Surgical Management of Hidradenitis Suppurativa: Factors Associated with Postoperative Complications and Disease Recurrence.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder. Treatment of HS remains challenging, and surgical procedures commonly follow attempts of conservative therapy. To date, a consensus regarding the optimal surgical technique has not been reached, and the implications of conservative therapy on future surgical outcomes have yet to be studied. Methods: A retrospective cohort study of 65 patients surgically treated for HS at a tertiary care center was conducted. Patients' medical records were screened for demographical, clinical, and surgical characteristics. Statistical analysis was conducted to determine associations with postoperative complications and disease recurrence. Results: Fifty patients (75.8%) were treated with systemic antibiotics before opting for surgical resection. Previous treatment with systemic rifampicin was associated with higher rates of postoperative complications (P = 0.029); however, systemic cephalexin and topical clindamycin were associated with a lower rate of complications (P = 0.007 and 0.040, accordingly). Medical history of smoking and surgical management with split-thickness skin grafts were associated with higher rates of postoperative complications (P = 0.012 and 0.014, accordingly). Patients with a greater number of lesions, and those treated with split-thickness skin graft, had higher rates of disease recurrence (P = 0.0018 and 0.003, accordingly).In a multivariate analysis a greater number of lesions (P = 0.0498) and the use of autologous split-thickness skin graft (P = 0.022) were independently associated with higher rates of disease recurrence. Conclusions: Previous conservative medical therapy bears the potential to modulate postoperative outcomes in HS patients, and should be taken into consideration. Despite reports of reliable results with split-thickness skin grafts, we found them to be associated with increased rates of diseases recurrence and postoperative complications.

Surgical Technique for Nasal Cleft Repair.

BACKGROUND: Congenital nasal cleft is a very rare yet challenging deformity to reconstruct. Atypical craniofacial clefts that involve the nasal ala are designated as number 1 and number 2 under the Tessier classification system. These clefts typically present as notches in the medial one-third of either nasal ala and may be accompanied by a malpositioned cartilaginous framework. Nasal clefts are smaller and far less common than familiar clefts of the lip and palate, but they pose equally challenging reconstructive planning. METHODS: Our described technique relies on usage of existing nasal tissue near the cleft. Local tissue rearrangement using a laterally based rotational alar flap, a medially based triangular flap, and a nasal wall advancement flap restores normal anatomy and provides an aesthetically pleasing result. RESULTS: Five children with isolated nasal cleft were treated by the senior author (A.M.) between 2010 and 2017. All patients presented with clefts of the soft tissue with no underlying cartilaginous involvement. There were no postoperative complications. Excellent aesthetic outcome was achieved in all patients. CONCLUSION: Isolated nasal cleft can be properly corrected with the described procedure in a single stage and with optimal result.

Complications of Post-Burn Tissue Expansion Reconstruction: 9 Years Experience with 42 Pediatric and 26 Adult Patients.

BACKGROUND: Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within the arsenal of tools at the plastic surgeon's disposal, tissue expansion provides an efficient modality for reconstruction despite the reported complication rates. OBJECTIVES: To critically review our experience with tissue expansion for burn scar reconstruction, comparing particularly the adult and pediatric populations. METHODS: We conducted a retrospective study of the outcomes of patients who underwent burn scar reconstruction with tissue expansion at Hadassah Medical Center between January 2003 and July 2012. The data included patient age, anatomical site of expansion, number of procedures, and associated complications. The outcomes of the above-mentioned populations were also compared with those in a control group of patients undergoing reconstruction with tissue expansion for indications other than burn scars. RESULTS: Sixty-seven tissue expansion procedures were carried out in 50 patients, 42 in the pediatric population (< 16 years of age) and 25 in the adult population. Complications were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference was found to be statistically significant. When the complication rate for each population was compared to its control group (tissue expansion for indications other than burn scar reconstruction, such as reconstruction for motor vehicle accident scarring, congenital nevi, or vascular malformations), no statistically significant difference was found between them (complication rates 19.8% and 12.5%, respectively). Furthermore, there was no statistically significant difference in complication rates between the different anatomical areas of expansion within both populations undergoing burn scar reconstruction. Most of the complicated cases completed successful reconstruction. CONCLUSIONS: Tissue expansion is a useful surgical tool in post-burn scar reconstruction, both in the adult and pediatric populations and in all anatomic sites, despite consistently high complication rates, especially in the pediatric population. This complication rate is not higher than in patients undergoing tissue expansion for indications other than burn scar reconstruction.

