Keloid Intralesional Excision Reduces Recurrence: A Meta-analytic Study of the Available Literature on 608 Keloids.

Background: The objective of this meta-analysis was to examine the effectiveness of keloid intralesional excision (KILE) in preventing recurrence. Treatment of keloids using surgical excision alone leads to high rates of recurrence. To date, there are no widely accepted guidelines for keloid treatment, and a multitude of adjunctive therapies are used to reduce recurrence. Despite these efforts, recurrence remains high. In this study, we conducted a meta-analysis of the existing literature on KILE to determine its role in recurrence reduction. Methods: A literature review using PubMed, Scopus, and Web of Science databases was performed. Two authors independently evaluated studies for eligibility. Incidence of keloid recurrence was recorded, and a comprehensive meta-analysis was performed to assess the pooled keloid recurrence rate, as well as the effect of additional therapies. Results: Twenty-two studies evaluating intralesional excision of 608 keloids were included in the study. Average time to follow-up was 19.2 months (range 6-35 months). A meta-analysis of proportions was conducted, demonstrating a pooled recurrence rate of 13% (95% confidence interval, 9%-16%). There was no evidence that using therapies in addition to KILE had a significant effect on the overall pooled recurrence rate. Conclusions: A meta-analysis of 608 keloids shows that KILE is an effective technique in preventing keloid recurrence, with a pooled recurrence rate of 13% compared with previously reported rates of 45%-100% after complete excision. Although there are no standard guidelines for keloid treatment, our meta-analysis shows that KILE is promising in recurrence reduction.

A Review of Meta-Analyses in Plastic Surgery: Need for Adequate Assessment of Publication Bias.

INTRODUCTION: Publication bias describes a phenomenon in which significant positive results have a higher likelihood of being published compared to negative or nonsignificant results. Publication bias can confound the estimated therapeutic effect in meta-analyses and needs to be adequately assessed in the surgical literature. METHODS: A review of meta-analyses published in five plastic surgery journals from 2002 to 2022 was conducted. The inclusion criteria for meta-analyses were factors that demonstrated an obligation to assess publication bias, such as interventions with comparable treatment groups and enough power for statistical analysis. Acknowledgment of publication bias risk, quality of bias assessment, methods used in assessment, and individual article factors were analyzed. RESULTS: 318 unique meta-analyses were identified in literature search, and after full-text reviews, 143 met the inclusion criteria for obligation to assess publication bias. 64% of eligible meta-analyses acknowledged the confounding potential of publication bias, and only 46% conducted a formal assessment. Of those who conducted an assessment, 49% used subjective inspection of funnel plots alone, while 47% used any statistical testing in analysis. Overall, only 9/143 (6.3%) assessed publication bias and attempted to correct for its effect. Journals with a higher average impact factor were associated with mention and assessment of publication bias, but more recent publication year and higher number of primary articles analyzed were not. CONCLUSIONS: This review identified low rates of proper publication bias assessment in meta-analyses published in five major plastic surgery journals. Assessment of publication bias using objective statistical testing is necessary to ensure quality literature within surgical disciplines.

Transfacial Two-pin External Mandibular Distraction Osteogenesis: A Technique for Neonatal Airway Obstruction from Robin Sequence.

Surgical management in those with moderate-to-severe airway obstruction includes tongue-lip adhesion, tracheostomy, and/or mandibular distraction osteogenesis. This article describes a transfacial two-pin external device technique for mandibular distraction osteogenesis, utilizing minimal dissection. Methods: The first percutaneous pin is transcutaneously placed just inferior to the sigmoid notch parallel to the interpupillary line. The pin is then advanced through the pterygoid musculature at the base of the pterygoid plates, toward the contralateral ramus, and exits the skin. A second parallel pin is placed spanning the bilateral mandibular parasymphysis distal to the region of the future canine. With the pins in place, bilateral high ramus transverse corticotomies are performed. Using univector distractor devices, the length of activation varies, with the goal of overdistraction to achieve a class III relationship of the alveolar ridges. Consolidation is limited to a 1:1 period with the activation phase, and removal is performed by cutting and pulling the pins out of the face. Results: To guide optimal transcutaneous pin placement, transfacial pins were then placed through twenty segmented mandibles. Mean upper pin (UP) distance was 20.7 ± 1.1 mm from the tragus. The distance between the cutaneous entry of the UP and lower pin was 23.5 ± 0.9 mm, and the tragion-UP-lower pin angle was 118.7 ± 2.9°. Conclusions: The two-pin technique has potential advantages regarding nerve injury and mandibular growth, given an intraoral approach with limited dissection. It may safely be performed on neonates whose small size may preclude the use of internal distractor devices.

