluble factor that has remained elusive up to date. Here we comparatively study cohorts of patients with Major and Non-Major Burns as well as healthy donors. MICB and ULBP1 are stress ligands of NKG2D that can be induced by heat stress. Remarkably, serum concentration levels of MICB and ULBP1 are increased by 3-fold and 20-fold, respectively, already within 24h post major thermal injury, and are maintained high for 28 days. In contrast, milder thermal injuries do not similarly enhance the serum levels of MICB and ULBP1. This kinetics coincides with a significant downregulation of NKG2D expression among peripheral blood NK cells. Downregulation of NKG2D by high concentration of soluble MICB occurs in cancer patients and during normal pregnancy due to over production by cancer cells or extravillous trophoblasts, respectively, as an active immune-evasion mechanism. In burn patients this seems an incidental outcome of extensive thermal injury, leading to reduced NKG2D expression. Enhanced susceptibility of these patients to opportunistic viral infections, particularly herpes viruses, could be explained by the reduced NKG2D expression. Further studies are warranted for translation into innovative diagnostic or therapeutic technologies.

Silicone nipple shields: an innovative postoperative dressing technique after nipple reconstruction

BACKGROUND

The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable.

METHODS

In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure.

RESULTS

No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments.

DISCUSSION

Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate.

Examining disaster planning models for large scale burn incidents--a theoretical plane crash into a high rise building

BACKGROUND

The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters.

METHODS

Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01.

RESULTS

Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario.

CONCLUSION

Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities.

Post-facelift flap necrosis treatment using charged polystyrene microspheres

BACKGROUND

Flap necrosis following facial rhytidectomy constitutes a vexing and grievous complication to the patient and the surgeon. Treatment modalities that can expedite wound healing and re-epithelialization rates are highly desired.

OBJECTIVES

To assess wound healing and re-epithelialization rates of open wounds following postrhytidectomy flap necrosis treated with commercially available charged polystyrene microspheres (Polyheal-1, Polyheal Ltd, Israel).

METHODS

Flap necrosis following rhytidectomy with open wounds in three female patients were treated using dressings soaked with Polyheal-1. Wound closure rates were documented.

RESULTS

The wounds demonstrated both accelerated granulation tissue formation and rapid re-epithelialization rates. No complications or side effects were encountered.

CONCLUSIONS

Charged polystyrene microspheres may offer a new and efficacious way to treat open wounds due to flap necrosis following facial rhytidectomy. Further research with larger patient numbers is still needed to verify these findings.

Simple continuous suture versus continuous horizontal mattress suture for plication of abdominal fascia: which is better?

BACKGROUND

Abdominal fascia plication using a simple continuous suture can sometimes cause tears in the fascia. This problem can be circumvented when the continuous horizontal mattress suture is used. No data exist from comparing the two suturing techniques. The aim of this study was to examine which technique can potentially cause greater tissue damage. The time required to perform each type of suture was also recorded.

METHODS

Wound closure pads were plicated using the simple continuous and continuous horizontal mattress techniques performed by a single operator using Ethilon 2-0 nylon sutures. To verify their resilience, plastic bags were inflated beneath the pads to 30, 60, and 120 mmHg and tears were recorded. The time needed to perform the procedures was recorded using a stopwatch.

RESULTS

Mean time for the continuous vertical mattress suture was 87 s and for the simple continuous suture 116 s. Tears in the pad that was plicated with the simple continuous pattern were significantly longer than those in the pad plicated with the continuous horizontal mattress pattern (fissure mean length ± SD = 3.958 ± 0.157 vs. 2.736 ± 0.157, respectively, p < 0.001). This finding was true for each of the three measured pressures (fissure mean length for 30 mmHg was 3.40 ± 1.807 vs. 2.12 ± 1.709 cm; for 60 mmHg, 3.94 ± 2.90 vs. 2.90 ± 1.893 cm; and for 120 mmHg, 4.54 ± 1.924 vs. 3.19 ± 2.110 cm; p < 0.001).

CONCLUSIONS

Continuous horizontal mattress pattern sutures were found to be superior to simple continuous pattern sutures in the suggested model, in terms of suturing time and damage to the pad. Further research in human subjects is still required.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article.