Strabismus and mental disorders among Israeli adolescents.

PURPOSE: To assess the association between strabismus and mental disorders in adolescents. METHODS: This case-control study included 662,641 Israeli teenagers that underwent medical evaluation by the Israel Defense Force as part of the preconscription assessment between 2005 and 2013. The association between common mental disorders (anxiety disorder, mood disorder, adjustment disorder, and attention deficit hyperactivity disorder [ADHD]) and either uncorrected strabismus or corrected strabismus was examined. The association with strabismus correction was assessed by the differences between the corrected and uncorrected groups. RESULTS: The mean age at the time of the examination was 17.3 ± 0.53 years, with a male predominance (59%). A total of 1,598 subjects (0.24%) had strabismus. Of those, 952 (60%) underwent successful correction and 646 (40%) did not undergo successful correction. A significant association was found between uncorrected strabismus and anxiety disorders (OR = 1.91; 95% CI = 1.02-3.57; P = 0.047) and between corrected strabismus and ADHD (OR = 2.62; 95% CI = 1.18-5.87; P = 0.03). Strabismus correction (as assessed by comparing the uncorrected and corrected strabismus groups) was not significantly associated with the mental disorders we examined, but a nearly statistically significant association with anxiety disorder was observed (OR = 2.978; 95% CI, 1.013-8.754; P = 0.06). CONCLUSIONS: The evidence from our cohort suggests that strabismus correction, even in the absence of visual impairment, is not associated with mental disorders examined in this study.

Expanded bi-pedicled "sleeve" flap for reconstruction of the upper extremity after large circumferential nevus excision in children.

BACKGROUND: Large congenital melanocytic nevi entail significant medical and cosmetic ramifications for patients and families. Reconstruction is a challenging endeavor, especially when the lesion is present on the limbs. The literature describes various methods by which a plastic surgeon can address reconstruction; yet, to date, there has been no series describing a method that provides consistent results with low complication rates. In this study, we describe our surgical technique for reconstruction of the upper extremity after excision of large circumferential CNM with a pre-expanded bi-pedicled flap, namely the "sleeve" flap. METHODS: A systematic review of our database of pediatric patients treated for large and giant nevi was performed. Patients with large and giant circumferential upper extremity nevi were retrieved, and their charts reviewed for demographics, number of procedures performed, duration of follow-up, and complications. RESULTS: Over a course of 12 years, eight patients with large or giant circumferential nevi of the upper extremity were treated at our institution with "sleeve" flap reconstruction. Mean follow-up time was 36 months. A single complication was seen. All reconstructions achieved satisfactory results, both functionally and cosmetically. DISCUSSION: We describe our surgical approach for treating upper extremity large and giant circumferential nevi with pre-expanded bi-pedicled "sleeve" flaps. When properly planned and executed, this technique enables successful treatment of large and giant nevi of the arm and the forearm. Although arduous and complex, the process yields excellent aesthetic results with low complication rates. This technique is promising as the reconstructive option of choice for these difficult lesions.

Relationship between anxiety and medical disorders among compulsory military service candidates between the years 1998-2013.

One of the most common psychiatric diagnoses among adolescents is anxiety disorder. Many of the anxiety symptoms are expressed physiologically, and therefore can mimic other medical conditions. The aim of this study was to examine the association between anxiety disorders and other medical conditions sharing common symptoms with anxiety (MDSCSA: Irritable Bowel Syndrome, asthma, migraine and hyperhidrosis). The study was based on the national database of the candidates for military service in Israel. Data for the years 1998-2013 was retrieved to create the study dataset. The final cohort population was comprised of 1,229,461 military service candidates. Anxiety prevalence and its association with other medical conditions sharing the same symptoms was examined in the cohort. The results showed significant statistical association between anxiety and IBS, asthma, migraine and hyperhidrosis. These findings support the fact that there is a clear association between anxiety disorder and the examined medical conditions. Moreover, in the military setting, the primary care physician has an important role in giving a correct diagnosis for soldiers presenting with symptoms that can be regarded both to anxiety and to other physical illnesses.

Complications of nonbreast tissue expansion: 9 Years experience with 44 adult patients and 119 pediatric patients.

