Optimal placement of a brachioplasty scar: a survey evaluation.

BACKGROUND: Brachioplasty has become a popular procedure to rejuvenate the upper arm, with its frequency increasing proportionately to the popularity of surgical weight loss procedures. The major complication of the procedure is undesirable, visible scarring. An ongoing, unresolved debate in the brachioplasty literature is the optimal placement of the brachioplasty scar. Some authors advocate a medially based incision along the bicipital groove, whereas others prefer to leave the scar posteriorly in the brachial sulcus. In addition, some advocate a sinusoidal scar over a straight-line closure. This study attempts to resolve the question of where and how to place the scar based on population surveys. METHODS: Photographs were taken of a model with her arm progressively abducted at the shoulder to a level of 90 degrees, with the elbow progressively flexed to 90 degrees and the arm externally rotated. Anterior and posterior views were included. Using Photoshop, a brachioplasty scar was digitally created and placed on the arm first medially in the bicipital groove, then posteriorly in the brachial sulcus. Straight-line scars and sinusoidal scars were also compared in each position. Before creating a computer-generated image of the scars, the scar lines were marked with a marking pen to ensure they could be followed with movement of the model's arm. An online survey was then created and distributed and included multiple variables: position of the scar, length of scar vs residual deformity, and acceptability based on phase of scar in time (early vs late result). The scale was numerical from 1 to 5, with 1 being a very objectionable scar and 5 being a very acceptable scar. The survey was disseminated among the general public, plastic surgeons, and patients in the Yale Cosmetic Surgery Resident Clinic who were either seen in consultation for brachioplasty or who underwent the procedure. RESULTS: Electronic surveys were distributed to and completed by the general public (n = 117), local plastic surgery residents and attendings (n = 10), and patients who had undergone or were seen in consultation for brachioplasty (n = 9). Among all participants, in the chronic phase, a medial straight scar received an average rating of 4.00, a posterior straight scar received an average rating of 3.14, a posterior sinusoidal scar received an average rating of 2.61, and a medial sinusoidal scar received an average rating of 2.03. Across age groups, gender, plastic surgeons, and patients, the medially based straight brachioplasty scar is more acceptable than the posteriorly based straight scar (4.00 vs 3.14, P < 0.001). If the scar shape is made sinusoidal, a posteriorly based scar is favored over a medial one (2.61 vs 2.03, P < 0.001), yet this is still not as aesthetically pleasing as a medial straight scar (4.00 vs 2.61, P < 0.001). Furthermore, survey participants accepted a longer scar over a residual deformity (58.8% vs 41.2%). CONCLUSIONS: Based on the preferences of the populations surveyed, we conclude that the medially based straight scar is the most aesthetically acceptable option when performing a brachioplasty.

A targeted approach to sentinel lymph node biopsies in the parotid region for head and neck melanomas.

INTRODUCTION: Cutaneous melanoma is on the rise in the United States, and the head and neck region is the primary site in 20% of patients. Lymph node status is the best indicator of prognosis for melanoma. In the head and neck, sentinel lymph node (SLN) biopsy presents particular challenges, with the parotid region posing difficulties that include locating the lymph nodes, less frequent visualization of blue dye, and the possibility of higher morbidity because of the proximity of lymph nodes to important neurovascular structures. Surgical approaches to the SLN dissection in the parotid region are variable, and may include superficial or total parotidectomies. Parotid-sparing SLN biopsies for head and neck melanomas were evaluated to determine rates of local recurrence. METHODS: The charts of 301 patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma were reviewed. The location of the primary melanoma was noted, and the sentinel lymph node dissections from the operative reports were documented. Demographic and outcome data were recorded, including course of melanoma management, local recurrence, and postoperative course. RESULTS: Fifty-eight patients underwent SLN biopsy of lymph nodes in the parotid region. Parotid-sparing SLN biopsies comprised 94.8% of total surgical approaches for SLN biopsies in the parotid region. Of the remaining patients who underwent SLN biopsies in the parotid region, 5.17% had a superficial parotidectomy and none had a total parotidectomy. Sentinel lymph nodes were found in all depth layers of the parotid, and LNs were dissected out successfully without the need to remove the parotid in the most cases. The parotid region recurrence rate was 0% for SLN biopsies that either included or spared the parotid gland. There were no localized complications from the sentinel lymph node biopsies. CONCLUSIONS: The parotid-sparing SLN biopsy was performed without any local recurrence in the parotid region. The parotid-sparing SLN biopsy can be carried out in a safe, efficient manner without affecting the rate of local recurrence or postoperative complication. This less-invasive SLN biopsy procedure precludes the complications associated with parotidectomies and may reduce the morbidity for patients with melanomas of the head and neck.

