Ultrasound as an Educational Tool in Facial Aesthetic Injections.

Injection therapies for cosmetic enhancement, particularly antiaging treatments, are increasingly popular. However, once the needle has penetrated the skin, the injector is "blind" to the depth and exact location of the needle tip. Duplex ultrasound use before and after treatment can allow the injector to visualize in real time the individual anatomy, thereby improving and confirming the accuracy of the injections through visualization of both the target layer and the vital structures to be avoided. Previously injected permanent filler treatments can also be visualized. In this way, ultrasound use becomes an important educational tool in promoting "safer" facial injection therapy. It shifts static anatomy to mobile real-time facial anatomy, thereby establishing itself as an invaluable learning tool through follow-up imaging, with subsequent optimization in techniques and patient outcomes.

Topical Hemostatic-Anesthetic Solution to Reduce Bleeding During Mohs Micrographic Surgery: A Case Control Study.

BACKGROUND: Between stages of Mohs micrographic surgery, the wound is dressed and the patient waits for the histopathological results.
OBJECTIVE: To investigate the efficacy of a hemostatic-anesthetic solution-impregnated gauze in decreasing bleeding between Mohs stages.
MATERIALS AND METHODS: Twenty patients were treated with a hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL), and 20 others were treated with a saline solution for control. At the second Mohs stage, size measurements of the blood stain on a Telfa pad and the defect were recorded. The Rotation Thromboelastometry Method (ROTEM) was used to investigate a possible effect of lidocaine and adrenaline on the clot stability induced by tranexamic acid.
RESULTS: The ratio of blood stain size to Mohs defect size in the hemostatic anesthetic solution group was 1:1.47, whereas the ratio in the control saline group was 1:3.37 (P<.001). Results of the ROTEM test showed that lidocaine and adrenaline did not interfere with the effect of tranexamic acid on clot formation and stability.
CONCLUSION: The application of gauze impregnated with tranexamic acid, adrenaline, and lidocaine on a surgical wound may be effective in reducing bleeding between Mohs stages.

J Drugs Dermatol. 2016;15(7):851-855.

Corrigendum: Examining the Correlation between Objective Injury Parameters, Personality Traits and Adjustment Measures among Burn Victims.

[This corrects the article on p. 49 in vol. 3, PMID: 25874193.].

Adhesive skin closure technique for closure of fasciotomy wounds in pediatric patients: a case series.

BACKGROUND: Closure of fasciotomy wounds poses a challenge, particularly in pediatric cardiac patients who are too high risk for general anesthesia and often require anticoagulant treatment. The adhesive skin closure technique enables wound closure without the need for a secondary procedure such as surgery requiring anesthesia. OBJECTIVES: This study sought to describe a treatment modality that assists in fasciotomy wound edge approximation without the need for surgery, while additionally aiding in achieving fast and aesthetic results in the aforementioned patient population. A case series of 4 pediatric patients with fasciotomy wounds is presented. MATERIALS AND METHODS: Adhesive skin closure strips (Steri-Strips, 3M, St. Paul, MN) were placed perpendicular to the cleansed wound leaving small gaps for drainage, thus achieving complete propinquity. The strips were replaced sequentially with new strips every 2 to 3 days. Digital pictures of the wounds were obtained until complete closure of the wounds was achieved. Outcome variables included wound closure success rates and complication rates including infection, bleeding, and late scar formation. RESULTS: Patient ages ranged from 2 weeks to 2 years, 9 months (mean: 10.5 months), average period of open wound prior to closure was 6.75 days (range: 5-11 days), treatment duration ranged from 15 to 26 days (mean: 21 days), and average follow-up was 4.5 months. One patient died due to their primary condition. No local infections, wound dehiscence with the treatment regimen, or any other immediate complications were encountered. There was a late complication in 1 patient who presented with a hypertrophic scar. CONCLUSIONS: Use of the adhesive skin closure method to close fasciotomy wounds in pediatric patients in which surgical procedures were nonadvisable produced favorable results.

Examining the Correlation between Objective Injury Parameters, Personality Traits, and Adjustment Measures among Burn Victims.