BACKGROUND: Tissue expansion is a common reconstructive technique that has been associated with significant complications since its inception. However, the existing literature mostly focuses on complications associated with pediatric tissue expansion only or describes a combined population of adult and pediatric patients, including breast tissue expansion; despite the fact that each of these groups of patients has different characteristics that may affect tissue expansion. OBJECTIVE: In this study we present a critical review of our experience with complications of nonbreast tissue expansion in adult and pediatric patients and compare between these groups. METHODS: The charts of patients who underwent nonbreast tissue expansion at Hadassah Medical Center between January 2003 and July 2012 were reviewed. Data were collected including the age of the patient, anatomical site of the expansion, indication and complications. RESULTS: A total of 202 expansion procedures were performed on 119 pediatric patients (<16 years) and 56 expansion procedures on 44 adult patients. The overall complication rate was 18.2%, with 40 pediatric procedures having complications (19.8%) and 7 adult procedures (12.5%). The difference in complication rates between the two groups was not found to be statistically significant. There was no statistically significant difference in complication rate between the different anatomical areas of expansion in both adult and pediatric patients or between the indications for operation. Most (68%) of the cases with complications underwent subsequent successful reconstruction. CONCLUSIONS: Despite the consistent high complication rate, tissue expansion can be used as a good reconstructive method in both adult and pediatric patients in all anatomic areas and for different indications.

Periorbital reconstruction with the expanded pedicled forehead flap.

BACKGROUND: The complexity of structures within the periorbital region makes reconstruction of this area particularly a challenging endeavor. Within the literature, different techniques have been described for reconstruction of the external lamellae of the upper and lower eyelids as well as the medial and lateral canthal regions.Herein, we present the expanded pedicled forehead flap as a versatile and useful surgical option for reconstruction of various defects around the eye globe. PATIENTS AND METHODS: A tissue expander is inserted underneath the forehead skin and serially expanded. The pedicle of the expanded pedicled flap is designed either from the superior portion of the expanded skin and interpolated to reconstruct the upper and lower eyelids, and the medial or lateral canthal areas; or from the inferior portion of the expanded skin and interpolated over the eyebrow to reconstruct the area between the upper eyelid crease and eyebrow.Fifteen patients with periorbital nevi or severe scarring were treated using the expanded forehead flap between the years 2003 and 2012. Thirteen patients had complex periorbital defects involving multiple anatomic areas, and 2 patients had defects confined to the upper eyelid area only. RESULTS: Operative and postoperative course for 13 patients was uneventful. One patient had a late infection of the tissue expander but nonetheless continued with the reconstructive process. In 1 patient, the tissue expander was removed due to infection, and subsequent reconstruction was not carried out. The aesthetic and functional results of reconstruction were very good, and with excellent skin color and thickness match. In 1 patient, the flap was defattened in an ancillary procedure. No partial or complete flap loss was observed in this study. SUMMARY: We conclude that the expanded pedicled forehead flap is a safe and reliable method for reconstruction of different segments of the periorbital region, while providing good aesthetic and functional reconstructive results with minimal donor-site morbidity.

The role of free tissue transfer in posterior neck reconstruction.

Reconstruction of the posterior neck is one of the rarer procedures performed by plastic surgeons; we used free flaps for the closure of defects in this area in six cases over the past 4 years. Six patients were located requiring posterior neck reconstruction between the years 2007 and 2013. Five of these patients required reconstruction due to oncologic resections, while one underwent serial removal of a giant congenital nevus. Five of these reconstructions involved the use of a free anterolateral thigh/vastus lateralis flap, and the sixth received a pre-expanded deep inferior epigastric perforator flap. Satisfactory dorsal neck reconstruction was achieved with the free flap approach: it produced excellent healing, contour and coverage of hardware. There was only one early minor complication, allowing early return to daily activities and continuation of planned oncologic treatment. Free flap reconstruction of the posterior neck area is a safe and relatively rapidly performed procedure that yields good results both functionally and aesthetically. In this article, we review the literature on the options available for reconstruction of the posterior neck, describe our surgical experience in such cases, and suggest an algorithm to guide in choosing the optimal approach for a given patient.

Changes of PI3K/AKT/BCL2 signaling proteins in congenital Giant Nevi: melanocytes contribute to their increased survival and integrity.