Level I sparing radical neck dissections for cutaneous melanoma in the lymphoscintigram era.

INTRODUCTION: Excision of regional lymph nodes (LNs) in the neck as part of the management for tumors of the head and neck dates back to the 19th century. Crile originally reported the technique of performing a radical neck block dissection in 1905, with notable modifications to the extensive dissection reported throughout the 20th century by Suarez, Ballantyne, Ariyan, and Shah among others. These modifications have aimed to reduce the morbidity encountered by performing the radical neck dissection while balancing the need to remove diseased structures in the head and neck. In this report, we evaluate the outcomes of performing a functional radical neck dissection while sparing the level I LNs as indicated by lymphoscintigraphy. METHODS: The charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. The location of the primary melanoma and clinical course was noted. Those patients who underwent neck dissections were documented and the extent of the dissections from the operative reports was noted. Demographic and outcome data were recorded, including clinical course of melanoma presentation, local recurrence, and postoperative management. Student t test and χ tests were used to determine statistical significance between groups. P values less than 0.05 were considered statistically significant. RESULTS: A total of 41 patients who were documented to have had a head and neck primary melanoma underwent a functional radical neck dissection. Level I dissections were deemed necessary in 39% of these cases, whereas 61% of patients received functional radical neck dissections with sparing of level I LNs. Specific recurrence of melanoma in the submandibular basin was equivocal for LN sparing dissections (n=1) as compared to excision of level I LNs (n=1) (4% vs 6.25%, P=0.488). Follow-up metastatic rates between the 2 groups were also comparable (44% vs 56%, P=0.328). Overall metastatic rate in follow-up for all patients undergoing LN dissection was 48.8%. There was no statistically significant difference between the average age of patients at diagnosis, Breslow depth, Clark level, and staging between patients who underwent functional radical neck dissections with either excision or sparing of level I LNs. CONCLUSIONS: Clinical and pathological presentation between patients who needed level I sparing dissections and those who did not, failed to demonstrate a statistically significant difference allowing for an adequate comparison. Our results indicate that if lymphoscintigraphy does not show drainage to level I LNs, the functional radical neck dissection can be tailored to spare level I LNs without affecting local recurrence. When not indicated by lymphoscintigram, sparing of level I nodes can be performed safely without changing clinical outcomes, while saving operating room time and minimizing potential damage to the buccal branch of facial nerve and the submandiblular gland.

Synthesis, photocatalytic and antidiabetic properties of ZnO/PVA nanoparticles.

A series of ZnO and ZnO/poly(vinyl alcohol) (PVA) catalysts were prepared using sol-gel method. An X-ray diffraction analysis confirmed the existence of the wurtzite ZnO phase, and scanning electron microscopy (SEM) observation revealed the formation of spherical ZnO and ZnO/PVA nanoparticles. The decomposition of methylene blue (MB) and methyl orange (MO) induced by the synthesized pure ZnO and ZnO/PVA nanoparticles was studied under ultraviolet-visible irradiation. Among the catalysts evaluated, ZnO/5PVA was the most active in the decomposition of MB, whereas ZnO/7PVA was the most active catalyst in the decomposition of MO. Moreover, an investigation of the biological activity of pure ZnO and ZnO/PVA indicated that ZnO/5PVA exhibited the best performance in lowering the glucose level in diabetic rats.

High efficiency solar desalination and dye retention of plasmonic/reduced graphene oxide based copper oxide nanocomposites.