Safety of Mandibular Osteotomies in Infants with Pierre Robin Sequence: Computer-Aided Modeling to Characterize the Risks of Various Techniques.

BACKGROUND: Mandibular distraction osteogenesis is effective for the correction of severe tongue-based airway obstruction in infants with Pierre Robin sequence. Involved osteotomies may damage developing tooth buds and/or the inferior alveolar nerve. The authors evaluated the theoretical safety of various osteotomy techniques to better define infantile mandibular anatomy using computer-aided modeling. METHODS: Seven mandibular osteotomy techniques (oblique, inverted-L, multiangular, walking stick, high oblique, vertical/high inverted-L, and horizontal) were simulated using computed tomography studies from infants with Pierre Robin sequence and without other associated conditions. Software was used to manually segment the mandibular bone, inferior alveolar nerve, and tooth buds. RESULTS: Sixty-five computed tomography scans were included, yielding 130 hemimandibles. The horizontal osteotomy pattern had significantly lower theoretical risk of tooth bud (p < 0.001) and inferior alveolar nerve involvement (p < 0.001) than all other patterns. Osteotomies with high vertical components (i.e., vertical, walking stick, and multiangular) had lower theoretical tooth bud involvement than the more proximal oblique and inverted-L osteotomies (p < 0.001). Average lingula location was measured at a point 65 percent of the mandibular width from anterior mandibular border and 63 percent of the mandibular height from the inferior mandibular border. CONCLUSIONS: Surgical planning with computed tomography scans can help evaluate an infant's mandibular anatomy to select an osteotomy that reduces morbidity risks. Regardless of technique, tooth buds and the inferior alveolar nerve are often included in osteotomies. The lingula location in this study demonstrates a position more superior and posterior than that previously described. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Pindborg tumor in early childhood: a rare tumor in the youngest patient reported to date.

Pindborg tumor is a benign expansile and slow growing odontogenic tumor that occurs mainly in adulthood. Limited management data exist for its treatment in young patients. We report the case of a 5-year-old patient and provide recommendations for the care of pediatric patients diagnosed with this rare odontogenic tumor.

Robin sequence without cleft palate: Genetic diagnoses and management implications.

Robin sequence (RS), the triad of micrognathia, glossoptosis, and airway obstruction, is a major cause of respiratory distress and feeding difficulties in neonates. Robin sequence can be associated with other medical or developmental comorbidities in ~50% of cases ("syndromic" RS). As well, RS is variably associated with cleft palate (CP). Previous studies have not investigated differences in clinical characteristics of children with RS based on presence or absence of CP. We retrospectively reviewed 175 children with RS and compared genetic diagnoses, medical and developmental comorbidities, severity of airway obstruction, and feeding outcomes between those with and without CP. Strikingly, 45 of 45 (100%) children with RS without CP were classified as syndromic due to presence of comorbidities unrelated to RS, while 83 of 130 (64%) children with RS with CP were classified as syndromic. Among 128 children with syndromic RS, there were no differences in severity of airway obstruction, surgical intervention rate or type, or feeding outcome at 12 months based on CP status. Our findings support the conclusion that the pathogenesis of RS without CP is distinct from RS with CP and more likely to cause additional medical or developmental problems. Alternatively, children with RS without CP and without additional anomalies present may be under recognized.

Partial suturectomy for phenotypical craniosynostosis caused by incomplete fusion of cranial sutures: a novel surgical solution.