BACKGROUND: Burn victims experience immense physical and mental hardship during their process of rehabilitation and regaining functionality. We examined different objective burn-related factors as well as psychological ones, in the form of personality traits that may affect the rehabilitation process and its outcome. OBJECTIVE: To assess the influence and correlation of specific personality traits and objective injury-related parameters on the adjustment of burn victims post-injury. METHODS: Sixty-two male patients admitted to our burn unit due to burn injuries were compared with 36 healthy male individuals by use of questionnaires to assess each group's psychological adjustment parameters. Multivariate and hierarchical regression analysis was conducted to identify differences between the groups. RESULTS: A significant negative correlation was found between the objective burn injury severity (e.g., total body surface area and burn depth) and the adjustment of burn victims (p < 0.05, p < 0.001, Table 3). Moreover, patients more severely injured tend to be more neurotic (p < 0.001), and less extroverted and agreeable (p < 0.01, Table 4). CONCLUSION: Extroverted burn victims tend to adjust better to their post-injury life while the neurotic patients tend to have difficulties adjusting. This finding may suggest new tools for early identification of maladjustment-prone patients and therefore provide them with better psychological support in a more dedicated manner.

The arterial blood supply of the helical rim and the earlobe-based advancement flap (ELBAF): a new strategy for reconstructions of helical rim defects.

BACKGROUND: Several techniques are currently available for reconstruction of helical rim defects including Antia and Buch's technique. Some of these techniques produce unsatisfying aesthetic results or are time consuming or technically challenging. Herein, we present the earlobe-based advancement flap (ELBAF) technique and its anatomical basis for reconstruction of helical rim defects. METHODS: A case series of 13 patients with helical rim defects of up to 3.8 cm in length were reconstructed using the ELBAF technique solely or with additional procedures. Patients were followed for the occurrence of complications and evaluation of aesthetic results for up to 8 years. An anatomical assay that included cadaver dissection and anatomical corrosion technique was performed in order to support the ELBAF technique. RESULTS: Thirteen patients (68.5 ± 9 years, two females) with full-thickness helical rim defects of up to 3.8-cm length caused by basal cell carcinoma in 92.3% underwent reconstruction surgery using the ELBAF technique solely or with additional procedures. No complications related to the ELBAF technique were encountered during follow-up. Cadaver dissections demonstrated a consistent arterial blood supply emerging from the earlobe area, producing arteries that run circularly along the helical rim. CONCLUSIONS: Based on the axial vessel pattern, the ELBAF technique seems to be a useful strategy to reconstruct full-thickness helical defects of up to 3.8 cm in length. This procedure can be regarded as a valid addition to the ear reconstruction repertoire, which can be used alone or in combination with other established techniques. LEVEL OF EVIDENCE: Level 4, case series.

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.

Contexte : La thérapie postopératoire à pression expiratoire positive (PEP) favorise l'augmentation du volume des poumons, le dégagement des sécrétions et une meilleure oxygénation. Plusieurs appareils commerciaux sur le marché produisent les valeurs de PEP recommandées (de 10 à 20 cmH2O) lorsqu'on souffle dans un dispositif de résistance à ouverture fixe. On a fait l'hypothèse qu'un appareil bon marché et improvisé à partir d'un « gant dans lequel on souffle ¼ produirait des valeurs de PEP semblables dans une plus vaste plage de volumes d'expiration et de débits. Méthodes : La PEP pour différents volumes d'expiration (de 400 à2 000 mL) et débits expiratoires (10-80 L/min) a été comparée en utilisant un appareil commercial de PEP (Resistex, Mercury Medical, Clearwater, Floride) et un appareil improvisé à partir d'un gant, puis enregistrée par un respirateur Vela (CareFusion, San Diego, Californie). La dynamique des valeurs de la pression positive en fin d'expiration (PPFE) a été évaluée après cinq expirations consécutives. L'évaluation de l'appareil fabriqué à l'aide d'un gant a été effectuée en utilisant des gants de compositions et de tailles diverses. Résultats : L'appareil improvisé à partir d'un gant a produit un taux considérablement plus élevé de valeurs de PEP dans la plage recommandée que l'appareil Resistex (88,9% c. 20%, p<0,0001). Aucune différence importante n'a été observée entre les petites et les grandes tailles de gants (88,9% c. 82,9%, p>0,05). Le gant en latex poudré affichait un taux considérablement plus élevé de valeurs de PEP dans la plage recommandée que le gant en latex non poudré (88,9% c. 44,4%, p<0,001). Conclusions : Un appareil de PEP improvisé à l'aide d'un gant en latex poudré produit de plus grandes plages de PEP recommandée par spectre de débit d'expiration comparativement à un appareil commercial de PEP.