Water desalination via solar-driven interfacial evaporation is one of the most essential technologies to limit the problem of global freshwater scarcity. Searching for a highly efficient, stable, eco-friendly, and cost-effective solar-absorber material that can collect the full solar spectrum is critically important for solar steam generation. This study reports the development of a new solar thermal evaporation system based on plasmonic copper oxide/reduced graphene oxide (rGO). The silver nanoparticles in the composite exhibit a very strong solar absorption. Also, rGO and CuO nanoparticles offer excellent thermal absorptivity. Polyurethane was used as the support and as a thermal insulator. Moreover, filter paper was used for fast water delivery to the surface of the solar absorber. Ag/CuO-rGO nanocomposite is manifested to be one of the most efficient solar-absorbers reported to date for solar desalination which exhibits an average 2.6 kg m-2 h-1 evaporation rate with solar thermal efficiency up to 92.5% under 1 sun irradiation. Furthermore, the composite has excellent stability and durability as it displays stable evaporation rates for more than 10 repeated cycles in use, with no significant decrease in the activity. Besides, the successful removal of various organic dyes from contaminated water is also revealed, resulting in the production of clean condensed freshwater. Finally, this work commences a new avenue of synthesizing cost-effective thermal absorbers based on metal oxides.

Synthesis of sulfamic acid supported on Cr-MIL-101 as a heterogeneous acid catalyst and efficient adsorbent for methyl orange dye.

Typical highly porous metal-organic framework (MOFs) materials based on chromium benzenedicarboxylates (Cr-BDC) were prepared through a one-pot hydrothermal synthesis, and were then modified by loading the appropriate ratio of sulfamic acid (SA) using a simple impregnation technique. Pure and modified MIL-101 was characterized by XRD, TEM, SEM and FT-IR measurements. TEM and SEM measurements confirmed that the MIL-101 particles preserved their regular octahedral structure after loading with different weight contents of sulfamic acid. The total number of acid sites and Brønsted to Lewis acid sites ratio (B/L) were examined using potentiometric titration and pyridine adsorption. The acid strength and surface acidity of SA/MIL-101 gradually increased after the modification of Cr-MIL-101 by sulfamic acid crystals up to 55 wt%, then decreased again. The catalytic performance of the solid catalysts was confirmed in the synthesis of 14-phenyl-14H-dibenzo [a,j] xanthene and 7-hydroxy-4-methyl coumarin. In the two reactions, the sample with 55% sulfamic acid loaded on MIL-101 displayed the highest catalytic activity and acidity. The adsorption behaviors of sulfamic acid loaded on MIL-101 materials for methyl orange (MO) as an anionic dye were studied, and were exceptionally suitable for the Langmuir adsorption isotherm. All loaded adsorbents showed high adsorption capacity for methyl orange at 25 °C. The results indicate that the adsorption capacity was modified by changing the amount of sulfamic acid loaded on MIL-101.

Removal of aluminum from some water samples by sorptive-flotation using powdered modified activated carbon as a sorbent and oleic acid as a surfactant.

Bench-scale experiments were conducted in the laboratory, aiming to remove aluminum from water. They were based on using powdered activated carbon (PAC), which was prepared from olive stones generated as plant wastes and modified with an aqueous oxidizing agent as HNO3 as an effective sorbent and oleic acid (HOL) as a surfactant. The main parameters (namely: initial solution pHs, sorbent, surfactant and aluminum concentrations, shaking time, ionic strength and the presence of foreign ions) that influence the sorptive-flotation process were examined. Good results were obtained under the optimum conditions, according to which nearly 100% of aluminum, at pH 7 and at room temperature (approximately 25 degrees C), was removed. The procedure was successfully applied to recover aluminum spiked to some natural water samples. Moreover, a sorption and flotation mechanism is suggested.

Decision-making and Management of Ulnar Polydactyly of the Newborn: Outcomes and Satisfaction.