OBJECTIVE: Patients presenting with head shape changes phenotypical for craniosynostosis may have incomplete fusion of the involved sutures. The surgical literature is lacking in appropriate management strategies for these patients. In this paper, the authors evaluate their experience with a novel treatment strategy: suturectomy of only the fused portion followed by helmeting therapy in patients with skull deformity secondary to incomplete suture synostosis. METHODS: Patients with craniosynostosis with incomplete suture fusion requiring operative intervention between 2018 and 2020 were included for evaluation. Patients were selected for partial suturectomy if the patent portion of the suture had a normal appearance. All patients underwent craniectomy of the involved portion of the synostosed suture. Intraoperative ultrasound was used to reassess the degree of fusion at the time of surgery and incision planning. A 2- to 3-cm strip craniectomy was performed under direct visualization through a single minimal access incision. Postoperative helmeting was utilized for all patients. Demographic and perioperative data were collected, including laser scan data in the form of cranial index (CI) and cranial vault asymmetry (CVA), defined as the difference between two diagonal measurements, from the frontozygomaticus to the opposite eurion. RESULTS: Four males and 1 female with a mean age of 2.8 months (range 1.1-3.9 months) at presentation were included. All patients had incomplete sagittal synostosis (one patient also had an incomplete left lambdoid synostosis and another had an incomplete left coronal synostosis). The mean age at surgery was 3.5 months (range 2.0-4.7 months) without any major complications. All patients were compliant with postoperative helmeting. The average age at the last follow-up was 12.8 months (range 5.3-23.7 months) with a mean follow-up duration of 9.3 months (range 0.5-19.6 months). Final laser scan evaluations were available for 3 patients and showed an improvement of the CI from an average of 71.3 (range 70-73) to 84.3 (range 82-86). The CVA improved from an average of 9.67 mm (range 2-22 mm) to 1.67 mm (range 1-2 mm). CONCLUSIONS: Minimally invasive direct excision of the involved portion of fused cranial sutures followed by helmet therapy for phenotypical craniosynostosis is a safe and effective treatment strategy. This technique is suitable for very young patients and appears to offer similar outcomes to complete suturectomy. Further studies are required to see if this approach reduces the deformity severity for patients requiring vault remodeling later in life.

Neuro-Ophthalmological Manifestations of Craniosynostosis: Current Perspectives.

Craniosynostosis, a premature fusion of cranial sutures that can be isolated or syndromic, is a congenital defect with a broad, multisystem clinical spectrum. The visual pathway is prone to derangements in patients with craniosynostosis, particularly in syndromic cases, and there is a risk for permanent vision loss when ocular disease complications are not identified and properly treated early in life. Extensive advancements have been made in our understanding of the etiologies underlying vision loss in craniosynostosis over the last 20 years. Children with craniosynostosis are susceptible to interruptions in visual input arising from strabismus, refractive errors, and corneal damage; any of these aberrations can result in understimulation of the visual cortex during childhood neurodevelopment and permanent amblyopia. Elevated intracranial pressure resulting from abnormal cranial shape or volume can lead to papilledema and, ultimately, optic atrophy and vision loss. A pediatric ophthalmologist is a crucial component of the multidisciplinary care team that should be involved in the care of craniosynostosis patients and consistent ophthalmologic follow-up can help minimize the risk to vision posed by such entities as papilledema and amblyopia. This article aims to review the current understanding of neuro-ophthalmological manifestations in craniosynostosis and explore diagnostic and management considerations for the ophthalmologist taking care of these patients.

Sleep Outcomes in Neonates with Pierre Robin Sequence Undergoing External Mandibular Distraction: A Longitudinal Analysis.

BACKGROUND: Robin sequence is a common cause of upper airway obstruction in newborns. Herein, we report sleep outcomes in neonates undergoing external mandibular distraction osteogenesis. METHODS: In this retrospective, 14-year, single-institution study of neonates with Robin sequence undergoing mandibular distraction osteogenesis, we compare respiratory parameters and sleep architecture before versus after surgery. RESULTS: Thirty-one neonates were included; age was 13 days (interquartile range, 5 to 34 days) at preoperative polysomnography and 80 days (interquartile range, 50 to 98 days) at postoperative polysomnography. All neonates had severe obstructive sleep apnea at baseline (defined as pre-operative obstructive apnea hypopnea index ≥ 10). Postoperatively, there was a significant reduction in obstructive apnea hypopnea index [38.3 (interquartile range, 23.4 to 61.8) preoperatively versus 9.4 (interquartile range, 5.3 to 17.1) postoperatively; p < 0.0001], and a significant improvement in sleep efficiency and oxygen saturation nadir. Although 26 neonates (84 percent) had a 50 percent reduction in obstructive apnea hypopnea index postoperatively, all neonates had obstructive sleep apnea, and 15 neonates (48 percent) had persistent severe obstructive sleep apnea following surgery. CONCLUSIONS: We report the largest cohort of sleep outcomes in neonates with Robin sequence and severe obstructive sleep apnea undergoing external mandibular distraction osteogenesis. Although the severity of obstructive sleep apnea improves postoperatively, the disease persists in all neonates. We propose that neonates undergo polysomnography before and soon after mandibular distraction osteogenesis to objectively assess improvement in obstructive sleep apnea, as they may require additional evaluation for sites of multilevel airway obstruction and treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Effect of Cleft Palate Repair on Polysomnography Results.