Treatment of wounds following breast reduction and mastopexy with subsequent wound dehiscence with charged polystyrene microspheres.

BACKGROUND: Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM). MATERIALS AND METHODS: Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented. RESULTS: The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered. CONCLUSIONS: Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

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.

The effect of acellular dermal matrix on drain secretions after immediate prosthetic breast reconstruction.

In recent years the acellular dermal matrix (ADM) has gained popularity in prosthetic breast reconstruction. These procedures involve placement of a closed suction drain in the reconstructed breast. Although it is now widely accepted that ADM has an overall positive effect on the outcome of breast reconstruction, data regarding its effect on postoperative drain secretions is lacking. This study was designed to quantitatively evaluate the influence of ADM on postoperative drain secretions in the setting of immediate prosthetic breast reconstruction (IPBR). This is a prospective, comparative controlled study. Two groups of 16 patients each underwent skin sparing mastectomies (SSM) and IPBR with or without ADM. Closed suction drains were left in all the reconstructed breasts and daily secretion volumes were recorded and compared. Postoperative complications were also noted. Patients in the ADM group showed higher daily and overall secretion volumes compared with patients in the control group (p = 0.014) and the time for removal of the drains was higher by an average of 5 days (13 compared with 8 days, respectively; p = 0.004). There was no correlation between ADM and infection. This study provides the first objective evidence that ADM contributes to elevated and prolonged drain secretions when used for IPBR. This might affect possible prosthesis-related complications (e.g., rotation and malposition, capsular contraction, seroma formation, and infection). This study also noted erythema of the post-mastectomy skin flaps in selected patients, which may be attributable to a local inflammatory reaction to the ADM rather than infection.

Custom-fit polymeric membrane dressing masks in the treatment of second degree facial burns.

Second degree facial burns usually impart high wound site pain levels and patient discomfort due to the abundance of facial sensory innervation, as well as the development of edema and inflammation that accompany wound healing. Frequent changing of adherent dressings causes additional procedural pain and may prolong healing due to recurring damage to the wound bed. We applied face masks, made on-site from a drug free polymeric membrane dressing, to 8 patients with superficial and deep 2nd degree facial burns. Time to full re-epithlialization was recorded during treatment. Pain, overall comfort, and result satisfaction were evaluated using a questionnaire (10-point Likert scales. From 1=minimum to 10=maximum) on follow-up (mean follow up 14.4 months, range 9-18). These results were compared to a historical cohort of patients with facial burns that were treated with an antibiotic ointment. Results showed mean re-epithelialization time of 6.5 days (as compared to 8.5 days in the cohort group), low pain ratings (mean: 2.6; range: 4.7 in the control group), mixed comfort levels (mean: 4.7/10; 4 in the control group) and high result satisfaction (mean: 7.8; 6.2 in the control group). Nursing staff described pain-free dressing changes and positively noted non-adherence and high absorbance capacity of the polymer, necessitating less dressing changes. Inflammation was contained to the actual site of injury. No complications in terms of infection or allergic reaction were observed. Overall, the polymeric membrane facial dressing seems to be a promising means of reducing pain and ensuring uninterrupted wound healing in 2nd degree facial burns.

Birth wind and fire: raising awareness to operating room fires during delivery.

OBJECTIVE: We researched whether the obstetric operating room (OR) qualified as a fire-risk environment so as to take preventive measures accordingly. METHODS: We analyzed a series of iatrogenic burns inflicted during birth by collecting clinical data and comparing it with known OR fire risk factors and with other factors that repeated in all cases in search of unique characteristics of the obstetric OR. RESULTS: All three cases shared in common the same type of oxygen-rich open ventilation system, alcohol-based prepping solution, and the hastiness of cesarean delivery while spontaneous vaginal delivery was already in progress. CONCLUSION: The obstetric OR is, as suspected, a fire-prone zone in more ways than the regular OR. Therefore, preventive measures should be undertaken and awareness for the possibility for such occurrences should be raised.

