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.

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.

The hatchet and bilobed flaps revisited: shedding new light on traditional concepts.

BACKGROUND: The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results. OBJECTIVE: We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap. METHODS: We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years. RESULTS: Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity. CONCLUSIONS: We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

Back to basics: reconstruction of defects on the lower half of the nose.

BACKGROUND: Surgical reconstruction of defects on the lower half of the nose mandates special considerations. Simple excision and suturing might cause a depressed scar and nostril flaring. Hence, the preoperative plan should be designed properly to avoid disfigurement and to achieve a successful reconstruction. OBJECTIVE: Three basic reconstructive concepts are essentially combined: 1.) The ratio between scar length and defect diameter should be extended beyond the standard 3:1 ratio; 2.) The defect should be positioned asymmetrically within the inferior half of the excision outline; and 3.) Para-median defects mandate an inferior, horizontal advancement ("sliding") flap to avoid nostril flaring. A salvage technique is also discussed. METHODS: Data from patients treated by Mohs micrographic surgery for tumors of the inferior aspect of the nasal dorsum and reconstructed according to the proposed course of action was collected and reviewed. RESULTS: The proposed reconstructive path proved successful for all patients. Although one case required salvage skin grafting, all patients had aesthetically pleasing results. No postoperative complications were noted. CONCLUSIONS: Simple excision and primary suturing is a viable method for treating lesions on the lower half of the nose, provided that the surgeon follows a set of basic reconstructive principles.

"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.

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.

Defying consensus: correct sizing of full-thickness skin grafts.

BACKGROUND: Full-Thickness skin grafts are routinely used to reconstruct defects throughout the body. When planning the size of the graft, the surgeon usually copies a template from the defect and measures the graft to fit its full dimensions. This may lead to an oversized graft, resulting an unaesthetic outcome. OBJECTIVE: To evaluate discrepancy in size between the excised full-thickness skin and the excision (donor) site. METHODS: Data from 20 cases of full-thickness excisions was reviewed and analyzed. RESULTS: There was a considerable difference in length of both the short and long axes between the excised full-thickness skin and the excision site. CONCLUSIONS: The initial size of a full-thickness skin graft should be smaller than the defect it is planned to cover.

Nasal ala reconstruction with a crus helix composite graft: a stepladder approach.

BACKGROUND: Defects of the nasal ala present a complex reconstructive challenge. Composite grafts comprise all layers required to successfully reconstruct these full thickness deformities making them the ideal reconstructive method, yet they are usually avoided because of unjustified disreputable failure rates. OBJECTIVE: The authors introduce a stepladder approach for alar reconstruction with a crus of helix composite graft according to the severity and complexity of the defect. METHODS: Data from 25 patients who underwent correction of full thickness alar defects with composite grafts was collected and reviewed. RESULTS: There were no complete graft failures in any of the cases. Ten patients (40%) had partial graft necrosis ranging from 5 to 50% (average 18%); two of them (20%) were heavy smokers. CONCLUSIONS: Composite grafts should be considered for reconstruction of full thickness nasal ala defects, given the correct surgical technique is implemented.

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.

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.

A new simple, safe, and easy solution for upper lip dermabrasion.

BACKGROUND: Upper lip wrinkling is a common complaint of patients seeking perioral rejuvenation. Lately, manual dermabrasion has become more popular due to its safety, minimal cost, and favorable results. In several hospitals, the ability to efficiently sterilize sand paper has been questioned. METHODS: Between 2007 and 2010, 29 patients underwent manual dermabrasion of the skin of the upper lip using an electric cautery scratch pad during their surgeries. RESULTS: The average patient was aged 60.2 years. The average healing period was 5.8 days. Patient satisfaction from the procedure ranged from very good to excellent. No serious or long lasting complications have been encountered during our follow-up period.

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.

3D Mohs surgery: a new concept.

Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

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

BACKGROUND: The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable. METHODS: In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure. RESULTS: No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments. DISCUSSION: Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate.

Cardiorespiratory fitness and plasma homocysteine levels in adult males and females.

BACKGROUND: High levels of plasma homocysteine constitute a risk for cardiovascular disease. Physical activity, known to reduce CVD risk, has been related to levels of Hcy. Recently, higher Hcy was shown to be associated with lower cardiovascular fitness in women but not in men. OBJECTIVES: To further explore the relationship between cardiorespiratory fitness and plasma total homocysteine levels in a large cohort of adult males and females. METHODS: This cross-sectional study included 2576 fitness and Hcy examinations in adults (62% males) aged 30-59 years randomly drawn from a population undergoing a periodic health examination in the Sheba Medical Center's Executive Screening Survey. Blood tests were collected for tHcy and a sub-maximal exercise test was performed to estimate cardiorespiratory fitness. Information on CVD/CVD risk factors (coronary heart disease, cerebrovascular accident, diabetes, hypertension or dyslipidemia) was self-reported. RESULTS: Mean tHcy plasma levels were 14.4 +/- 7.7 and 10.2 +/- 3.0 micromol/ml, and mean maximal oxygen uptake 36.5 +/- 11.7 and 292 +/- 9.5 ml/kg/min for males and females, respectively. A multiple regression analysis, adjusting for age, body mass index and CVD/CVD risk factors, showed no association between cardiorespiratory fitness and level of tHcy in males (P = 0.09) or in females (P = 0.62). CONCLUSIONS: In this sample no association was found between level of cardiorespiratory fitness and plasma tHcy in men or women. The inconsistency of findings and the small number of studies warrant further research of the association between cardiorespiratory fitness and tHcy, an association that may have clinical implications for the modifications of cardiovascular risk factors.

The role of antibiotics in rhinoplasty and septoplasty: a literature review.

BACKGROUND: Prophylactic antimicrobial therapy during nasal surgery is common among surgeons worldwide, although the effectiveness of this practice is controversial. The authors reviewed the literature to evaluate the value of antibiotic prophylaxis. METHODS: A MEDLINE search was preformed using the key terms septoplasty, rhinoplasty, infections and antibiotics. The authors identified eleven studies written in English or German that addressed the effectiveness of prophylactic antibiotics, infection rate and bacteremia during nasal surgery. Due to the small number of studies statistical re-analysis was discarded. RESULTS: The articles demonstrated an overall very low incidence of bacteremia or infection. The studies failed to demonstrate a difference between patients who received antibiotic prophylaxis during nasal surgery and patients who did not; with the only exception being cases of complicated revision rhinoplasties. CONCLUSION: Our review suggests that the infection rate after elective nasal surgery is very low, making routine antibiotic prophylaxis redundant. Preventive systemic antibiotics are indicated in complicated revision rhinoplasties, prolonged placement of nasal packs and for patients who are susceptible to infections.

Late-onset facial abscess formation after cosmetic soft tissue augmentation with bio-alcamid.

Bio-Alcamid (BA) (polyalkylimide) was introduced in Europe in 2001. It is a nonresorbable injectable filler for soft tissue augmentation, indicated for a wide variety of clinical applications in reconstructive and cosmetic surgery in conditions where subcutaneous volumetric compensation is required. Although BA biocompatibility was approved by a European Union Certificate (CE), the substance is not a natural component of biologic tissues, and thus inflammation and infection are still potential risks. The authors present a case of BA infection after minor trauma 3 years after bilateral injections to the malar regions in a 43-year-old woman, causing an abscess that required surgical drainage and parenteral antibiotics.

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.].

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.