Congenital Giant Nevi (CGN) are rare melanocytic lesions with the potential to regress into malignant melanoma. Simultaneous up-regulation and cooperative interactions of signaling pathways are crucial events in the pathogenesis of melanocytes. Our study aimed to identify changes in the expression and activation of proteins controlling survival and/or apoptosis of the key signaling pathways PI3K/AKT/BCL2 and Wnt/ß-catenin of CGN melanocytes. We applied a model of cultured melanocytes from paired CGN and normal appearing skin, and Western blot (WB) analyzed the expression and activation profile of survival and anti-apoptotic proteins of these signaling pathways, growth pattern, cell cycle and apoptosis. WB analysis demonstrated a significant higher expression level of activated AKT and of BCL2 proteins in the CGN melanocytes compared with paired melanocytes from normal appearing skin. A relative increase in the level of GSK3 and FOXO1 proteins, down stream targets of AKT, as well as of pß-catenin was also detected in the CGN melanocytes compared with the controls. These changes were not affected by growth of the CGN melanocytes in reduced serum (starvation). Both cell populations shared a similar growth pattern, with no significant differences in the proportion of apoptotic cells and in cell cycle fractions. These data demonstrate for the first time, changes in signaling proteins of cultured CGN melanocytes. Further, suggesting that the changes in AKT/BCL2 signaling molecules might mediate growth and anti-apoptosis processes at least in part, thus increasing the survival potential of CGN melanocytes and maintaining their integrity.

Dorsal augmentation with diced cartilage enclosed with temporal fascia in secondary endonasal rhinoplasty.

BACKGROUND: Placement of diced cartilage enclosed within an autologous fascia sleeve (DC-F) for nasal dorsum reconstruction is common in open rhinoplasty, but there are no data regarding its use in closed rhinoplasty (the endonasal approach). OBJECTIVES: The authors describe a technique for augmenting the nasal dorsum in secondary rhinoplasty with DC-F grafts via an endonasal approach. METHODS: In this study, the authors retrospectively review the cases of 18 patients who underwent closed rhinoplasty with the authors' technique between 2008 and 2011. Cartilage harvested from the septum, rib, or concha was diced into 0.5- to 1-mm cubes. A rectangle of deep temporal fascia (approximately 5 × 5 cm) was harvested by means of a single V-shaped incision overlying the temporal fossa, then wrapped around another 1-mL syringe and secured. The fascial cylinder was filled with the desired amount of diced cartilage and then sutured closed at both ends. This graft was placed into the dorsum of the nose via the endonasal approach. RESULTS: Average age of the patients was 32 years. The patients were followed for a minimum of 15 months. Donor site for cartilage harvest was conchal in 8 patients, septal and conchal in 6 cases, and costal in 4. Complications were encountered in 3 patients, only 1 of whom required surgical revision for contour irregularity. No resorption of cartilage was encountered in any patient after 15 months. Smooth continuity of the nasal dorsum was achieved in all our patients. CONCLUSIONS: Despite the lack of a large volume of patients for overwhelming and conclusive results, our study provides further confirmation that this technique is indeed an attractive option for nasal dorsum reconstruction.

Imaging of patients after the Lap-Band System application.

OBJECTIVE: We describe the use of imaging in the management of adjustable gastric-banding patients, and describe complications of banding that are diagnosed by imaging. MATERIALS & METHODS: Using a four-year period as an example of complications of this type of laparoscopic approach, we have retrospectively identified all patients with laparoscopic bands who were imaged in the radiology department at our large multispecialty hospital. Included are patients who had their bands placed by the hospital's surgeons as well as patients referred for consultation from other practices. RESULTS: Twenty-two of 165 patients who had banding as their sole weight loss surgery had 23 complications diagnosed by imaging. Complications included band slip (3), device issues (4), esophageal dilation (8), esophageal dysmotility (5), symptomatic gallstones (2) and a gastroesphageal diverticulum (1). Complications were detected by fluoroscopy (17), CT (4) or ultrasound (2). 17 patients had banding as one of multiple bariatric surgeries, with 13 complications: band slip (4), port infection (1), esophageal dilation (1), esophageal dysmotility (5), anastomotic leak (1) and internal hernia (2). Complications were detected with fluoroscopy (12) and CT (1). CONCLUSIONS: Fluoroscopy is generally the primary imaging modality used to diagnose complications of gastric banding. Esophageal dilation and dysmotility, which appear to be long-term sequelae of banding, were the most common complications identified by imaging.