The temporal suspension flap for malar defects: a novel technique.

Close opposition of full-thickness skin grafts to the recipient wound bed is felt to be critical for graft survival. This is usually accomplished by bolster dressings, basting sutures, or both. Herein, we describe a facile and rapid technique for placing quilting sutures in full-thickness grafts on the ear using a plain gut suture with a short, straight needle. This technique is especially valuable in facilitating precise approximation of grafts within the fossae of the anterior ear. In our experience, this approach promotes graft survival and produces excellent cosmetic results.

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.

HISTORIQUE: La nécrose d'un lambeau après une rhytidectomie du visage est une complication délicate et pénible pour le patient et le chirurgien. Des modalités thérapeutiques qui peuvent accélérer le taux de guérison et de réépithélialisation de la plaie sont fort souhaitables. OBJECTIFS: Évaluer le taux de guérison et de réépithélialisation de plaies ouvertes après la nécrose d'un lambeau de rhytidectomie traité à l'aide de microsphères chargées de polystyrène commerciales (Polyheal-1, Polyheal Ltd, Israël). MÉTHODOLOGIE: Les médecins ont traité la nécrose d'un lambeau après une rhytidectomie comportant des plaies ouvertes chez trois patientes à l'aide de pansements imbibés de Polyheal-1. Ils ont consigné le taux de fermeture des plaies. RÉSULTATS: Les plaies ont présenté à la fois la formation accélérée de tissu de granulation et un taux de réépithélialisation rapide. Cette guérison ne s'est pas accompagnée de complications, ni d'effets secondaires. CONCLUSIONS: Les microsphères chargées de polystyrène offrent peut-être un moyen nouveau et efficace de traiter des plaies ouvertes causées par la nécrose d'un lambeau après une rhytidectomie du visage. Des recherches plus approfondies auprès d'un plus grand nombre de patients s'imposent pour confirmer ces observations.

"Wet behind the ears": the postauricular training ground for local flaps.

Early in the course of surgical education, dermatologic and plastic surgery trainees shift from theory to practice. This shift must be done cautiously so as not to cause unnecessary damage to the patient, especially when attempting to reconstruct soft tissue defects on the face. Helical rim defects present an excellent opportunity because the postauricular region provides a safe environment for novice surgeons to practice the theoretical and manual aspects of basic flap reconstruction. This paper explains key features on how to plan basic flaps based on postauricular tissues.

Delay techniques for local flaps in dermatologic surgery.

Local flaps may be required to reconstruct defects on the face, neck, and scalp. Occasionally, delay techniques are indicated to reduce the risk for flap ischemia and subsequent necrosis. Delay may be employed before the flap is raised, as done to improve blood supply to a random flap when length to breadth proportions are not ideal, or after the flap is raised and before separation of the pedicle in the final reconstructive step to improve vascularity in the distal end of an interpolation flap. We present our techniques and results of delay procedures for interpolation and similar flaps.

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.

Reconstruction of full-thickness defects with bovine-derived collagen/elastin matrix: a series of challenging cases and the first reported post-burn facial reconstruction.

Reconstruction of full-thickness defects may benefit from integration of dermal substitutes, which serve as a foundation for split-thickness skin grafts, thus enhancing short and long-term results. We present a series of 7 patients who were treated between 2010 and 2012 for complicated full-thickness defects by the second-generation collagen/elastin matrix Matriderm® covered by a split-thickness skin graft. The defects resulted from malignancy resection, trauma, and post-burn scar reconstruction. Overall graft take was excellent and no complications were noted regarding the dermal substitute. Graft quality was close to normal skin in terms of elasticity, pliability, texture, and color. Good contour and cushioning of defects in weight bearing areas was also achieved. Matriderm was found to be a useful adjunct to full-thickness defect reconstruction, especially in difficult areas where the desired result is a scar of the highest quality possible.

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.