STUDY OBJECTIVES: In view of the risk that surgical repair of cleft palate may induce or worsen obstructive sleep apnea (OSA), the goal of this study was to assess presurgical and postsurgical polysomnography (PSG) results for children who underwent primary palatoplasty. METHODS: Retrospective case-control series for children with cleft palate repair performed between January 2008 and December 2016 at a tertiary pediatric center. Children underwent PSG before and after surgery. RESULTS: Sixty-four children (53.1% female) with a mean age of 2.0 ± 2.8 years (range 0.6-16.4) were included in the study. Pierre-Robin sequence was the most common comorbidity (67%). Before palatal repair, the mean obstructive apnea-hypopnea index (oAHI) was 3.4 ± 3.9 (range 0-17.9) events/h; this did not significantly change, with 5.9 ± 14.5 (range 0-105.7) events/h after surgery (P = 0.30). However, 34.4% of patients had a worsening of more than 1 obstructive event/h and 18.9% had a worsening of 5 or more obstructive events/h. The presence of a concomitant syndrome (eg, Treacher Collins) was a risk factor for postoperative OSA (odds ratio 4.2, 95% confidence interval 1.1-15.8, P = .03). CONCLUSIONS: OSA did not develop or worsen following primary palatoplasty. However, the oAHI increased by 5 or more events/h in approximately 20% of study participants. The presence of a syndrome was the only factor predictive of worsening OSA after palatoplasty. These findings suggest that palatoplasty does not worsen or cause OSA in most patients, and that nonsyndromic children are at low risk for the development or worsening of OSA.

Longitudinal Sleep Outcomes in Neonates With Pierre Robin Sequence Treated Conservatively.

STUDY OBJECTIVES: Although Pierre Robin sequence (PRS) is a major cause of neonatal obstructive sleep apnea (OSA), longitudinal studies reporting evolution with age are lacking. This study aimed to describe changes in sleep-related respiratory parameters and sleep architecture in neonates with PRS treated conservatively (defined for this paper as treatment without tracheostomy or mandibular distraction). METHODS: A retrospective, 14-year, single-institution study of neonates with PRS who underwent diagnostic polysomnography (PSG) and at least one follow-up PSG. Those treated with surgery were excluded. Data were analyzed using a mixed-effects model with subject-specific random effect. RESULTS: In a cohort of 21 infants, baseline PSG (mean age 0.9 ± 0.7 months) showed a total apnea-hypopnea index (AHI) of 24.3 ± 3.6 events/h, obstructive apnea-hypopnea index (OAHI) of 13.4 ± 1.6 events/h, central apnea index of 10.2 ± 3.2 events/h, and an arousal index of 28.3 ± 1.3 events/h (variables reported as least square means ± standard error of the mean). There was a significant reduction in AHI, OAHI, arousal index, and percentage of REM sleep with advancing age. Although 71% of infants achieved full oral feeds by one month of age, some infants remained underweight during infancy. CONCLUSIONS: These neonates with PRS and OSA, treated conservatively, had an improvement in OAHI with advancing age with the median age of OSA resolution at 15 months. Factors potentially responsible include craniofacial growth and maturational changes of respiratory control. Further studies are necessary to determine the long-term effects of conservative management on growth and neurodevelopmental outcomes in these infants.

Management of Airway Obstruction in Infants With Pierre Robin Sequence.

BACKGROUND: Pierre Robin sequence (PRS)-related airway obstruction is often treated surgically; however, objective measures predicting the need for surgery are poorly defined. METHODS: A retrospective chart review was performed on 171 neonates with PRS. Infants were grouped based upon intervention modality: nonsurgical (conservative) or surgical [mandibular distraction osteogenesis (MDO) or tracheostomy]. Demographic data, physical examination findings, and study results were compared between groups to determine risk factors for surgical intervention, and to predict long-term success or failure of those interventions. RESULTS: The most significant, objective risk factor among those receiving surgery was a poor preintervention sleep study [obstructive index (OI): 42.4 versus 12.9 for the conservative treatment group; P < 0.001]. Only 11% of those treated conservatively had an OI >20, whereas 67.5% of those treated surgically met this severity measure. Of those receiving surgery, tracheostomy was associated with neurologic impairment (P = 0.030) and low birth weight (P = 0.046) compared with the MDO group. Together with syndromic status, these risk factors were useful for predicting failure of MDO to avoid subsequent tracheostomy (test sensitivity and specificity were 64.2% and 100.0%, respectively). No long-term differences in speech or micrognathia were detected between the 3 groups; however, those treated conservatively or with MDO had improved long-term feeding and airway obstruction outcomes compared with the tracheostomy group. CONCLUSIONS: Surgical intervention for PRS-related tongue-based airway obstruction should be strongly considered with an OI >20. Tracheostomy should be reserved for complex patients with concomitant syndromic diagnosis, neurologic impairment, and low birth weight.