An Improvised "Blow Glove" Device Produces Similar PEP Values to a Commercial PEP Device: An Experimental Study

BACKGROUND

Postoperative positive expiratory pressure (PEP) therapy promotes increased lung volume, secretion clearance, and improved oxygenation. Several commercial devices exist that produce recommended PEP values (10-20 cmH2O) when the patient breathes through a fixed orifice resistor. It was hypothesized that an inexpensive, improvised "blow glove" device would produce similar PEP values over a wider range of expiration volumes and flow rates.

METHODS

PEP for different expiration volumes (400-2000 mL) and expiratory flow rates (10-80 L/min) was compared between a commercial PEP device (Resistex, Mercury Medical, Clearwater, FL) and an improvised "blow glove" device, recorded by a Vela ventilator (CareFusion, San Diego, CA). Dynamics in positive end expiratory pressure (PEEP) values were evaluated following five consecutive expirations. The "blow glove" device was evaluated using various glove compositions and sizes.

RESULTS

The improvised "blow glove" device produced a significantly higher rate of PEP values in the recommended range than the Resistex device (88.9% vs. 20%, p<0.0001). No significant difference was observed between small and large glove sizes (88.9% vs. 82.9%, p>0.05), but the powdered latex glove showed a significantly higher rate of PEP values in the recommended range than the powder-free latex glove (88.9% vs. 44.4%, p<0.001).

CONCLUSIONS

A "blow glove" PEP device using a powdered latex glove produces PEP values in the recommended range over a wider spectrum of expiratory flow rates and expiration volumes than a commercial PEP device.

Distant blunt forceps dissection in tissue expander insertion: a novel technique

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

Complex forehead defects: a novel reconstructive technique and review of available methods

Complex forehead defects may result from excision of tumors or trauma. The reconstructive challenge is determined by the extent of tissue loss, the quality of the remaining tissue, possibly comprised vascular supply to the affected region, and special considerations (eg, exposed bone or injury to underlying structures). This paper describes a novel reconstructive approach to correct a complex forehead defect with exposed bone and discusses the armamentarium of reconstructive options for such cases.

Distant blunt forceps dissection in tissue expander insertion: A novel technique

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

Characteristics of Improvised Explosive Device Trauma Casualties in the Gaza Strip and Other Combat Regions: The Israeli Experience

OBJECTIVE

Low-intensity conflict is characterized in asymmetrical conventional and nonconventional warfare. The use of improvised explosive devices (IEDs) in the Israeli-Palestinian conflict has evolved over the past few decades to include the addition of diesel, biological agents, shrapnel, and nitroglycerin to the explosive content. Due to its nature and mechanism, an IED injury might present as a multidimensional injury, impairing numerous systems and organs.

MATERIALS AND METHODS

The authors present a case series of 5 Israeli Defense Forces (IDF) soldiers wounded by an IED presenting a typical and similar pattern of burns to their faces, trunks, and limbs, in addition to ocular, ear/nose/throat, and orthopedic injuries. An analysis of the experience in treating the aforementioned injuries is included.

RESULTS

Improvement in casualties' burns and traumatic tattoos was observed following debridement, aggressive scrubbing with or without dermabrasion, and conservative local dressing treatment protocol. The authors found a positive correlation between improvement degree and treatment timing. Injury pattern was correlative to the protective gear worn by the soldiers. Wearing protective eye gear and wearing ceramic vests can diminish the extent of IED injuries, while creating typical patterns of injuries to be treated.

CONCLUSION

Based on these experiences, such injuries should be brought to a trauma center as soon as possible. Treating multidimensional trauma should be done in a facility with abilities to treat head injuries, eye injuries, penetrating injuries, blast injuries, and burns. Such specialized disciplines and facilities that have past experience with IEDs and war injuries are able to assess and treat these injuries in a more dedicated manner, resulting in better long-term rehabilitation.

Reconstruction of a lower eyelid defect with a V to Y island flap

Repair of full thickness defects in the lower eyelid following extirpation of malignant tumors presents a challenge to the reconstructive surgeon. There are several techniques to choose from, depending on the defect's size and location.