BACKGROUND: Polydactyly is the most common congenital hand deformity. There is currently no consensus among pediatricians or hand surgeons regarding optimal management of ulnar (post-axial) type B polydactyly leading to uncertainty in initial treatment decisions for infants with this type of deformity. METHODS: Parents of newborns with type B ulnar polydactyly were enrolled in a prospective, nonrandomized trial from 2010 to 2012. At enrollment they were offered: 1) no treatment, 2) suture ligature, 3) immediate excision under local anesthesia, and 4) delayed excision at four months of age under general anesthesia. After choosing a treatment option, parents were asked to complete an initial survey on their motivation for choosing a particular option, and then additional surveys at one and three month follow-up visits regarding outcomes and satisfaction. RESULTS: Fourteen newborns were enrolled in the study. Eleven patients had bilateral polydactyly for a total of 25 hands involved in the study. With statistical significance, parents chose an immediate bedside excision over all options. No surgical complications were noted and satisfaction scores were 9.8 or higher in all groups. CONCLUSIONS: A majority of parents whose children are born with type B post-axial polydactyly prefer to have the deformity addressed immediately with excision under local anesthesia at the bedside. This can be accomplished safely, with a satisfaction score of 9.8 out of 10 and no appreciable residual deformity. This may reduce emotional distress or embarrassment in parents who would otherwise have to deal with the deformity for at least a four-month period.

Flotation-separation of aluminum from some water samples using powdered marble waste and oleic acid.

Bench-scale experiments were conducted in the laboratory, aiming to remove aluminum from water. They were based on the use of powdered marble wastes (PMW), which are inexpensive and produced in large quantity, and thus potentially cause environmental problems, as an effective inorganic sorbent and oleic acid (HOL) as surfactant. The main parameters (solution pHs, sorbent, surfactant and aluminum concentrations, shaking time, ionic strength and the presence of foreign ions) that influence the sorptive-flotation process were examined. Good results were obtained under the optimum conditions, for which nearly 100% of aluminum at pH 7 and at room temperature (approximately 25 degrees C) was removed. The procedure was successfully applied to the recovery of aluminum spiked to some natural water samples. Moreover, a sorption and flotation mechanism is suggested.

Immediate fat grafting in primary cleft lip repair.

BACKGROUND: Successful cleft lip repair creates symmetric nasolabial morphology with minimal scar. Fat grafting is used in cosmetic and reconstructive settings to provide contour, condition tissue and aid healing. This study employs immediate fat grafting concurrent with primary cleft nasolabial repair. We hypothesize that simultaneous fat transfer is safe and may optimize the result. METHODS: This retrospective analysis included a series of consecutive infants who underwent primary cleft lip repair with immediate fat grafting. Demographic and peri-operative details were recorded. Post-operative photographs were analyzed by three blinded reviewers (Al-Omari et al. and Asher-McDade et al.). Kappa statistics were employed to assess inter-rater reliability (Randolph and Watkins MW). RESULTS: 30 children, 37 sides (13 left, 10 right, 7 bilateral; 62% complete, 38% incomplete) who underwent cleft lip repair at Yale were included. 20 underwent nasolabial repair with simultaneous fat grafting. Mean age of repair was 3.5 mo (range 1.5-6.4). Fat was hand suctioned from the thighs (15 left; 2 right; 3 both) with mean yield of 2.1 cc (range 1-5 cc). An average of 1.4 cc (range 0.5-2.5 cc) was injected to the philtrum, vermillion, piriform and ala. No complications were experienced with lip repair, fat harvest or graft injection. Mean follow-up was 24.7 months (range 12.4-60.2 months). Postoperative photographic assessment revealed minimal residual cleft stigmata with inter-rater reliability. Each ordinal score was statistically significant compared fat grafted repairs to those without fat grafting (p < 0.05). CONCLUSIONS: Simultaneous fat grafting and cleft lip repair can be performed safely. The augmentation and modulation of scar formation may optimize results. Prospective comparison is necessary to further corroborate our findings. LEVEL OF EVIDENCE: Therapeutic (Level IV).

Complication rates of lipoabdominoplasty versus traditional abdominoplasty in high-risk patients.