Decannulation and Airway Outcomes With Maxillomandibular Distraction in Treacher Collins and Nager Syndrome.

BACKGROUND: Treacher Collins syndrome is a rare disorder (1/50,000 live births) with features that include hypoplastic orbitozygomatic complex with downward slanting eyes, and maxillary/mandibular retrusion. Obstructive sleep apnea and tracheostomy-dependence are common. This study presents the outcomes of skeletal distraction on avoidance of tracheostomy and decannulation in this patient population. METHODS: The authors reviewed charts of all patients with Treacher Collins syndrome who underwent craniofacial reconstruction from 2003 to 2016. Primary outcome measures included decannulation of tracheostomy dependent patients and avoidance of tracheostomy. Secondary outcome measures included cephalometric parameters, polysomnography scores, and airway exposure scores on direct laryngoscopy. RESULTS: Twenty-five patients underwent mandibular and maxillary advancement to resolve upper airway obstruction. Mandibular distraction was performed in 24 of 25 patients, and maxillary distraction in 14 of 25 patients. Maxillary distraction was combined with mandibular distraction in 13 of 17 to accomplish greater advancement and counter-clockwise rotation of the entire maxillary-mandibular complex. Six of 7 patients, 85.7%, avoided a tracheostomy and 39% (7 of 18) were decannulated. Cephalometric changes in sella-nasion-A point, sella-nasion-B , occlusal plane angle, and posterior airway space were equivalent between the groups who were able to clear their obstruction and those who were not. CONCLUSIONS: Treacher Collins is a very challenging disease in which to resolve airway obstruction. Thus, thorough evaluation of the entire airway for all levels of obstruction is critical to successful outcomes. Future collaborative efforts between multiple institutions can help to increase our understanding and effective management of this rare disease.

Effects of Autologous Fat and ASCs on Swine Hypertrophic Burn Scars: A Multimodal Quantitative Analysis.

Background: Hypertrophic scar formation is unpredictable and poorly understood, afflicting both the pediatric and adult populations. Treatment methods with conservative and invasive approaches have low rates of compliance and high rates of morbidity. The purpose of this study was to test a reproducible scar model and investigate a new technique of scar modification through the use of adipose- derived progenitor stromal cells (ASCs). Methods: Twenty thermal deep-partial thickness contact burns were created on the dorsum of three 8-week-old domestic swine and allowed to mature for 10 weeks. Scars were then injected with 2 cc saline, expanded autologous ASCs, or 2 cc fresh lipoaspirate and sampled at 2 week intervals up to 10 weeks postinjection. Volumetric analysis with a 3-D scanner, mechanical elasticity testing through negative pressure transduction, and standardized photography evaluation with Image J was performed. RNA sequencing was performed on scar tissue samples, cultured cells, and fresh lipoaspirate to determine relevant gene transcription regulation. Immunohistochemistry was used to verify expression level changes within the scars. Results: Volumetric analysis demonstrates a reduction in average scar thickness at 6 weeks when injected with ASCs (-1.6 cc3) and autologous fat (-1.95 cc3) relative to controls (-0.121 cc3; P < 0.05). A decrease in overall tissue compliance is observed with fat or ASC injection when compared with unburned skin at 8 weeks (35.99/37.94 versus 49.36 mm Hg × mm; P < 0.01). RNA sequencing demonstrates altered regulation of fibroblast gene expression and a decreased inflammatory profile when scars are injected with autologous fat/ASCs over controls. Conclusion: Early results suggest that autologous fat and/or ASCs may improve healing of hypertrophic scarring by altering the cellular and structural components during wound remodeling up to 20 weeks after injury. This may have beneficial applications in early treatment of large or cosmetically sensitive immature burn scars.

Neonatal Mandibular Distraction Without a Consolidation Period: Is It Safe? Is it Effective?

PURPOSE: Consolidation is a standard part of most post-distraction protocols. This study aims to determine whether the deliberate omission of a consolidation period following mandibular distraction (MD) in neonates with Pierre Robin sequence (PRS) affected the airway outcomes and complication rates. PATIENTS AND METHODS: A retrospective chart review of 28 neonates with PRS who underwent MD for severe airway obstruction between 2009 and 2014 was performed. Neonates were split into 2 cohorts: those with a very short or no consolidation (no consolidation group, n = 18) and those with a traditional consolidation period (consolidation group, n = 10). RESULTS: Mean consolidation length was 25 days in the conventional consolidation group and 1.5 days in the no consolidation group (P < 0.01). Postoperatively, both groups showed equivalent improvements in their obstructive index as measured by polysomnography. Compared with the patients who underwent convention consolidation, patients in the "no consolidation" group did not require a greater number of repeat distraction, supplemental oxygen, or tracheostomy. Nor was there any significant difference in the number of complications between the 2 groups. CONCLUSION: In neonates with PRS treated with MD for severe airway obstruction, the omission of a consolidation period does not appear to significantly affect the complication rate or resolution of airway obstruction.

Reconstruction of the Isolated Columellar Defect: A Novel 2-Stage Technique and Review of the Literature.

The importance of the nasal complex cannot be overstated from a functional, social, and psychological perspective. The goal of reconstruction is to restore the trilaminar composition of the nose. This is accomplished by recreating the nasal lining and providing a cartilaginous framework to simultaneously support a patent airway and project the defining features to the overlying soft tissue. The columella is one of the smallest subunits of the nose, but the loss of this structure has important esthetic and structural implications. The ideal operation for an isolated defect of the columella remains elusive. The ideal reconstruction would match the pigmentation and texture of the surrounding nasal skin and provide a convex contour with underlying structural support. In addition, the donor site would not create a secondary deformity by disrupting normal anatomy. This report describes a novel 2-stage technique for reconstruction of the columella and reviews the current literature.

Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers.

BACKGROUND: Pressure ulcers (stages III and IV) are serious safety events (ie, never events). Healthcare institutions are no longer reimbursed for costs to care for affected patients. Medical devices are the leading cause of pediatric pressure ulcers. Face masks for noninvasive ventilation were associated with a high percentage of pressure ulcers at our institution. METHODS: A prospective cohort study investigated factors contributing to pressure ulcer development in 50 subjects using face masks for noninvasive ventilation. Color imaging, 3-dimensional surface imaging, and skin hydration measurements were used to identify early skin compromise and evaluate 3 interventions to reduce trauma: (1) a silicone foam dressing, (2) a water/polyethylene oxide hydrogel dressing, and (3) a flexible cloth mask. A novel mask fit technique was used to examine the impact of fit on the potential for skin compromise. RESULTS: Fifty subjects age 10.4 ± 9.1 y participated with color images for 22, hydration for 34, and mask fit analysis for 16. Of these, 69% had diagnoses associated with craniofacial anomalies. Stage I pressure ulcers were the most common injury. Skin hydration difference was 317 ± 29 for sites with erythema versus 75 ± 28 for sites without erythema (P < .05) and smallest for the cloth mask (P < .05). Fit distance metrics differed for the nasal, oronasal, and face shield interfaces, with threshold distances being higher for the oronasal mask than the others (P < .05). Areas of high contact were associated with skin erythema and pressure ulcers. CONCLUSIONS: This fit method is currently being utilized to select best-fit masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injuries and their complications. Improvement of mask fit is an important priority for improving respiratory outcomes. Strategies to maintain normal skin hydration are important for protecting tissue integrity.

Management of the Acutely Burned Hand.

Despite contributing a small percentage to the total body surface area, hands are the most commonly burned body part and are involved in over 90% of severe burns. Although the mortality of isolated hand burns is negligible, morbidity can be substantial given our need for functioning hands when performing activities of daily living. The greatest challenges of treating hand burns are 2-fold. First, determining the depth of injury can be difficult even for the most experienced surgeon, but despite many diagnostic options, clinical examination remains the gold standard. Second, appropriate postoperative hand therapy is crucial and requires a multidisciplinary approach with an experienced burn surgeon, hand surgeon, and hand therapist. Ultimately, the goals of treatment should include preservation of function and aesthetics. In this review, we present an approach to the management of the acutely burned hand with discussion of both conservative and surgical options. Regardless of the initial treatment decision, subsequent care for this subset of patients should be aimed at preventing debilitating postburn scar contractures that can severely limit hand function and ultimately require reconstructive surgery.