BACKGROUND: Concerns over the safety of combining extensive liposuction with abdominoplasty in a one-stage lipoabdominoplasty procedure persist. This study reports a comparison of the perfusion-related complication rates between lipoabdominoplasty and traditional abdominoplasty among high-risk patients, those more susceptible to complications secondary to a smoking history or previous significant supraumbilical abdominal scar. METHODS: The authors conducted a chart review of 161 patients from the Yale University Cosmetic Clinic who had undergone either lipoabdominoplasty (n = 93) or traditional abdominoplasty (n = 68) between 2004 and 2009. Patients were classified as high-risk patients if they were active smokers or had undergone previous abdominal surgery resulting in a significant supraumbilical abdominal scarring. Specific vascularity-related complications were compared between the techniques. RESULTS: Patients undergoing lipoabdominoplasty had a perfusion-related complication rate of 4.30 percent compared with 11.76 percent in those undergoing traditional abdominoplasty (p = 0.126). Among high-risk patients (26 smokers and 19 patients with significant supraumbilical scars), there was no statistically significant difference for perfusion-related complications, including skin necrosis, wound infection, and wound dehiscence. The need for surgical revision was 10.75 percent in patients undergoing lipoabdominoplasty, whereas 20.58 percent of patients undergoing traditional abdominoplasty needed revision surgery (p = 0.116). CONCLUSIONS: Lipoabdominoplasty is not associated with a statistically significant increase in perfusion-related complication rates as compared with traditional abdominoplasty, despite the fact that it involves potential trauma to the vascularity of the elevated abdominoplasty flap. This holds true even in patients who are at increased risk for perfusion-related complications secondary to a history of active smoking or a previous supraumbilical scar.

Free palmaris longus graft tenodesis effectively treats swan neck adduction collapse secondary to thumb basilar joint arthritis.

BACKGROUND: Compensatory thumb metacarpophalangeal joint hyperextension may occur with basilar joint arthritis and subluxation. Instability at the metacarpophalangeal joint must be corrected when the basilar joint is operated on. The authors use a simple surgical procedure that provides correction of thumb metacarpophalangeal joint hyperextension by a free palmaris longus graft to provide volar tenodesis across the metacarpophalangeal joint. METHODS: Twelve patients (14 extremities) were evaluated at a minimum of 11 months postoperatively. Outcome analysis was performed using the Disability of the Arm, Shoulder, and Hand Questionnaire, the McGill Pain Questionnaire, and a patient satisfaction survey. Clinical assessments evaluated thumb appearance, range of flexion and extension at the metacarpophalangeal joint, opposition, span, and cylindrical grip strength and pinch strength. Special attention was devoted to stability of the metacarpophalangeal joint while maintaining range of motion and strength. RESULTS: The average score on the Disability of the Arm, Shoulder, and Hand Questionnaire was 13.0 (good return of function), and the McGill Pain Questionnaire revealed mild to no postoperative pain. Overall postoperative patient satisfaction was high. There was good range of motion at the metacarpophalangeal joint (mean flexion, 44 degrees), and assessment of thumb strength revealed a mean tip pinch strength of 6.8 pounds and a mean key pinch strength of 8.7 pounds. Firm thumb stability was demonstrated during these strength measurements. CONCLUSIONS: Thumb metacarpophalangeal joint tenodesis can be an alternative to arthrodesis in patients who have swan neck deformity of the thumb secondary to basilar joint arthritis. It has the advantage of retaining useful motion. The procedure provides high patient satisfaction and good thumb function, strength, and range of motion. It is easily performed simultaneously with trapezial resection arthroplasty without complications.

Threatened lower extremity in a neonate from a severely constricting amniotic band: a case for limb salvage after a 6-year functional follow-up.

A child presented at birth with a threatened lower limb from severe constriction band. Limb salvage was performed by emergency z-plasty reconstructions and subsequent sural nerve grafting to a fibrotic segmental deficit in the sciatic nerve. Follow-up over a 6-year period enables us to provide a favorable outlook with regard to functional use of the extremity and absence of chronic lymphedema, but she does have a significant limb length discrepancy. There is virtually no information on long-term functional outcome of such cases, although textbook teaching advises one to attempt emergency salvage of an extremity that is threatened by a severely constricting congenital amniotic band. Follow-up of our patient equips us with outcome information so that we can now better inform parents when once again faced with this problem in the neonate.